Versys Fiber Metal Taper Hip Prosthesis Surgical Technique
Versys Fiber Metal Taper Hip Prosthesis Surgical Technique
 Surgical Technique
VerSys® Fiber Metal Taper Hip Prosthesis Surgical Technique                                              1
                                     Surgical Technique	                                            5
                                        Incision	                                                   5
                                        Exposure of the Hip Joint	                                  5
                                        Determination of Leg Length	                                5
                                        Osteotomy of the Femoral Neck	                              5
                                        Preparation of the Femur	                                   7
                                        Intramedullary Reaming (Optional)	                          8
                                        Attachment of the Rasp Alignment Tip (Optional)	           10
                                        Femoral Rasping	                                           10
                                        Trial Reduction	                                           11
                                        Insertion of the Femoral Component	                        12
                                        Attachment of the Femoral Head	                            12
                                        Wound Closure	                                             12
Postoperative Management 12
Determination of Abductor                   Component Size Selection/                  Large patients and obese patients
Muscle Tension and Femoral                  Templating                                 may have magnification greater than
Offset                                      Preoperative planning for insertion        20 percent because their osseous
Once the requirements for establishing      of a cementless femoral component          structures are farther away from the
the desired postoperative leg length        requires at least two views of the         surface of the film. Similarly, smaller
have been decided, the next step is to      involved femur; an anterior/posterior      patients may have magnification less
consider the requirement for abductor       (A/P) view of the pelvis centered at the   than 20 percent. To better determine
muscle tension. When the patient has        pubic symphysis, and a frog leg lateral    the magnification of any x-ray film, use
a very large offset between the center      view on an 11x17-inch cassette. Both       a standardized marker at the level of
of rotation of the femoral head and the     views should show at least 8 inches of     the femur. (Templates of 15 and 10
line that bisects the medullary canal,      the proximal femur. In addition, it may    percent magnification can be obtained
the insertion of a femoral component        be helpful to obtain an A/P view of the    by special order.)
with a lesser offset will, in effect,       involved side with the femur internally
                                                                                       Preoperative planning is important
medialize the femoral shaft. To the         rotated. This compensates for
                                                                                       in choosing the optimal acetabular
extent that this occurs, laxity in the      naturally occurring femoral anteversion
                                                                                       component, and in providing an
abductors will result.                      and provides a more accurate
                                                                                       estimation of the range of acetabular
                                            representation of the true medial to
VerSys Fiber Metal Taper stems are                                                     components that might ultimately be
                                            lateral dimension of the metaphysis.
offered in two offsets (standard and                                                   required.
extended) in a 135-degree neck angle.       When templating, magnification of
                                                                                       The initial templating begins with the
This versatility in offset and length       the femur will vary depending on the
                                                                                       A/P roentgenogram. Superimpose the
enables the surgeon to reproduce            distance from the x-ray source to the
                                                                                       acetabular templates sequentially on
almost any offset encountered.              film, and the distance from the patient
                                                                                       the pelvic x-ray with the acetabular
                                            to the film. The VerSys Hip System
Although rare, it may not be possible                                                  component in approximately 40
                                            templates (Fig. 1) use standard 20
to restore offset in patients with an                                                  degrees of abduction. Range of motion
                                            percent magnification, which is near
unusually large preoperative offset or                                                 and hip stability are optimized when
                                            the average magnification on most
with a severe varus deformity. In such                                                 the socket is placed in approximately
                                            clinical x-rays.
cases, the tension in the abductors can                                                35 to 45 degrees of abduction. Assess
be increased by lengthening the limb, a                                                several sizes to estimate which
method that is especially useful when                                                  acetabular component will provide the
the involved hip is short. If this option                                              best fit for maximum coverage. In most
is not advisable and if the disparity is                                               cases, select the largest component
great between the preoperative offset                                                  possible, being certain that the
and the offset achieved at surgery by                                                  outside diameter isn't too large to seat
using the longest head-neck implant                                                    completely in the acetabulum. (Refer to
possible, some surgeons may choose                                                     the various Zimmer Acetabular System
to osteotomize and advance the greater                                                 surgical techniques for specific details
trochanter to eliminate the slack in the                                               on acetabular reconstruction.)
abductor muscles. Technical variations
in the placement of the acetabular
components can also reduce the
differences in offset.
                                            Fig. 1
4   VerSys® Fiber Metal Taper Hip Prosthesis Surgical Technique
    Consider the position and thickness         The specific objectives in templating      Next, check the fit of the stem on the
    of the acetabular component in              the femoral component include:             lateral x-ray. If the lateral x-ray reveals
    estimating the optimum femoral neck                                                    that the A/P dimension of the isthmus
                                                1)	 determining the anticipated size of
    length to be used. (To simplify this, the                                              is greater than the medial-lateral (M/L)
                                                    the implant to be inserted, and
    acetabular templates are on a separate                                                 dimension shown on the A/P film,
    acetate sheet from the femoral              2)	 determining the height of the          it may be advantageous to increase
    templates.) Mark the acetabular size            implant in the femur and the           the size of the stem to better fill the
    and position, and the center of the             location of the femoral neck           isthmus. Template the next larger size
    head on the x-rays. This allows any             osteotomy. Now select the              femoral component on the A/P x-ray to
    femoral component to be matched                 appropriate femoral template.          determine the amount of cortical bone
    with the desired acetabular component           The VerSys Fiber Metal Taper Hip       that would be removed by reaming to
    by placing the femoral template over            Prosthesis is available in twelve      this size. The cortical thickness of the
    the acetabular template. This will              standard body sizes (9 through         walls must be great enough to allow
    provide the best estimation of femoral          20mm) and ten large metaphyseal        for additional reaming. If a larger
    component size and head-neck length             (LM) sizes (11 through 20mm).          stem would better fill the isthmus, it
    necessary to achieve the correct leg                                                   is preferable to insert the larger stem.
                                                The femoral templates show the neck
    length.                                                                                This can be accomplished by enlarging
                                                length and offset for each of the head/
                                                                                           the isthmus in the M/L dimension with
    The VerSys Hip System includes several      neck combinations (-3.5 to +10.5mm,
                                                                                           intramedullary drills. When a larger
    head diameters. In most patients with       depending on head diameter). Note
                                                                                           size is chosen to better fill the isthmus
    an average-sized acetabulum, consider       that skirts are present on +10.5mm
                                                                                           on the lateral x-ray, reevaluate the A/P
    a femoral head with an intermediate         heads, and on the +3.5mm size 22mm
                                                                                           x-ray to ensure that the fit of the
    diameter, such as 28mm or 32mm. The         head.
                                                                                           proximal and distal bodies is
    intermediate femoral heads allow the
                                                To estimate the femoral implant size,      acceptable.
    use of an acetabular component with
                                                assess both the distal stem size and
    an outside diameter small enough to                                                    Careful attention during this process
                                                the body size on the A/P radiograph,
    seat completely in the bone while also                                                 helps the surgeon achieve the goal
                                                and then check the stem size on the
    allowing for a polyethylene liner of                                                   of implanting a stem that will provide
                                                lateral radiograph. Superimpose
    sufficient thickness.                                                                  maximum stability and contact with the
                                                the template on the isthmus and
                                                                                           host bone.
    In special circumstances, such as           estimate the appropriate size of
    the treatment of small patients             the femoral stem. The stem of the
    and patients with congenital hip            femoral component should fill, or
    dysplasia and small acetabular              nearly fill, the medullary canal in the
    volume, it is preferable to use a 22mm      isthmus area on the A/P x-ray film.
    diameter head to allow for adequate         Next, assess the fit of the body in the
    polyethylene thickness.                     metaphyseal area. The medial portion
                                                of the body of the component should
                                                fill the proximal metaphysis as fully as
                                                possible, compatible with the anatomic
                                                endosteal contours of that region.
 VerSys® Fiber Metal Taper Hip Prosthesis Surgical Technique                                                                         5
After establishing the proper size of         Surgical Technique                          Osteotomy of the Femoral Neck
the femoral component, determine                                                          A common technical error in total
the height of its position in the                                                         hip replacement surgery is insertion
proximal femur and the amount of              Incision                                    of the femoral component in a varus
offset needed to provide adequate             In total hip arthroplasty, exposure         position. The likelihood of this error
abductor muscle tension. Generally, if        can be achieved through a variety           can be reduced if visualization of the
the leg length and offset are to remain       of methods based on the surgeon’s           posterior femoral neck is improved.
unchanged, the center of the head of          preference. The VerSys Fiber Metal          To accomplish this, remove all of
the prosthesis should be at the same          Taper Hip Prosthesis can be implanted       the remaining soft tissue from the
level as the center of the femoral head       using most surgical approaches.             posterior femoral neck, exposing the
of the patient’s hip. This should also                                                    intertrochanteric crest and the junction
correspond to the center of rotation                                                      between the femoral neck and greater
of the templated acetabulum. To               Exposure of the Hip Joint                   trochanter. Release some of the
lengthen the limb, raise the template         Develop the exposure of the posterior       inferior capsule to expose the lesser
proximally. To shorten the limb, shift        capsule. To facilitate this, place          trochanter. When the ideal position
the template distally. The extended           the leg in internal rotation. The key       of the appropriately selected femoral
offset option offers lateral translation of   landmark for division of the short          component was determined during the
5mm. This allows for an offset increase       external rotators is the tendon of          preoperative planning, the distance
of 5mm without changing the vertical          the piriformis muscle. This tendon          between the top surface of the lesser
height or leg length. The femoral head        runs parallel to the posterior border       trochanter and the level of the collar
lengths will also affect leg length and       of the gluteus medius and can be            was noted. In the example used, this
offset.                                       readily palpated as it approaches the       measurement was 15mm. Use this
                                              posterior superior portion of the greater   information to determine the level for
Once the height has been determined,          trochanter. Retract the gluteus medius      the femoral neck osteotomy.
note the distance in millimeters from         superiorly and identify the tendon of
the underside of the collar to the top        the piriformis.
of the lesser trochanter by using the
millimeter scale on the template. For
example, one might decide from the            Determination of Leg Length
templating that a 52mm OD socket,             Establish landmarks and obtain
with a size 15 prosthesis and a +3.5 x        measurements before dislocation of
28mm diameter femoral head, placed            the hip so that, after reconstruction, a
15mm above the lesser trochanter, are         comparison of leg length and femoral
the appropriate choices.                      shaft offset can be obtained. From this
                                              comparison, adjustments can be made
Proximal/distal adjustments in                to achieve the goals established during
prosthesis position can reduce the            preoperative planning. There are
need for a femoral head with a skirt.         several methods to measure leg length.
(The skirted heads allow less range           One method is to fix a leg length caliper
of motion than the non-skirted heads          to the wing of the ilium. Take baseline
which may increase the chance of              measurements to a cautery mark at the
dislocation.)                                 base of the greater trochanter while
                                              marking the position of the lower limb
                                              on the table.
6   VerSys® Fiber Metal Taper Hip Prosthesis Surgical Technique
This alignment of the Osteotomy Guide     bring it in from the superior portion       as viewed on the A/P and lateral
would be appropriate for most femurs      of the femoral neck to complete the         radiographs. This is usually in the area
that have a neck shaft angle of 135       osteotomy cut, or use an osteotome to       of the piriformis tendon insertion in the
degrees. However, if the femur has        finish the cut.                             junction between the medial trochanter
a neck shaft angle more than or less                                                  and lateral femoral neck. Use the Box
than 135 degrees, adjustments to                                                      Osteotome (Fig. 3), Trochanteric Router,
                                          Preparation of the Femur
the position of the Osteotomy Guide                                                   or Burr to remove this medial portion
                                          To appropriately insert the femoral
should be made. Since the desired                                                     of the greater trochanter and lateral
                                          prosthesis, adequate exposure of the
position, in the example used, of                                                     femoral neck.
                                          proximal femur must be obtained. The
the height of the femoral component
                                          femur should extend out of the wound,       The opening must be large enough for
is 15mm proximal to the top of the
                                          and soft tissue should be removed           the passage of each sequential Rasp to
lesser trochanter, adjust the template
                                          from the medial portion of the greater      ensure neutral rasp/implant alignment.
proximally and distally until that
                                          trochanter and lateral portion of the       However, the opening should not be
relationship has been established.
                                          femoral neck. It is crucial to adequately   significantly larger than the Rasp or
At that point, use electrocautery to
                                          visualize this area so the correct          implant. An insufficient opening may
inscribe a line across the femoral neck
                                          insertion site for femoral reaming can      result in varus stem positioning. Before
parallel to the under surface of the
                                          be located. Refer to the preoperative       using the next size Rasp, be sure that
Osteotomy Guide.
                                          planning at this point. Identify the mid-   the opening is large enough. If it is not,
Using the inscribed line as a guide,      femoral shaft extension intraoperatively    use the Box Osteotome again.
perform the osteotomy of the femoral
                                                                                      After removing the cortical bone, insert
neck. To prevent possible damage to
                                                                                      the Tapered Awl (Fig. 4) or Curette (Fig.
the greater trochanter, stop the cut
                                                                                      5) to open the medullary canal. This
as the saw approaches the greater
                                                                                      will provide a reference for the direction
trochanter. Remove the saw and either
                                                                                      of femoral rasping.
Fig. 6
     Attachment of the Rasp                       Femoral Rasping                            NOTE: Do not use the VerSys Enhanced
     Alignment Tip (Optional)                     Begin the rasping sequence with a          Taper Rasps (7892-09/19-50) to
     NOTE: The Rasp Alignment Tip is only         standard Rasp that is at least two sizes   implant the Fiber Metal Taper Hip
     necessary if intramedullary reaming is       smaller than the estimated implant         Prosthesis.
     performed.                                   size. The VerSys Fiber Metal Taper stem
                                                  should be implanted with the VerSys
     Before impacting a Rasp, attach the
                                                  System Rasps (7892-009/020), or LM
     Rasp Alignment Tip to the end of the
                                                  Rasps (7892-011/020-30) (Figs. 8a
     Rasp (Fig. 7a) ensuring that the tip
                                                  and 8b).
     is fully engaged with the distal rasp
     threads (Fig. 7b). The Rasp Alignment
     Tips are labeled to correspond with
     their mating Rasp (i.e., a 14mm
     Rasp requires a 14mm Rasp Tip).
     The purpose of the Rasp Alignment
     Tip is to centralize the Rasp within
     the reamed canal and minimize
     malalignment of the Rasp which may
                                                            a. System Rasp                    b. LM Rasp
     cause the prosthesis to be positioned
     in varus or valgus. The Rasp Alignment
     Tips measure 1mm in diameter less
     than their labeled size to maintain
     appropriate distal clearance with a
     femoral canal while still centralizing the
     rasp in a reamed canal.
a.
Fig. 8
b.
     Fig. 7
  VerSys® Fiber Metal Taper Hip Prosthesis Surgical Technique                                                                      11
When inserting the Rasp (Fig. 9), be         1.	 Progress to the next larger rasp        Trial Reduction
sure that it advances with each blow of          size. This is recommended for           Assemble the appropriately sized
the mallet. If the Rasp can be seated            cases where adequate cancellous         Porous/Enhanced Taper (POR/ET), or
at least 5mm below the osteotomy,                bone is available on the anterior       Extended Offset (EXT) Neck Provisional
progress to the next rasp size and               and posterior sides of the proximal     and Provisional Femoral Head to the
repeat until the predicted final rasp size       femur and the distal medullary          Rasp and perform a trial reduction
has been seated. If the predicted final          canal has enough room to accept         (Fig. 10).
rasp size can be countersunk more than           the next larger size rasp. The distal
                                                                                         Check the leg length and offset of
5mm and adequate cancellous bone is              canal may need to be reamed to a
                                                                                         the femur by referencing the lengths
available in the metaphysis region, two          larger diameter to accept the next
                                                                                         measured prior to dislocation of the
choices are available for improved fit:          size implant.
                                                                                         hip. It is important at this stage to
                                             2.	 Progress to the same size large         reposition the leg exactly where it was
                                                 metaphyseal (LM) Rasp. (LM              during the first measurement. Adjust
                                                 Rasps are available in sizes 11mm       the neck length by changing Provisional
                                                 through 20mm.) This option is           Femoral Heads to achieve the desired
                                                 recommended for cases where there       result. For the 28mm Femoral Head,
                                                 is at least 4mm of cancellous bone      the VerSys Hip System has five neck
                                                 medially and adequate cancellous        lengths (-3.5 to +10.5mm) which
                                                 bone on the anterior and posterior      provide a total range of 14mm of neck
                                                 sides of the implant. Additional        length. When satisfactory leg length,
                                                 reaming is not required to use the      offset, range of motion, and stability
                                                 corresponding LM implant.               have been achieved, dislocate the hip.
                                             NOTE: Once the LM Rasp has been
                                             inserted, a standard Rasp of any
                                             size cannot be used to prepare the
                                             canal and provide adequate fit with a
                                             standard implant.
Fig. 9                                                                                   Fig. 10
12   VerSys® Fiber Metal Taper Hip Prosthesis Surgical Technique
     Insertion of the Femoral                    The Rasps and corresponding implants         Attachment of the Femoral Head
     Component                                   are sized such that a press-fit is created   Once the implant is fully seated in
     Press the implant down the canal by         proximally. The most distal portion          the femoral canal, place the selected
     hand until it will no longer advance        of the porous surface (medial side) is       Femoral Head Provisional onto the
     (Fig. 11).                                  flush with the implant and gradually         taper of the implant. Perform a trial
                                                 increases to 0.5mm proud (per surface)       reduction to assess joint stability,
     Place the Stem Impactor in the implant
                                                 in the most proximal area. Thus, the         range of motion, and restoration
     insertion slot located on the stem
                                                 implant is 1mm larger than the Rasp          of leg length and offset. When the
     shoulder (Fig. 12). Begin to tap the
                                                 in both the A/P and M/L dimensions.          appropriate femoral head implant is
     Impactor Handle with a mallet until
                                                 This relationship can be seen on the         confirmed, remove the Femoral Head
     the prosthesis is fully seated or until
                                                 templates. Therefore when the implant        Provisional and check to ensure that
     the implant will no longer advance.
                                                 is seated, a 0.5mm press-fit per surface     the 12/14 taper is clean and dry. Then
     The prosthesis should be seated until
                                                 is achieved. Note that the metaphyseal       place the selected Femoral Head on the
     the most proximal part of the porous
                                                 press-fit engagement provides the            taper and secure it firmly by twisting
     surface is level with the osteotomy line.
                                                 implant with greater rotational stability    it and striking it once with the Head
     If the implant is not advancing with
                                                 than the Rasp.                               Impactor. Test the security of the head
     each blow of the mallet, stop insertion
                                                                                              fixation by trying to remove by hand.
     and remove the component. Then rasp
     or ream additional bone from the areas                                                   NOTE: Do not impact the Femoral Head
     that are preventing the insertion, and                                                   onto the taper before driving in the
     insert the component again.                                                              prosthesis as the Femoral Head may
                                                                                              loosen during impaction.
                                                                                              Wound Closure
                                                                                              After obtaining hemostasis, insert a
                                                                                              Hemovac® Wound Drainage Device
                                                                                              and close the wound in layers.
                                                                                              Postoperative
                                                                                              Management
                                                                                              The postoperative management of
                                                                                              patients with a VerSys Fiber Metal Taper
                                                                                              implant is determined by the surgical
                                                                                              technique, patient’s bone quality,
                                                                                              fit of the implant, and the surgeon’s
                                                                                              judgment.
     Fig. 11                                     Fig. 12
  VerSys® Fiber Metal Taper Hip Prosthesis Surgical Technique                                                                                                           13
                                                                                                        F
                                                                                                            D
                                                                                        LM
                                                A                                                                                  E
                                                                                                                               C
*The VerSys Fiber Metal Taper Hip Prosthesis is available with an HA/TCP coating. The product numbers for this option begin with a 65- prefix instead of a 00- prefix
This documentation is intended exclusively for physicians and is not intended for laypersons.
Information on the products and procedures contained in this document is of a general nature
and does not represent and does not constitute medical advice or recommendations. Because
this information does not purport to constitute any diagnostic or therapeutic statement with
regard to any individual medical case, each patient must be examined and advised individually,
and this document does not replace the need for such examination and/or advice in whole or
in part. Please refer to the package inserts for important product information, including, but not
limited to, contraindications, warnings, precautions, and adverse effects.
97-7862-102-00 Rev. 2 1012-H02 .5ML Printed in USA ©2001, 2005, 2007, 2011 Zimmer, Inc.