Surgical Technique

ADR

Contents

Introduction .............................................................................................................. 3

Indications ............................................................................................................... 4

Contraindications ..................................................................................................... 4

Case Studies ............................................................................................................ 5

Preoperative Planning .............................................................................................. 6

Patient Positioning ....................................................................................................7

Surgical Technique ....................................................................................................7

Postoperative Treatment ..........................................................................................11

Sterilization ............................................................................................................. 12

Implants .................................................................................................................. 13

Dimensions ............................................................................................................. 14

Instrument Set ........................................................................................................ 16

Nota Bene

The surgical technique described in this brochure is the procedure suggested by the authors for uncomplicated surgery. The surgeon must, however, decide which procedure is the most suitable and effective for each individual patient.

3

3

The ADR stem has been clinically used since 2007 and is designed for uncemented fixation in difficult bone conditions and deformities of the proximal femur, such as dysplasia. The combination of longitudinal ribs and conical geometry provides excellent primary fixation.

The ADR range includes 12 cementless conical femoral stems and provides two offset versions for each size. The modular instrumentation provides surgeons with a considerable level of flexibility during surgery, allowing optimum joint geometry reconstruction, even in difficult proximal bone conditions.

Thanks to the symmetrical circular cross-section of the implants, anteversion or retroversion can be easily modified during surgery without changing the preparation of the femoral canal. Moreover, the implants are designed in a way that no leg length discrepancies will occur when switching from the standard to the lateralized version (or vice versa).

“I have been using the ADR stem since 2009 in more than 150 cases. For me, the true benefit of this system is the combination of a monoblock implant with all the advantages of modularity. The modular trial components offer intra-operative flexibility in finding the optimal implant position, but the final implant doesn’t need modularity due to its symmetrical circular and tapered design”.

Dr. Alberto Belluati, Ravenna, Italy December 2013

Smith & Nephew Orthopaedics would like to thank Dr. Alberto Belluati for his support in refining the ADR surgical technique.

Introduction

54

Indications

The ADR Standard and Lateral femoral stems are indicated for:

• Advanced degeneration of the hip joint as a result of degenerative, post-traumatic or rheumatoid arthritis

• Fracture or avascular necrosis of the femoral head

• Conditions resulting from previous operations, such as osteosynthesis

• joint reconstruction, arthrodesis, hemiarthroplasty or hip total prosthesis

• Cylindrical configuration of the proximal medullar cavity (CDH, coxa valga)

• Increased anteversion of the femoral neck (cross section allows anteversion of the stem to be adjusted as desired)

• Deformities of the proximal end of the femur after osteotomies, fractures, growth disorders or congenital deformities

Contraindications

• Acute or chronic infections, local or systemic

• Local infections of the area operated

• Severe muscle, nerve or vascular diseases that endanger the extremity in question

• Lacking bone substance or inadequate bone quality that endangers a stable seating of the prosthesis, especially

– Trumpet-shaped proximal femur

– Considerable weakening of the bone structure at the proximal end of the femur

• All concomitant diseases that may endanger the function of the implant, such as:

– Any allergies to implant materials

– Renal insufficiency

– Cardiac insufficiency (e.g. as a result of increased metal/ion concentration in the blood)

• Pregnancy

Indications/Contraindications

54

Case Studies

Preoperative

Preoperative

Postoperative

Postoperative

Male, 57 years of age, cox arthrosis

Male, 52 years of age, hip dysplasia in poliomyelitic limb Combination of ADR stem and POLARCUP™

Combination of ADR stem and R3™ cup

76

Preoperative Planning

Preoperative planning requires:• X-rays

• Templates for the acetabular component and the stem or

• Digital templates for the acetabular component and the stem

Preoperative planning is essential for determining the size of the femoral and acetabular components.

Templating should define the reaming required for the restoration of the cup’s center of rotation, while the height and angle of the neck resection determine the optimal length and offset. This is particularly important in patients with leg length discrepancy.

Standardized AP and lateral X-rays are essential to ensure accurate planning. The femur must be positioned in neutral rotation to produce orientation that matches the templates.

An adequate length of the femoral diaphysis should be included on the X-rays. The correct stem size is determined by laying the stem template over the X-ray and selecting the optimum fit of the stem. The center of rotation of the femoral head is matched by selecting the appropriate neck length.

Note• In order to select the appropriate implant size it

is important to achieve intimate contact between the middle third of the prosthetic stem and the femoral cortex.

• During bone preparation a certain amount of bone will be removed by the reamers and some penetration of implant’s ribs will occur. Therefore, during planning about 1 mm of the prosthetic outline should overlap the cortical bone in the region of the middle third of the implant in both sizes.

76

Surgical Technique

Position of the patient and approach

For the purpose of this description a posterolateral approach is chosen. Surgery is performed with the patient in a lateral decubitus position.

Whether an anterolateral, lateral, posterolateral or posterior approach is used is at the surgeon’s discretion. The skin incision and muscle detachment depend on the selected approach.

Femoral exposure

To expose the proximal femur, flex and internally rotate the femur with the knee flexed 90 degrees. Place a medium femoral retractor under the proximal femur.

98

Surgical Technique

Removing the femoral head

Laterally, the osteotomy commences at the trochanteric fossa (perpendicular to the neck axis), while medially it ends approximately a finger breadth above the lesser trochanter. The height of the neck resection may be modified to address (in the presence of sounds a little ‘stilted’) abnormal anatomy as determined by preoperative templating and intraoperative measurements. The osteotomy can be performed before or after dislocation of the femoral head. The acetabulum is replaced following standard routine.

Preparation of the femur

The medullary cavity is opened with the offset box chisel, allowing the correct anteversion required for the implant – starting as close as possible to the greater trochanter base to allow good varus/valgus positioning.

Connect the T-handle (75023563) to the awl (75006556/420068).

The femoral reamer is then introduced in the medullary canal.

Ensure that the awl is parallel to the femoral axis and that there is full access to the femoral canal.

Start widening the femoral canal with the smallest size of the conical modular reamer

(75004515/21000162) and proceed progressively reaming until cortical bone contact has been achieved (a noticeable resistance should be felt).

NoteCheck the depth of insertion of each reamer by aligning the marking on the reamer shaft to the apex of the greater trochanter.

98

Trial reduction

Once the appropriate size has been reached, a modular trial stem with a proximal trial neck is used to determine the exact position and correct size of the final implant.

The trial is polished and the distal part has only half number of the implant’s ribs in order to facilitate its extraction and to guarantee a secure primary fixation of the implant. The trial stem and the corresponding trial neck (Standard or Lateral) is chosen based on the last reamer size.

• To assemble the trial neck positioner 75000639/21000336, first the flat knurled nut is screwed onto the handle and the adapter is then connected to the handle.

• The screw 75000636/21000333 is put into the selected proximal trial neck and fixed with the screw driver 75000637/21000334.

• The trial neck positioner is connected to the proximal trial neck and turned until the coupling is correctly locked.

• The connection between the positioner and the proximal trial neck is secured by screwing the flat knurled nut against the connecting adapter.

• Afterwards, the selected distal trial stem is connected to the proximal trial neck and firmly tightened with the screw driver through the cannulated trial positioner.

The trial stem is introduced into the prepared femoral canal. Thanks to the modularity, the surgeon can adjust anteversion or switch from standard to lateral offset without removing the distal part. Two clearly visible reference lines are marked on the proximal part to help the surgeon to reproduce the desired degree of anteversion angle during final implantation.

The trial reduction is repeated until optimal offset, leg length, ROM and stability is achieved. Afterwards, the trial stem is removed.

In the event of difficulties reconnecting a separated proximal body to the distal stem, the adapter trial stem 75100899 and the extraction bar 75023564 with the slap weight can be used to remove the distal stem directly.

Surgical Technique

12

1110

Insertion Implant

We recommend that the plastic protective cover on the taper is not removed until the stem is in its final position and the ball head is ready to be attached to the cone. Manually insert the prosthesis of the appropriate size until resistance can be felt.

The impactor (75004527/21000174) is used for final seating into the femoral canal.

The tip of the instrument is inserted into the impacting hole in the shoulder of the prosthesis. The fork-shaped flange surrounds the neck of the prosthesis. By using the instrument the implant is rotated into the desired anteversion.

Then the implant is impacted into its final position. The depth of penetration as established in preoperative planning, is verified.

NotePressing the stem in by hand is insufficient.

In case of a pre-existing anteversion, please make sure that the neck of the prosthesis does not sit on the rim of the femoral neck cortex. Some bone may be removed with a fine chisel until there is a gap between the neck of the prosthesis and the bone.

If needed, the intermediate spaces remaining between the prosthesis and the proximal bone are packed tightly with the chips of cancellous bone which have been obtained during the procedure.

Ball head introduction

Remove the plastic taper protection. Before positioning the ball head, carefully wash the stem cone with water and then dry. Then position the ball head and secure in place with slight rotation.

Surgical Technique

1110

The ball head is slightly impacted using a plastic impactor (75002160/110242). The joint is then reduced, manipulated and retested to ensure proper functioning.

NotePressing the prosthetic head onto the trunnion solely by hand provides inadequate fixation. Ceramic heads must never be impacted using a metal instrument.

Wound closure

Reinsert the muscle tissue. Insert a subfascial and subcutaneous redon drain and close the wound with intracutaneous sutures for aesthetic reasons.

Stem explantation

The ADR stem can be explanted using the

following instruments:

• Stem extractor (75002424/111053)

• Extraction bar (75023564)

• Modular weight (75006921/506-2107)

The postoperative treatment depends on the patient’s age and general state of health. The operated leg can be immediately weight bearing. For 48 hours a splint (foam) in slight abduction is recommended. The use of crutches can be helpful during the first days.

The use of antibiotics and thrombosis prophylaxis as well as suture removal are at the surgeon’s discretion.

Postoperative Treatment

Surgical Technique

1312

ImplantsAll the implants described in this Surgical Technique are sterile when they are delivered by the manufacturer. Resterilization is not allowed.

InstrumentsSystem components and instruments are not sterile when they are delivered. Before use they must be cleaned by the usual methods in accordance with internal hospital regulations and sterilized in an autoclave in accordance with the legal regulations and guidelines applicable in the relevant country.

For detailed information please refer to leaflet (Lit. no. 1363.)

The correct settings are given in the instructions for use provided by the autoclave manufacturer. Instrument manufacturers and dealers accept no responsibility for sterilization of products by the customer.

Sterilization

1312

Standard stem SAP No. Item. No. Size75002018 11000270 175002019 11000271 275002020 11000272 375002021 11000273 475002022 11000274 575002023 11000275 675002024 11000276 775002025 11000277 875002026 11000278 975002027 11000279 1075002028 11000280 1175002029 11000281 12

Demo Implant Standard stem SAP No. Size75102214 6

Lateral stem SAP No. Item. No. Size75002030 11000282 175002031 11000283 275002032 11000284 375002033 11000285 475002034 11000286 575002035 11000287 675002036 11000288 775002037 11000289 875002038 11000290 975002039 11000291 1075002040 11000292 1175002041 11000293 12 Demo Implant Lateral stem SAP No. Size75102215 6

Implants

ADR cementless Material Ti6Al4V ISO 5832-3 Cone 12/14

1514

SpecificationSize Stem

length (mm)

Diameter (mm)

CCD angle

Standard

CCD angle

Lateral1 127 13 138 1322 129 14 138 1323 132 15 138 1324 134 16 135 1305 137 17 135 1306 139 18 135 130

Size Stemlength

mm)

Diameter (mm)

CCD angle

Standard

CCD angle

Lateral7 142 19 133 1288 145 20 133 1289 148 21 133 128

10 151 22 131 12511 154 23 131 12512 157 24 131 125

Neck Length Standard (mm)Size XS/–3 S/+0 M/+4 L/+8 XL/+12

1 29 32 35 39 402 28 31 35 39 403 27 30 34 38 424 29 31 35 39 425 28 31 35 39 426 27 30 34 38 427 29 32 36 40 428 28 31 35 39 429 28 31 35 39 42

10 29 32 36 40 4211 29 32 36 39 4212 28 31 35 39 42

Neck Length Lateral (mm)Size XS/–3 S/+0 M/+4 L/+8 XL/+12

1 32 34 38 42 462 31 34 38 41 463 30 33 37 41 454 32 34 38 42 465 31 34 38 42 466 30 33 37 41 457 32 35 39 43 478 32 34 38 42 469 31 34 38 42 46

10 33 36 39 43 4711 32 35 39 43 4712 31 34 38 42 46

Neck Offset Standard (mm)Size XS/–3 S/+0 M/+4 L/+8 XL/+12

1 25 27 30 32 352 25 27 30 32 353 25 27 30 32 354 28 30 33 36 385 28 30 33 36 386 28 30 33 36 387 31 33 36 39 428 31 33 36 39 429 31 33 36 39 42

10 34 36 39 42 4511 34 36 39 42 4512 34 36 39 42 45

Neck Height Standard (mm)Size XS/–3 S/+0 M/+4 L/+8 XL/+12

1 26 28 31 34 372 26 28 31 34 373 25 27 30 33 364 25 27 30 33 365 25 27 30 33 366 24 26 29 32 357 25 27 30 33 358 25 27 30 32 359 24 26 29 32 35

10 25 27 29 32 3511 24 26 29 31 3412 24 26 28 31 34

Neck Offset Lateral (mm) Size XS/–3 S/+0 M/+4 L/+8 XL/+12

1 30 32 35 38 412 30 32 35 38 413 30 32 35 38 414 33 35 38 41 445 33 35 38 41 446 33 35 38 41 447 35 38 41 44 478 35 38 41 44 479 35 38 41 44 47

10 38 41 44 47 5011 38 41 44 47 5012 38 41 44 47 50

Neck Height Lateral (mm) Size XS/–3 S/+0 M/+4 L/+8 XL/+12

1 27 29 31 34 372 26 28 31 33 363 26 28 30 33 364 26 28 30 33 355 25 27 30 33 356 25 27 29 32 347 26 28 30 33 358 25 27 30 32 359 25 27 29 32 34

10 25 27 29 32 3411 25 27 29 31 3412 25 26 28 31 33

Dimensions

Neck height

Diameter

XXL/+16

XL/+12

L/+8

M/+4

S/+0

XS/-3

CCD angle

Stem lenght

Standard

Neck length Standard

Lateral

Neck length Lateral

1514

Neck height

Diameter

XXL/+16

XL/+12

L/+8

M/+4

S/+0

XS/-3

CCD angle

Stem lenght

Standard

Neck length Standard

Lateral

Neck length Lateral

Dimensions

1716

Base Tray Set No. 75200155

SAP No. Art. No. Name Size 75023565 75023565 Basic Case 75007661 990019 Easy Tray Lid plastic 75006921 506-2107 Modular Slap Weight 75004527 21000174 Stem Impactor with Fork 75023564 75023564 Extraction Bar4 75002424 111053 Extractor5 75023563 75023563 T-Handle Long, AO coupling6 75006419 41000029 Box Chisel Straight7 75002160 110242 Head Impactor8 75006556 420098 Awl9 75100843* 75100843 Trial Femoral Head 28 XS/-3 75100844 75100844 Trial Femoral Head 28 S/+0 75100845 75100845 Trial Femoral Head 28 M/+4 75100846 75100846 Trial Femoral Head 28 L/+8 75100847 75100847 Trial Femoral Head 28 XL/+12 75100848 75100848 Trial Femoral Head 28 XXL/+16 75100849* 75100849 Trial Femoral Head 32 XS/-3 75100850 75100850 Trial Femoral Head 32 S/+0 75100851 75100851 Trial Femoral Head 32 M/+4 75100852 75100852 Trial Femoral Head 32 L/+8 75100853 75100853 Trial Femoral Head 32 XL/+12 75100854 75100854 Trial Femoral Head 32 XXL/+16 75100855* 75100855 Trial Femoral Head 36 XS/-3 75100856 75100856 Trial Femoral Head 36 S/+0 75100857 75100857 Trial Femoral Head 36 M/+4 75100858 75100858 Trial Femoral Head 36 L/+8 75100859 75100859 Trial Femoral Head 36 XL/+12* special size (optional)

Optional: SAP No. Art. No. Name Size 75210288       75210288       SET 22 mm Trial Femoral Heads     S/+0 to XL/+12 75210292 75210292       SET 40 mm Trial Femoral Heads     XS/-4 to L/+8 75210293 75210293       SET 44 mm Trial Femoral Heads     XS/-4 to L/+8

Instrument Set

1716

Instrument Set

4

5

689

7

1918

Reamer Tray Set No. 75200155

SAP No. Item. No. Name Size 75023567 75023567 Reamer Case 75007661 990019 Easy Tray Lid plastic 75004515 21000162 Reamer 1 75004516 21000163 Reamer 2 75004517 21000164 Reamer 3 75004518 21000165 Reamer 4 75004519 21000166 Reamer 5 75004520 21000167 Reamer 6 75004521 21000168 Reamer 7 75004522 21000169 Reamer 8 75004523 21000170 Reamer 9 75004524 21000171 Reamer 10 75004525 21000172 Reamer 11 75004526 21000173 Reamer 12

Instrument Set

1918

Instrument Set

2120

Trial Tray Set No.75200155

SAP No. Art. No. Name Size 75023566 75023566 Trial Case 75007661 990019 Easy Tray Lid plastic 75000616 21000313 Trial Stem 1 75000617 21000314 Trial Stem 2 75000618 21000315 Trial Stem 3 75000619 21000316 Trial Stem 4 75000620 21000317 Trial Stem 5 75000621 21000318 Trial Stem 6 75000622 21000319 Trial Stem 7 75000623 21000320 Trial Stem 8 75000624 21000321 Trial Stem 9 75000625 21000322 Trial Stem 10 75000626 21000323 Trial Stem 11 75000627 21000324 Trial Stem 12 75000628 21000325 Trial Neck 1–3 STD 75000629 21000326 Trial Neck 4–6 STD 75000630 21000327 Trial Neck 7–9 STD 75000631 21000328 Trial Neck 10–12 STD 75000632 21000329 Trial Neck 1–3 LAT 75000633 21000330 Trial Neck 4–6 LAT 75000634 21000331 Trial Neck 7–9 LAT 75000635 21000332 Trial Neck 10–12 LAT 75000636 21000333 Screw for Trial Stem4 75000637 21000334 Screw Driver5 75000639 21000336 Trial Neck Positioner6 75023568 75023568 Marking Plate 7 75100899 75100899 Adapter Trial Stem

Instrument Set

2120

4

5

6

7

Instrument Set

2322

Notes Notes

2322

Notes Notes

2524

Notes Notes

2524

Notes Notes

Manufacturer Contact

Smith & Nephew Orthopaedics AG

Oberneuhofstrasse 10d

6340 Baar

Switzerland

™ Trademark of Smith & Nephew Lit. No. 01464-en (1610) Ed. 03/14