Epoca Shoulder Arthroplasty System Fracture. Hemi and total joint replacement for fractures.

Transcription

1 Epoca Shoulder Arthroplasty System Fracture. Hemi and total joint replacement for fractures. Technique Guide This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation.

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3 Table of Contents Introduction Epoca Shoulder Arthroplasty System 2 AO Principles 4 Indications and Contraindications 5 Clinical Cases 6 Surgical Technique Preoperative Planning 8 Patient Positioning 9 Hemiarthroplasty for Fractures 10 Implantation of a Glenoid Component 29 Care and Maintenance 43 Product Information Implants 44 Special Implants 48 Instruments 49 Bibliography 59 Image intensifier control Warning This description alone does not provide sufficient background for direct use of the instrument set. Instruction by a surgeon experienced in handling these instruments is highly recommended. Processing, Reprocessing, Care and Maintenance For general guidelines, function control and dismantling of multi-part instruments, as well as processing guidelines for implants, please contact your local sales representative or refer to: For general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, as well as processing of Synthes nonsterile implants, please consult the Important Information leaflet (SE_023827) or refer to: Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 1

4 Epoca Shoulder Arthroplasty System. Anatomic reconstruction of the proximal humerus. RH Resurfacing Head Stem for Fractures and Degenerative Conditions 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 resurfacing head is intended for minimally invasive treatment of early stage arthritis or other arthropathies with cartilage damage. Thin surface allows for minimum bone removal Anatomic reconstruction of articulating surface Stable and bone sparing crown fixation TiNb coated version for nickel sensitive patients The Epoca Shoulder Arthroplasty system aims to restore glenohumeral kinematics in fractures and degenerative cases. The Epoca implant facilitates anatomic reconstruction of the proximal humerus. Anatomic design mimics contour of the medial calcar and medullary canal Non-protruding lateral design reduces risk of damage to the insertion facet of the supraspinatus tendon Medial and lateral holes in the stem allow for stable reattachment of the tuberosities Available in a variety of diameters and lengths, L and XL stems for revision Titanium for nickel sensitive patients 2 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

5 Glenoid Reco Glenoid Eccenter Disc Allows medial and posterior offset adjustments Independent adjustment of the head vs. shaft Press-fit assembly outside the patient The Epoca shoulder prosthesis is intended for use as a hemi- or total shoulder replacement Ensures congruent glenohumeral implant surfaces to achieve normal range of motion Reduced size and beveled rim for normal mobility and reduced risk of impingement Hybrid application with shell screws Cementless application with metalback glenoid The Epoca Reco glenoid reconstruction device is intended to reestablish a stable fulcrum in order to prevent antero superior subluxation of the humeral head. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 3

6 AO Principles 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 conjunction with stem-implant Preservation of blood-supply Anatomical reduction and osteosynthesis of the tuberosities 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 4 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

7 Indications and Contraindications Indications Irreparable fractures of the proximal humerus Posttraumatic conditions with advanced joint destruction Failed previous osteosynthesis A glenoid component may be indicated in cases of cartilage destruction or in case of an associated irreparable glenoid fracture 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 function of the implant Any other pathology which needs treatment priority Conditions which can adversely affect joint replacement 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 stress from sports, etc.) Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 5

8 Clinical Case 1 Female patient, 65 years old Comminuted 4-part fracture with ischemic head, right shoulder Preoperative AP view Axillary view Postoperative AP view Axillary view 6 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

9 Clinical Case 2 Female patient, 65 years old Comminuted 4-part fracture with ischemic head and osteoporosis, left shoulder Preoperative AP view Postoperative AP view Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 7

10 Preoperative Planning Complete the preoperative radiographic assessment with standard AP, lateral and axillary views. A CT scan is required when the axillary view is not optimal, i.e. when more information about the lesser tuberosity is required. An AP view of the contralateral humerus is optional. It is helpful to estimate the size of the prosthetic head and stem. Place the template on the AP view of the contralateral humerus to estimate the head and stem size. Then, draw the outer contour of the proximal humerus and the implant on transparent paper or on an electronic support using a computer assisted planning tool. Flip the image horizontally and superimpose it on the pathological side. Determine the required corrections. Preoperative planning for glenoid replacement Glenoid replacement may be indicated in cases of anterior fracture dislocations which are associated with significant glenoid fractures, such as Ideberg type II fractures. When planning a glenoid replacement procedure, axial CT scan views are recommended in order to assess the amount of glenoid damage and the correction needed. Additionally, a CT-based three-dimensional reconstruction of the glenoid (with the removal of the humeral head from the 3-D model) could help estimate the shape and size of glenoid defects. 8 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

11 Patient Positioning Position the patient in a beach-chair position. Avoid hyperextension and lateral inclination of the cervical spine 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 images can be obtained when needed. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 9

12 Hemiarthroplasty for Fractures 1 Approach 1 Standard deltopectoral approach Start the incision over the acromioclavicular joint and extend it 8 cm inferior over the anterior deltoid, lateral to the deltopectoral groove. Alternatively, follow Langer s skin tension lines starting from the acromioclavicular joint. Open the fascia over the deltopectoral groove and identify the cephalic vein. Retract the deltoid with the cephalic vein laterally, and the pectoralis major medially. Incise the clavipectoral fascia. 2 Expose fracture Irrigate and remove the hematoma to expose the fracture. Check the vascularity of the humeral head and confirm that joint 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 extraarticular path. Suture the biceps tendon to the pectoralis major fascia. Locate the split in the supraspinatus tendon induced by the fracture. Enlarge the split in the supraspinatus tendon, as required, for access to the joint. Retrieve the fractured humeral head and set it aside for later use. Examine the glenoid. Consider ORIF or glenoid replacement if there is a relevant fracture of the glenoid or glenoid rim. 1 see Hertel et al., Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

13 3 Prepare tuberosities for later fixation Implant S 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 drill bit. The two holes should be approximately aligned with the medial and lateral perforations of the prosthetic stem. Drill the holes close to the point of transition from tendon to bone. Using the wire portion of the wire-cable, pass the 1.0 mm wire-cables through the drill holes. Alternatively, cerclage wires or high strength sutures can be used. Park the wirecables posteriorly, so that they do not interfere with the remaining steps of the procedure. Note: The wire portion of the wire-cable can be shortened to the desired length. Expose the shaft by extending, adducting, and externally rotating the humerus. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 11

14 Hemiarthroplasty for Fractures 4 Determine stem height Instrument Ruler, length 250 mm, Stainless Steel Measure the medial metaphyseal extension on the retrieved head. This distance determines the precise height of the stem, i.e: how much the stem must protrude in respect to the medial fracture line. Note the height for later reference. X 5 Select trial head Instruments E Trial Heads, sizes 40 to 54 E Osteotomize any remaining metaphyseal extensions to better visualize the head. Compare the retrieved humeral head with the available trial heads. Choose the trial head that closely matches the retrieved head. Save the humeral head for later use as bone graft. Note: If the AP and lateral radii differ, choose an intermediate trial head size. 12 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

15 6 Open medullary canal and determine retrotorsion Instruments Combined Hammer E Retrotorsion Bar B 6.0 mm E Goniometer E Rasps, sizes 6 to 14 E 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 retrotorsion bar into the threaded hole of the rasp. Hold the gonio meter onto the lateral side of the retrotorsion bar. For the first rough adjustment, align the rasp to 25 retrotorsion with reference to the axis of the forearm. This measurement reflects the median retrotorsion value for a normal population. 1 1 see Hertel et al., Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 13

16 Hemiarthroplasty for Fractures Hammer in the rasp until proper seating is obtained. If the rasp penetrates too deep into the medullary cavity, use the next larger rasp size until the correct prosthetic height is obtained. Should you have difficulties fully inserting the chosen rasp, remove additional bone along the medial endosteal region using a sharp curette. This will allow the rasp to seat and self-lock a few millimeters deeper. The pronounced calcar design provides the rasp and the implants with self-centering, self-rotating and self-locking capabilities. Confirm the retrotorsion by cross-checking against the bicipital groove. The distance between the deepest point in the bicipital groove and the center line of the rasp should be approximately 8 mm. 2 8mm 2 see Hempfing et al., Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

17 7 Insert trial stem Instruments Combined Hammer E Trial Stems, sizes 6 to 14 E E Goniometer E Slotted Hammer/Extractor E Retrotorsion Bar B 3.0 mm Attach the inserter/extractor to the selected trial stem. Apply controlled light blows to the top of the inserter / extractor with the hammer. Hammer until the trial stem protrudes above the shaft, as determined in step 4. To confirm the retrotorsion of the trial stem, insert the 3.0 mm retrotorsion bar into the hole of the trial stem. Use the goniometer to measure the retrotorsion. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 15

18 Hemiarthroplasty for Fractures 8 Attach trial eccenter disc Instruments E / 2 Screwdriver Epoca, width across 2.0 mm, for Trial Implants E Trial Eccenter Disc Attach the trial eccenter disc to the trial stem. Align the letter A on the trial eccenter disc with the lateral line on the trial stem. This position reflects the normal (median) offset. Lock the trial eccenter disc using a 2.0 mm hex screwdriver in the proximal hole. 16 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

19 9 Insert trial head Instruments E Trial Heads, sizes 40 to 54 E E / 2 Screwdriver Epoca, width across 2.0 mm, for Trial Implants E / 3 Screwdriver Epoca, width across 2.5 mm, for Trial Implants E Trial Eccenter Disc Use a 2.0 mm hex screwdriver to back out the set screws from the trial head in order to allow for correct seating. Be careful not to back out the set screws too far, as they may fall out. Mount the trial head on the trial eccenter disc. Align the appropriate marking on the trial head with the center line on the trial stem ( L for left humerus, R for right humerus). Lock the trial head in position by tightening the anterior set screw. Verify that the offset is appropriate for the patient s anatomy. The ideal position is reached when the head meets the 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 eccenter disc with the 2.0 mm hex screwdriver. Use the 2.5 mm hex screwdriver to rotate the trial eccenter disc until the desired head position is achieved. Note: Should the screw in the trial head be missing, a screw from another trial head may be used instead. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 17

20 Hemiarthroplasty for Fractures For further adjustment, loosen the anterior set screw on the trial 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 and unlocking the set screws, the 2.5 mm hex screwdriver is used only to rotate the eccenter disc. Record the offset position of the trial head. 18 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

21 10 Remove trial implants Instruments Combined Hammer E Slotted Hammer/Extractor E / 2 Screwdriver Epoca, width across 2.0 mm, for Trial Implants E Trial Eccenter Disc Once the offset position of the trial head is recorded, remove the 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 screwdriver. Mount the inserter / extractor onto the trial stem. Lightly tap against the inserter / extractor to back out the trial stem. Note: To avoid possible damage to the thread, ensure that the inserter / extractor is fully threaded into the trial stem. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 19

22 Hemiarthroplasty for Fractures 11 Assemble implants Instruments E / 1 Press E / 3 Eccenter / Impactor E / 4 Torque Wrench for Press E / 6 Holders for Press, sizes 6 to 14 E / 14 Choose the stem holder that corresponds to the size of the shaft. Hold the half of the stem holder with two pegs with the etched side facing up. Orient the distal end of the stem toward the operator and slide the stem over the pegs. Slide the other half of the stem holder over the pegs. This assembly allows the stem to be firmly held in the press. Important: Ensure that the etched side of the stem holder is facing up. Improper assembly may cause jamming. Position the eccenter on the stem. Align the letter recorded during trial implantation (step 9) with the center line of the stem. Place the assembly in the press and place the eccenter / impactor over the eccenter. Make sure that the eccenter sits flush on the stem. Using the torque wrench, turn the handle of the press clockwise in a controlled, slow motion, until a click is heard, signifying the positive engagement of the eccenter and the stem. Turn the torque wrench counterclockwise and remove the eccenter / impactor. Remove the stem-eccenter assembly from the press. 20 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

23 Place the head on the stem assembly. Align the recorded offset position with the lateral marking on the implant or the contact 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 clockwise until a click is heard. Remove the implant from the press. Remove the stem holder and check for adequate seating of the head and the eccenter. Note: No visible gap should be present between the base of the head and the humeral stem. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 21

24 Hemiarthroplasty for Fractures 12 Implant prosthesis Choose the final implantation method according to the type of stem being used (cemented / uncemented). Instruments Combined Hammer E Goniometer E Retrotorsion Bar B 3.0 mm E Impactor Mount the plastic liner onto the head impactor. 12a Final implantation for cemented stems Do a final irrigation of the medullary canal. Insert a cement restrictor to prevent excess cement from flowing into the distal humerus. Place a vent tube in the medullary canal. Dry the cavity. Inject cement 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 retrotorsion bar. 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 harvested from the retrieved head to improve healing between tuberosities and shaft. Note: Follow the manufacturer s instructions for preparation, injection and setting of the bone cement. Insert the implant, first manually, then using the head impactor until the predetermined anatomic prosthetic height is reached. The implant will be protruding as defined in steps 4 and 7 of this procedure. 22 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

25 12b Final implantation for pressfit, cementless stems Introduce the prosthesis into the medullary canal. To confirm proper placement and orientation of the implant, use the 3.0 mm retrotorsion bar and the goniometer to recheck the retrotorsion. Lightly tap on the head impactor with the hammer until the implant is fully seated. The position must correspond to the predetermined anatomic prosthetic height. If the implant s position is too high, more bone rasping along the medial cortex is required. If the implant finds its stable position in a location that is too distal, use a shaft one size larger. Alternatively, the smaller shaft can be stabilized in the correct position using bone cement. Note: The implant must protrude as defined in steps 4 and 7. Fill the collar region with autogenous bone graft harvested from the retrieved head to improve healing between tuberosities and shaft. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 23

26 Hemiarthroplasty for Fractures 13 Pass wire-cables through stem/tuberosities With the humeral head still in the anteriorly dislocated position, pass the wire-cables that were initially placed in step 3 through the greater tuberosity / rotator cuff junction through the medial and lateral perforations of the stem. 24 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

27 14 Reduce the joint Reduce the joint i.e. the prosthetic head to the glenoid and to the greater tuberosity. Pass the wire-cable through the lesser tuberosity. Important: After passing the wire-cable through the tuberosities and stem, cut the wire portion of the wire-cable off at the 10 mm intermediate section only. 10 mm Reduce the lesser tuberosity to the prosthesis. Use sutures to readapt the split in the rotator cuff to obtain preliminary reduction of the tuberosities. Avoid over-reduction of the greater tuberosity, especially in a distal direction. The most medial insertion line of the supraspinatus must be flush with the edge of the prosthetic head, not distal to it. Fill any void under the tuberosities with cancellous bone graft harvested from the retrieved head. Use absorbable sutures for preliminary reduction and adaptation of the relevant fragments. Embrace and compress the tuberosities to the rectangular cross section of the shaft to obtain rotational stability. Pass the end of the distal cable through the crimp and repeat the step with the proximal cable. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 25

28 Hemiarthroplasty for Fractures 15 Apply wire tightener and crimping pliers Instruments E Crimping Pliers E Wire Tightener for Cerclage Tension the cables manually but do not tighten them too much. Hold the distal cable and apply the wire tightener. Open the cable tightening nut and pass the cable. Tighten the nut so that the cable is fix. Before fully tightening, apply the crimping pliers over the crimp. Note: Do not tighten the cable too much before applying the crimping pliers. Once the cable is fully tightened, applying the crimping pliers will be difficult. 26 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

29 16 Tighten and crimp cables Instruments E Crimping Pliers E Wire Tightener for Cerclage 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 to not over-tension the cables. When using embracing cables, additional devascularizing vertical sutures between shaft and tuberosities are not necessary. The use of embracing cables requires a tenotomy and tenodesis of the biceps tendon. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 27

30 Hemiarthroplasty for Fractures 17 Cut the cable ends Instrument E Cutting Pliers for Cerclage Using the cutting pliers, cut the ends of the cable while holding the cable. Repeat this step for the proximal cable. 28 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

31 Implantation of a Glenoid Component A glenoid component may be indicated in cases where there is associated cartilage damage to the glenoid or where there are irreparable glenoid fractures in which gleno-humeral stability is a concern. Note: The size of the glenoid implant is determined by the size of the humeral head component. 1 Approach and exposure Adequate exposure of the glenoid is essential for implantation. Exposure must permit the use of straight instruments such as reamers and drill bits. In fractures, exposure of the glenoid generally follows the space between the tuberosities. Introduce a tear-drop ring retractor (or another instrument such as a Fukuda Ring Retractor) to displace the greater tuberosity in a posterior and inferior direction. Remove any remnants of the cartilage. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 29

32 Implantation of a Glenoid Component 2 Locate center point Locate the true center of the glenoid, which is slightly inferior to the midpoint of Saller s line (vertical line dividing the glenoid into anterior and posterior halves). This is the slippage point of the humeral head during concentric motion. 30 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

33 3 Ream glenoid Instruments Kirschner Wire B 2.5 mm, length 280 mm Guide Extension Epoca, rigid, with Quick Coupling E5211-4L E5211-4R Drill Guide, left Drill Guide, right Reamer Epoca B 28 mm, for Glenoid, with Quick Coupling Reamer Epoca B 32 mm, for Glenoid, with Quick Coupling The shape of the drill guide matches the shape of the glenoid implant. Determine the desired anatomic position of the glenoid implant by placing the drill guide (left or right) on the glenoid. The central hole of the drill guide should cover the center point located in step 2. Hold the drill guide in the corrected position. Introduce the 2.5 mm Kirschner wire and re-check the positioning. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 31

34 Implantation of a Glenoid Component Assemble the smallest reamer (28 mm) onto the rigid guide extension. Note: Ensure the reamer and the rigid guide extension are coaxially aligned during assembly. Check that the reamer is properly attached to the rigid guide extension. Couple the assembly to power equipment. If there is sufficient exposure, place the reamer assembly over the Kirschner wire, position the reamer firmly against the glenoid, and ream. If there is not enough exposure to be able to slide the reamer over the Kirschner wire, remove the Kirschner wire. Place the reamer assembly on the glenoid, then reintroduce the Kirschner wire through the assembly into the previously drilled central hole, and ream. Optional Alternatively, free-hand reaming is possible without the use of guide wires. The reamer produces a uniformly concave surface, 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 glenoid and the extent of reaming. During the reaming process, correct the retro- or anteversion while preserving as much dense subchondral 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 bigger) continue reaming with the reamer B 32 mm to gain superior and inferior extension of the prepared surface. The drop shape of the drop-shaped ring retractors (available in the General Shoulder Instruments Set ) facilitate glenoid reaming by creating sufficient and comfortable working space for the reamer. To facilitate cleaning of the reamers, place them in water immediately following usage. 32 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

35 4 Prepare for trial glenoid Instruments Kirschner Wire B 2.5 mm, length 280 mm E5211-4L E5211-4R E5211-6K E5211-6L Drill Guide, left Drill Guide, right Drill Bit B 7.4 mm, length 150 mm, for Glenoid and Shell Screw Drill Bit B 7.4 mm, length 200 mm, for Glenoid and Shell Screw If the Kirschner wire has been removed, reinsert it. Reintroduce 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 a landmark to determine the alignment of the longitudinal axis of the glenoid. It is recommended to position the inferior hole slightly posterior and the superior hole slightly anterior to 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 implant type. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 33

36 Implantation of a Glenoid Component 4a Cemented all-poly glenoid For cemented all-poly glenoid, drill to a depth of 19 mm. 19 mm * 4b Hybrid 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 as comminuted anterior glenoid rim fractures require bridging. 21 mm * 4c Pressfit metalback glenoid For pressfit metalback glenoid, drill to a depth of 21 mm. 21 mm * Remove the Jacobs chuck but leave the drill bit in situ to stabilize the drill guide while drilling the second hole. Prepare the proximal hole using the long drill bit (200 mm). Remove the drill bits, Kirschner wire and drill guide. *mm depth includes the height of the drill guide 34 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

37 5 Introduce trial glenoid Instruments E5211-8E Holding Forceps for Trial Glenoid E Trial Glenoids, size 42 to 54 E Select the trial glenoid that matches the size of the humeral head. Trial Glenoids Head size Trial size 40/42 40/42 44/46 44 /46 48/50 48/50 52/54 52/54 Art. No. E E E E E E E E Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 35

38 Implantation of a Glenoid Component Use the trial glenoid holding forceps to insert the trial glenoid. Check the fit of the trial implant and ensure that the rear surface of the trial fits firmly to the reamed surface of the glenoid. If not, additional reaming of the glenoid is required. Alternatively, gaps may be filled with autogenous bone graft. In case of a comminuted anterior glenoid rim fracture, the glenoid implant is stabilized by 15 or 20 mm shell screws while the fracture fragment can be reduced and fixed with a simple osteosuture. Note: A simple suture loop to readapt the radial labral tear occurring at the 2 o clock position is often sufficient. 36 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

39 6 Implant glenoid component Instruments Combined Hammer E Holding Forceps for Glenoid F F Screwdriver, hexagonal, width across 4.5 mm Screwdriver, hexagonal, width across 2.5 mm E Glenoid Impactor E Metalback Impactor E Drill Sleeve 2.5 (22) E Drill Bit B 2.5 mm Tap for Epoca Shell Screws, length 200 mm Insertion Guide for Epoca Shell Screws Handle with Quick Coupling, length 150 mm Ensure that the plastic impactor liner is mounted on the glenoid impactor. Option A. Cemented all-poly glenoid Clean and dry the drilled cavities. Consider using a suction device introduced through the base of the coracoid process to evacuate undesired fluids. Introduce a small amount of bone cement (methylmethacrylate) into the two drilled cavities (0.15 ml in each cavity) using a 1 ml syringe. Note: Avoid overflow of the cement onto the faceplate of the glenoid as this will lead to a thin and brittle cement layer. Consult the manufacturer s instructions for proper bone cement usage. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 37

40 Implantation of a Glenoid Component Mount the glenoid implant on the special holding forceps and introduce the implant in the correct orientation (the narrow part facing up). Introduce the glenoid implant and seat it into its final position with light hammer taps on the glenoid impactor. 38 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

41 Option B. Hybrid glenoid (with shell screws) Position the insertion guide for the shell screws over the guide wire. Optional (in cases of dense or sclerotic bone) Align the insertion guide with the pre-drilled holes and manually tap using the tap for Epoca Shell Screws. Note: The color coding on the tap corresponds to the shell screw lengths (10 mm = green, 15 mm = blue, 20 mm = yellow). Insert the previously selected shell screws (see step 5) with the long, 4.5 mm, hexagonal screwdriver. The shell screw should be slightly below the surface of the bone. Note: The shell screws can be inserted with or without the use of the insertion guide for Epoca Shell Screws. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 39

42 Implantation of a Glenoid Component Introduce a small amount of bone cement (0.13 ml methylmethacrylate) into each shell screw using a 1 ml syringe. Note: Avoid overflow of the cement onto the faceplate of the glenoid, as this will lead to a thin and brittle cement layer. Consult the manufacturer s instructions for bone cement usage. Place the glenoid implant in position using the glenoid holding forceps. Set the glenoid implant into place using the hammer and glenoid impactor. 40 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

43 Option C. Pressfit metalback glenoid Place the metalback glenoid implant in position using the metalback impactor. Lightly tap the glenoid implant into place using the hammer and glenoid impactor. Note: The metalback glenoid can be fixed with 3.5 mm cortex screws at the bottom of the pegs for additional stability. Optional Additional screw fixation depends upon surgeons intraoperative judgment and preference. For this purpose, a special aiming drill guide is available. Introduce the cylindrical drill guide in the cylindrical metal-back peg and drill with a 2.5 mm drill bit. Measure the screw length and introduce a standard 3.5 mm cortical screw. Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 41

44 Implantation of a Glenoid Component Place the glenoid implant in position using the glenoid holding forceps. Set the glenoid implant into place using the hammer and glenoid impactor. 7 Complete implantation of humeral component Remove the humeral retractors and expose the proximal humerus. Complete implantation of a standard humeral component. 42 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

45 Care and Maintenance E5115-5/1 Press Epoca 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 locations and repeat as necessary until a noticeable smooth actuation of the screw mechanism is achieved. Failure to apply oil prior to use may cause undesired performance and lack of calibrated force upon the implant assembly. Note: The autoclavable oil is purchased separately. For best results turn the press with torque wrench clockwise and counterclockwise until smoother movement is noticed Reamer Epoca B 28 mm, for Glenoid, with Quick Coupling Reamer Epoca B 32 mm, for Glenoid, with Quick Coupling Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 43

46 Implants (all Implants are sterile packed) Humeral Stem, uncemented Titanium alloy (TAV) with Ti+HA coating Also for Nickel sensitive Patients Art. No. Size (mm) Length (mm) / / / / / Humeral Stem, cemented Stainless Steel Art. No. Size (mm) Length (mm) / / / / / Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

47 Titanium Eccenter Titanium alloy (TAV) Art. No. Usage /5 Standard Head Stainless Steel Art. No. B (mm) Height (mm) / / / / / / / / / optional / 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) and optional optional Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 45

48 Implants Shell Screws for hybrid Glenoid Titanium alloy (TAV) For use with Polyethylene Glenoid component Art. No. Length (mm) Glenoid / to / to / to Metalback component for cementless Glenoid Titanium alloy (TAV) For use with Polyethylene Glenoid Art. No. Size Glenoid / / / Cortex Screw B 3.5 mm Optional for use with Metalback Glenoid Art. No. Length (mm) S S S S S S S S S S S Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

49 Tubercable Stainless Steel For Tubercula Refixation in Trauma surgery Art. No / B (mm) Wire-cable S Wire-Cable B 1.0 mm, with Crimp Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 47

50 Special Implants (all Implants are sterile packed) Head for Allergy Patients Stainless Steel, with TiNb coating Art. No. B (mm) Height (mm) / / / / / / / / / optional / optional Stem for Allergy Patients, sterile See Humeral Stem, uncemented (Titanium alloy TAV) Art. No /11 to /13 48 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

51 Instruments Epoca Humerus: Stem instruments Modular Tray for Humeral Stem Epoca, Trial Instruments, size 1/1, without Contents, Vario Case System Modular Tray for Humeral Stem Epoca, Rasp Instruments, size 1/1, without Contents, Vario Case System Note: The instrument set also contains the empty additional modular tray Combined Hammer E Starter Rasp Epoca, size 6 E Retrotorsion Bar Epoca B 6.0 mm E Goniometer Epoca Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 49

52 Instruments E Rasp Epoca, size 6 E Rasp Epoca, size 8 E Rasp Epoca, size 10 E Rasp Epoca, size 12 E Rasp Epoca, size 14 E Slotted Hammer/Extractor Epoca E Trial Stem Epoca, size 6 E Trial Stem Epoca, size 8 E Trial Stem Epoca, size 10 E Trial Stem Epoca, size 12 E Trial Stem Epoca, size 14 E 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 50 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

53 E Trial Eccenter Disc Epoca E Trial Head Epoca, size 40 E Trial Head Epoca, size 42 E Trial Head Epoca, size 44 E Trial Head Epoca, size 46 E Trial Head Epoca, size 48 E Trial Head Epoca, size 50 E Trial Head Epoca, size 52 E Trial Head Epoca, size 54 E Trial Head Epoca, size 56 (optional) E Trial Head Epoca, size 58 (optional) E5115-8/38 E5115-8/44 E5115-8/48 Humeral Cover Epoca B 38 mm, for Trial Stem Humeral Cover Epoca B 44 mm, for Trial Stem Humeral Cover Epoca B 48 mm, for Trial Stem E Impactor Epoca Ruler, length 250 mm, Stainless Steel (optional) Curette, oval, with Toothing, length 300 mm (optional) Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 51

54 Instruments Epoca Humerus: Press instruments Vario Case for Epoca Humerus Press Instruments E5115-5/1 Press Epoca E5115-5/6 E5115-5/8 E5115-5/10 E5115-5/12 E5115-5/14 Holder Epoca for size 6, for Press Holder Epoca for size 8, for Press Holder Epoca for size 10, for Press Holder Epoca for size 12, for Press Holder Epoca for size 14, for Press E5115-5/3 Eccenter/Impactor Epoca E5115-5/4 Torque Wrench Epoca, for Press 52 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

55 Instruments Epoca Glenoid Modular Tray for Epoca Glenoid, Insertion Instruments, size 1/1, without Contents, Vario Case System Modular Tray for Epoca Glenoid, Preparation Instruments, size 1/1, without Contents, Vario Case System E5211-4L E5211-4R Drill Guide Epoca, left Drill Guide Epoca, right Kirschner Wire B 2.5 mm with trocar tip, length 280 mm, Stainless Steel Guide Extension Epoca, rigid, with Quick Coupling Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 53

56 Instruments Reamer Epoca B 28 mm, for Glenoid, with Quick Coupling Reamer Epoca B 32 mm, for Glenoid, with Quick Coupling 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 Tap for Epoca Shell Screws, length 200 mm Insertion Guide for Epoca Shell Screws Handle with Quick Coupling, length 150 mm 54 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

57 E Trial Glenoid Epoca, size 42 E Trial Glenoid Epoca, size 46 E Trial Glenoid Epoca, size 50 E Trial Glenoid Epoca, size 54 F Screwdriver Epoca, hexagonal, width across 4.5 mm E Metalback Impactor Epoca E Holding Forceps Epoca for Glenoid E Glenoid Impactor Epoca Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 55

58 Instruments E Drill Sleeve Epoca 2.5 (22) E Drill Bit Epoca B 2.5 mm F Screwdriver, hexagonal, Epoca, width across 2.5 mm DHS/DCS T-Handle with Quick Coupling (optional) 56 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

59 Additional instruments Adapter for Quick Coupling to Epoca Reamer Thread E Wrench Epoca, width across 10 Spare parts E Spare Screws for Trial Head Epoca E5115-7P E P Impactor Head Epoca Synthetic Headpiece for Impactor for Glenoid Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 57

60 Instruments Cerclage Instruments E Crimping Pliers E Wire Tightener for Cerclage E Cutting Pliers for Cerclage Notes: Ordering information for the General Shoulder Instruments Sets can be found in the brochure Ordering information for the Epoca Revision Instruments can be found in the technique guide Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

61 Bibliography Stanley Hoppenfeld and Piet deboer, Surgical Exposures in Orthopaedics The Anatomic Approach, Third Edition, 2003, pp Hertel R, Knothe U, Ballmer FT. Geometry of the proximal humerus and implications for prosthetic design. J Shoulder Elbow Surg. 2002;11(4): Hempfing A, Leunig M, Ballmer FT, Hertel R. Surgical landmarks to determine humeral head retrotorsion for hemiarthroplasty in fractures. J Shoulder Elbow Surg. 2001;10(5): Epoca Shoulder Arthroplasty System Fracture Technique Guide Synthes 59

62 60 Synthes Epoca Shoulder Arthroplasty System Fracture Technique Guide

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64 Synthes GmbH Eimattstrasse 3 CH-4436 Oberdorf Ö öAF2ä This publication is not intended for distribution in the USA. All surgical techniques are available as PDF files at Synthes GmbH All rights reserved AF DSEM/TRM/0714/ /2014