tornier aequalis press-fit · preoperative planning ... its stepped surface geometry maximizes bone...

S U R G I C A L T E C H N I Q U E

TORNIER

AEQUALIS™ PRESS-FITShoulder System

SURGICAL TECHNIQUE

Table of Contents: Rationale of the AEQUALIS™ Press-Fit Prosthesis .........................................................................................3

The AEQUALIS™ Press-Fit Prosthesis ................................................................................................................4

Surgical Technique ...............................................................................................................................................5

1. Preoperative planning .....................................................................................................................................5

2. Patient positioning ...........................................................................................................................................5

3. Delto-pectoral approach ................................................................................................................................6

4. Humeral head osteotomy ............................................................................................................................ 10

5. Reaming the humeral shaft ........................................................................................................................ 12

6. Choice of humeral inclination and retroversion ................................................................................... 13

7. Metaphyseal preparation ............................................................................................................................ 15

8. Trial humeral implant positioning and choice of the humeral head offset ................................. 16

9. Determination of the trial head size ........................................................................................................ 18

10. Humeral implant assembly and positioning ........................................................................................ 21

11. Reduction of the glenohumeral joint and closure ............................................................................. 11

Instruments ......................................................................................................................................................... 23

Implants ............................................................................................................................................................... 26

2

Rationale of the AEQUALIS™ Press-Fit Prosthesis

Glenohumeral arthritis is characterized by persistent pain, loss of glenohumeral motion and loss of glenohumeral joint space.

Prosthetic replacement of the glenohumeral joint seeks to relieve pain and restore normal kinematics and biomechanics.

Due to the relatively fixed geometry of first and second generation shoulder prosthesis, the possibilities to reproduce the normal kinematics of the glenohumeral joint are limited and often result in abnormal or reverse scapulo-humeral rhythm.

By anatomically reconstructing the proximal humerus, normal kinematics and biomechanics can be restored allowing for normal scapulo-humeral rhythm. Due to the highly variable anatomy of the proximal humerus, it is necessary to utilize a prosthesis, which takes into account the normal spherical shape of the humeral head along with the variable inclination, retroversion and combined medial and posterior offsets of the humeral head replacement in order to adapt the prosthesis to the individual patient’s anatomy.

The AEQUALIS™ prosthesis is the first third generation shoulder prosthesis. It is not only modular without the gap between the collar and the head, but also adaptable to allow restoration of the patient’s healthy anatomy and maintain the normal superior profile*.

The AEQUALIS™ Press-Fit Shoulder Prosthesis is specifically designed for long term stability of the humeral component. Its stepped surface geometry maximizes bone support for an optimal primary fixation and secondary fixation. The unique instrumentation allows compacting of the metaphyseal bone to give added support to the prosthesis and to prevent distal migration. Compaction grafting along the calcar increases the press-fit helping to avoid postoperative subsidence.

The stem is available in five diameters. 7, 9, 11, 13 and 15 mm. Four neck angles of 125, 130, 135 and 140 degrees allow the humeral implant to be better adapted to the humeral resection surface.

Ten articular heads are available, corresponding to the anatomical variations encountered in practice. Diameter and thickness are related, each corresponding to the anatomical variations.

For the largest three sizes, 50, 52 and 54 millimeters diameters, two thicknesses are available.

It is possible to reproduce the combined offset of the articular surface, medial and posterior offsets, by means of an original eccentric dial system.

* Adaptability and modularity of shoulder prosthesis. P. Boileau and Gilles Walch

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The AEQUALIS™ Press-Fit ProsthesisDesigned to reproduce the anatomy.

• Unique stair-step metaphyseal geometry for strong primary and long term fixation

• Grit blasted surface

• Titanium polished stem: 7, 9, 11, 13, 15 ø mm.

• Widebody metaphyseal segment

• Adaptable humeral head

• Cobalt chromium alloy

Eccentric dial heads system

Variable inclination neck

4

Figure 1: The whole arm is draped free and prepared under sterile conditions.

Surgical Technique

1. Preoperative planning

• Four plain shoulder A-P x-rays: neutral, internal rotation, external rotation and axillary.

• CT Scan for the most accurate assessment of glenoid version.

• Arthrography with contrast to confirm integrity of the rotator cuff if there is a clinical question about the cuff integrity.

2. Patient positioning

General anesthesia modified beach chair position (Figure 1).

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SURGICAL TECHNIQUE

(fig. 1)The entire arm is draped free

and prepared under sterile conditions.

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247803.qxp:TO_PRESS FIT_UDST061_inter.qxd 4/18/08 9:35 AM Page 17

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3. Delto-pectoral approach

An incision is made from the coracoid along the Deltopectoral groove, lateral to the axillary fold to avoid a postoperative contracture (Figure 2).

The Delto-pectoral interval is developed (Figure 3).

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3 Delto-pectoral approach

An incisionis made from the coracoid alongpectoral groove, lateral to the axillary foldpostoperative contracture (fig. 2).



Coracoid

Figure 2

Deltoid and cephalic vein

Pectoralis major

Figure 3: As necessary, a partial release of the anterior deltoid insertion facilitates deltoid retraction.

6

The upper border of the subscapularis is identified. Theclavi-pectoral fascia is released up to the coracoidbetween the coracoacromial ligament and the conjoinedtendon of the coracobrachialis and short head of thebiceps brachii muscles (fig. 4).

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7



Coracoacromial ligament

Conjoined tendon

Long head of the biceps

Pectoralis major

Subscapularis

Subscapularis

The upper border of the subscapularis is identified. The clavi-pectoral fascia is released up to the coracoid between the coracoacromial ligament and the conjoined tendon of the coracobrachialis and short head of the biceps brachii muscles (Figure 4).

Inspect the bicipital groove to remove any osteophytes, loose bodies or excessive biceps tenosynovian. Move the biceps laterally (on the left) to check the groove.


7



Figure 4: Arm in abduction, rotated externally with an angled retractor placed above the coracoid process.

Figure 5: Arm abducted and internally rotated. The long head of the biceps is exposed. The pectoralis insertion occasionally needs to be incised 1 or 2 cm.

IDENTIFICATION OF THE AXILLARY NERVE

RELEASE

8



7

Identification of the Axillary Nerve (Figure 6)

Subscapularis Tendon Release

• The upper limit of the subscapularis tendon, which is often covered by an extension of the subcoracoid serous bursa, lies immediately below the tip of the coracoid process (Figure 7).

• The inferior border is defined by the anterior circumflex vessels.

Figure 6: Arm in neutral rotation, elbow at side, with anterior flexion to loosen the anterior structure (coraco-biceps).

Coracobrachialis short head of biceps

Pectoralis major


RELEASE

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RELEASE

8




RELEASE

8



SupraspinatusOpen the rotator interval from the glenoid to the top of the lesser tuberosity

Lesser tuberosity

Greater tuberosity

Subscapularis

Biceps groove. Long head of the biceps

Circumflex vessels

Figure 7: Arm externally rotated, elbow towards the body. the coraco-humeral ligament marks the upper medial border of the subscapularis; the lower border is defined by the anterior circumflex vessels

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Lesser tuberosity

Greater tuberosity

A modified Mason-Allen interlocking suture is placed at the top corner of the subscapularis adjacent to the rotator interval (Figure 8).

After opening the rotator interval, the anterior subscapularis is incised 1 cm medial to its insertion on the lesser tuberosity. Then, with a progressive rotation of the arm, the inferior capsule is released up to the posterior aspect of the humeral head (Figure 9). The release of the upper pectoralis and latissimus dorsi tendons facilitates the exposure and release of the inferior glenohumeral capsule.

Superior arthrotomy: the coraco-humeral ligament is preserved.

Mason-Allen interlocking suture technique

Figure 8

Figure 9

9

A modified Mason-Allen interlocking suture is placed atthe top corner of the subscapularis adjacent to the rotatorinterval (fig. 8).

1

2

3

4 5

6



9


1

2

3

4 5

6



9


1

2

3

4 5

6



Superior part of subscapularis

The inferior release is a key step for adequate glenoid release.

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An anterior capsulotomy is performed with a release of the middle and inferior glenohumeral ligament to mobilize the muscle and produce a long flap of subscapularis which allows tension-free reinsertion following the procedure, regardless of the position of the arm (Figure 10).

With these adequate releases, the humeral head is dislocated into the delto-pectoral interval by abduction of the arm progressive external rotation extension. In cases of severe restriction of external rotation (0° or less), it is recommended to release more of the pectoralis insertion.

4. Humeral head osteotomy

All osteophytes are carefully trimmed from the humeral head. It is recommended to use a curved osteotome to separate the interval between the osteophyte and the cortical bone.

The osteotome is placed inferiorly and directed upwards. The goal is to identify the exact capsular insertion at the anatomic neck.

If additional exposure is necessary to visualize the superior articular margin, a curved awl or sharp Hohmann is placed under the long head of the biceps and through the supraspinatus attachment to retract both. The cut is then marked with a bovie.

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An anterior capsulotomy is performed with a release of themiddle and inferior glenohumeral ligament to mobilize themuscle and produce a long flap of subscapularis whichallows tension-free reinsertionregardless of the position

the humeral head is interval of

rotation In rotation (0° or less), it is

of the pectoralis insertion.

4 Humeral head osteotomy

All osteophytes are carefully trimmed from the humeralhead. It is recommended to use a curved osteotome toseparate the interval between the osteophyte and thecortical bone. The osteotome is placed inferiorly and directed upwards.The goal is to identify the exact capsular insertion at theanatomic neck.

If additional exposure is necessary to visualize thesuperior articular margin, a curved awl or sharp Hohmannis placed under the long head of the biceps and throughthe supraspinatus attachment to retract both. The cut isthen marked with a bovie.



10










10










10










Fukuda Darrach

Long flap of subscapularis

Hohmann

Figure 10

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Superiorly and anteriorly, the anatomical neck contains the tendon insertions of the rotator cuff (supraspinatus and subscapularis), and inferiorly it is entirely continuous with the cartilage of the head and inferior cortical surface of the humerus. Posteriorly however, there is a 6 to 8 mm area which does not contain cartilage or tendon insertions; the cut should be made through the rim of the cartilage in a manner to preserve the posterior nonarticular bare area.

• The humeral head may be cut freehand (Figure 11):

• Or with a cutting guide using an oscillating saw along the limit of the anatomical neck (Figure 12 & 13):

Superiorly and anteriorly, the anatomical neck containsthe tendon insertions of the rotator cu� (supraspinatusand subscapularis), and inferiorly it is entirely continuouswith the cartilage of the head and inferior corticalsurface of the humerus. Posteriorly however, there is a 6to 8 mm area which does not contain cartilage or tendoninsertions; the cut should be made through the rim of thecartilage in a manner to preserve the posterior non-articular bare area.

• The humeral head may be cut freehand (fig. 11):

• Or with a cutting guide using an oscillating saw alongthe limit of the anatomical neck (fig. 12 & 13):

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1

2

3

The cutting guide is positioned around theneck. The two fixation hooks are securely fixedaround the neck by first tightening the adjustment knob followed by knob . Firm three pointthen achieved by inserting the 3 mm guide pinguide into the humeral head .

The oscillating saw is thenused flat on the cutting guide.

(fig. 13)

(fig. 12)






11

1

2

3



(fig. 13)

(fig. 12)






11

1

2

3



(fig. 13)

(fig. 12)



Figure 11

Figure 12: The cutting guide is positioned around the anatomical neck. The two fixation hooks are securely fixed around the neck by first tightening the adjustment knob 1 followed by knob 2. Firm three point fixation is then achieved by inserting the 3 mm guide pin through the guide into the humeral head 3.

Figure 13: The oscillating saw is then used flat on the cutting guide.

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5. Reaming the humeral shaft

Accurate visualization of the plane through which the humerus is cut (Figure 14) allows the hinge point to be located. Typically, the entrance point into the humeral canal is 3 mm medial from this point (to prevent damage to the greater tuberosity). The hinge point is defined as the intersection of the proximal metaphyseal humeral axis and the highest point of the cut described previously (Figure 15).

The arm is placed in extreme external rotation, with the elbow towards the body utilizing careful progressive reaming to avoid the risk of a spiral fracture.

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5 Reaming the

Accurate visualizationhumerus is cut (fig.located. Typically, thecanal is 3 mm medialto the greaterthe intersection of theaxis and the highest(fig. 15).

The arm is placed inelbow towards thereaming to avoid the risk

2 mm



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5 Reaming the



2 mm



12

5 Reaming the



2 mm



12

5 Reaming the



2 mm



12

5 Reaming the



2 mm



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5 Reaming the



2 mm



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5 Reaming the



2 mm



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5 Reaming the



2 mm



In case the cut is too superior, the re-cutting guide may be used to remove an additional 2 mm.

1. Apply the guide on the humerus as shown.

2. Insert the pins. 3. Remove the cutting guide and rotate 180°

4. Reposition the guide on the pins.

5. Make the recut with the oscillating saw placed flat on the guide.

Figure 14

Hinge point

Figure 15

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The humeral shaft is progressively reamed using reamers of increasing diameter from 7, 9, 11, 13 to 15 mm (Figure 16).

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The reamer is inserted up to the collar.

The humeral shaft is progressively reamed using reamers of increasing diameter from 7, 9, 11, 13 to 15 mm (fig. 16).

Reaming is completed once initialcontact is made with the cortical bone

of the diaphysis.

(fig. 16)


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The reamer is inserted up to the collar.

The humeral shaft is progressively reamed using reamers of increasing diameter from 7, 9, 11, 13 to 15 mm (fig. 16).

Reaming is completed once initialcontact is made with the cortical bone

of the diaphysis.

(fig. 16)


Reaming is completed once initial contact is made with the cortical bone of the diaphysis.

Figure 16: The reamer is inserted up to the collar.

6. Choice of humeral inclination and retroversion

Once reaming of the humeral shaft has been completed, the final reamer used is left in the humerus. The inclination is then measured using the inclination guide (Figure 17). The inclination guide is then slid downwards and seated in the slots along the reamer.

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6 Choice of humeral inclination and retroversion

Once reaming of the humeral shaft has been completed,the final reamer used is left in the humerus. Theinclination is then measured using the inclination guide(fig. 17). The inclination guide is then slid downwards andseated in the slots along the reamer.


Figure 17

13

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The inclination is then assessed by reading the gradedscale on the guide (template) (fig. 18). There are 4 possibleinclinations, 125°, 130°, 135° and 140°.When the angle lies between two values, the lowershould be selected for the prosthesis.The mobile platemust sit flat on the anatomical cut. It may be necessary toslightly reorient the reamer using the handle to obtainoptimal positioning of the inclination guide.

Humeral retroversion is markedwith theby making a groove into the greater tuberosityretroversion osteotome (fig. 19). This groove willorient the compactor fin.

Remove the reamer and the inclination guide. Using asmall rongeur, notch the cortical bone at the level of thegroove to allow passage of the compactor fin (fig. 20).


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The inclination is then assessed by reading the gradedscale on the guide (template) (fig. 18). There are 4 possibleinclinations, 125°, 130°, 135° and 140°.When the angle lies between two values, the lowershould be selected for the prosthesis.The mobile platemust sit flat on the anatomical cut. It may be necessary toslightly reorient the reamer using the handle to obtainoptimal positioning of the inclination guide.

Humeral retroversion is markedwith theby making a groove into the greater tuberosityretroversion osteotome (fig. 19). This groove willorient the compactor fin.

Remove the reamer and the inclination guide. Using asmall rongeur, notch the cortical bone at the level of thegroove to allow passage of the compactor fin (fig. 20).


The inclination is then assessed by reading the graded scale on the guide (template) (Figure 18). There are 4 possible inclinations, 125°, 130°, 135° and 140°.

When the angle lies between two values, the lower should be selected for the prosthesis. The mobile plate must sit flat on the anatomical cut. It may be necessary to slightly reorient the reamer using the handle to obtain optimal positioning of the inclination guide.

Humeral retroversion is marked with the inclination guide by making a groove into the greater tuberosity with the retroversion osteotome (Figure 19). This groove will serve to orient the compactor fin.

Remove the reamer and the inclination guide. Using a small rongeur, notch the cortical bone at the level of the groove to allow passage of the compactor fin (Figure 20).

Figure 18

Figure 19

Figure 20

Fin

The monobloc compactors are used to prepare themetaphyseal bone (fig. 20).

Start with the compactor of the smallest size andprogress sequentially to the desired size. Retroversion isobserved by aligning the fin of the compactor with theslot created by the osteotome described previously.Compaction is completed when metaphyseal stability isobtained.

It is important to avoid varus prosthetic placement. This isaccomplished by positioning the compactor fin as farlaterally as possible into the greater tuberosity.

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16

7 Metaphyseal preparation

135°

The compactor should be seated to themeasured previously with theexample: for a 135° angle, stop when its(fig. 21).


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Figure 20: Push the compactor laterally while impacting. Impact on the axis of the compactor.

Fin

7. Metaphyseal preparation

The monobloc compactors are used to prepare the metaphyseal bone (Figure 20).

Start with the compactor of the smallest size and progress sequentially to the desired size. Retroversion is observed by aligning the fin of the compactor with the slot created by the osteotome described previously. Compaction is completed when metaphyseal stability is obtained.

It is important to avoid varus prosthetic placement. This is accomplished by positioning the compactor fin as far laterally as possible into the greater tuberosity.

The compactor should be seated to the neck angle measured previously with the inclination guide. For example: for a 135° angle, stop when its ridge is reached (Figure 21).




15

16


135°






15

16


135°






15

16


135°






15

16


135°



Figure 21

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8. Trial humeral implant positioning and choice of the humeral head offset

The humeral trial stem and trial neck are assembled. The trial neck chosen corresponds to the inclination determined with the inclination guide. The trial neck is slid onto the rail of the trial humeral stem (Figure 22). The system is secured by tightening the fixation screw with the 3.5 mm hexagonal screwdriver (Figure 23).

The trial stem-neck assembly is introduced into the prepared humeral shaft using the T-handle, taking care to observe the correct orientation of the fin (Figure 24). The T-handle is then removed.

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8 Trial humeral implant positioning and choice of the humeral head o�set

The humeral trial stem and trial neck are assembled. Thetrial neck chosen corresponds to the inclinationdetermined with the inclination guide. The trial neck isslid onto the rail of the trial humeral stem (fig. 22). Thesystem is secured by tightening the fixation screw withthe 3.5 mm hexagonal screwdriver (fig. 23).

The trial stem-neck assembly isprepared humeral shaft using theobserve the correct orientation of T-handle is then removed.


17





17





17





Figure 22

Figure 23

Figure 24

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It may be necessary to use the trial stem impactor to firmly seat the collar of the trial stem on the cut (Figure 25).

If the humeral trial prosthesis fits too low on the cutting surface or if there is insufficient bony support, it is recommended to either use an impaction grafting technique with bone from the humeral head or cement the prosthesis to the proper height.

In case of the necessity to cement the AEQUALIS™ stem, it is recommended that the same trial stem diameter as the optimal compactor be used.

If the trial stem of the chosen size is unstable it is recommended to cement.

Use the broach of the smaller diameter (7 mm) and progress sequentially to the desired size (Figure 26).

After positioning the trial head in an anatomic position, the entire trial prosthesis is then removed. Cement is injected into the canal after diaphyseal obturation and drying.

The definitive humeral implant is positioned and then impacted taking care to align the prosthetic fin with its slot in the tuberosity.

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It may be necessary to use the trial stem impactor to firmly seat the collar of the trial stem on the cut (fig. 25).

If the humeral trial prosthesis fits too low on the cuttingsurface or if there is insu�cient bony support, it isrecommended to either use an impaction graftingtechnique with bone from the humeral head or cementthe prosthesis to the proper height.

In case of the necessity to cement the Aequalis stem, it isrecommended that the same trial stem diameter as theoptimal compactor be used.If the trial stem of the chosen size is unstable it isrecommended to cement. Use the broach of the smaller diameter (7 mm) andprogress sequentially to the desired size (fig. 26).After positioning the trial head in an anatomic position, the entire trial prosthesis is then removed. Cementis injected into the canal after diaphyseal obturation anddrying. The definitive humeral implant is positioned and thenimpacted taking care to align the prosthetic fin with its slotin the tuberosity.


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It may be necessary to use the trial stem impactor to firmly seat the collar of the trial stem on the cut (fig. 25).

If the humeral trial prosthesis fits too low on the cuttingsurface or if there is insu�cient bony support, it isrecommended to either use an impaction graftingtechnique with bone from the humeral head or cementthe prosthesis to the proper height.

In case of the necessity to cement the Aequalis stem, it isrecommended that the same trial stem diameter as theoptimal compactor be used.If the trial stem of the chosen size is unstable it isrecommended to cement. Use the broach of the smaller diameter (7 mm) andprogress sequentially to the desired size (fig. 26).After positioning the trial head in an anatomic position, the entire trial prosthesis is then removed. Cementis injected into the canal after diaphyseal obturation anddrying. The definitive humeral implant is positioned and thenimpacted taking care to align the prosthetic fin with its slotin the tuberosity.


Optional

Direct laterally

Figure 25

Figure 26

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9. Determination of the trial head size

• Caliper or clamshell measurement of the diameter of the resected head (Figure 27).

• Directly on the trial head template (Figure 28).

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9 Determination of the trial head size

• Caliper or clamshell measurement of the diameter of the resected head (fig. 27).


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19




Humeral trial head

Clamp

Cut humeral head

Figure 27

Figure 28: 2 thicknesses are available for a 50, 52, or 54 mm diameter head.

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The next step is to reproduce the articular surface offset using the eccentric index system.

The trial head is held with the trial head clamp and placed over the neck trunion (Figure 29A).

The head is then rotated until the ideal coverage of the humeral neck cut is obtained (Figure 29B).

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The next step is to reproduce the articular surface o�setusing the eccentric index system.The trial head is held with the trial head clamp and placedover the neck trunion (fig. 29 A). The head is then rotated until the ideal coverage of thehumeral neck cut is obtained (fig. 29 B).

No seY


20


No seY


20


No seY


20


No seY


Figure 29A: Posterior offset is preserved by choosing the indexed position which allows perfect coverage of the humeral surface cut.

Trial neck

Figure 29B

Yes

No

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The entire trial prosthesis is then removed using the extractor-hammer. The posterior face of each trial head is marked from 1 to 8, corresponding to 8 possible index positions. The appropriate figure is read from the mark on the superior pole of the neck, to give the selected anatomical index (Figure 30).

Figure 30: Direct reading of anatomical index after removal of trial prosthesis (in this case index n° 4).

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The entire trial prosthesis is then removed using theextractor-hammer. The posterior face of each trial head ismarked from 1 to 8, corresponding to 8 possible indexpositions. The appropriate figure is read from the mark onthe superior pole of the neck, to give the selectedanatomical index(fig. 30).

IMPORTANT NOTEGLENOID REPLACEMENT MUST BE PERFORMED AT THIS POINT, IF NECESSARY.

PLEASE REFER TO THE AEQUALIS GLENOID SURGICAL TECHNIQUE.

1

2


21

The entire trial prosthesis is then removed using theextractor-hammer. The posterior face of each trial head ismarked from 1 to 8, corresponding to 8 possible indexpositions. The appropriate figure is read from the mark onthe superior pole of the neck, to give the selectedanatomical index(fig. 30).

IMPORTANT NOTEGLENOID REPLACEMENT MUST BE PERFORMED AT THIS POINT, IF NECESSARY.

PLEASE REFER TO THE AEQUALIS GLENOID SURGICAL TECHNIQUE.

1

2


IMPORTANT NOTE:Glenoid replacement must be performed at this point, if necessary. Please refer to the AEQUALIS™ Glenoid Surgical Technique.

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IMPORTANT NOTE:The head should be assembled to the implant stem with clean gloves in a dry environment.

10. Humeral implant assembly and positioning

After removing the trial humeral prosthesis, the final stem and head are chosen using the same parameters for diameter and inclination of the stem size and offset of the head.

The head is positioned on the stem, aligning the offset number with its position, using the fin of the implant stem as a reference (Figure 31).

Should a humeral head ever have to be removed, position the Humeral Head Removal instrument below the inferior part of the head and firmly tap with the mallet to loosen the head.

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10 Humeral implant assembly and positioning

After removing the trial humeral prosthesis, the final stemand head are chosen using the same parameters fordiameter and inclination of the stem size and o�set of thehead.The head is positioned on the stem,aligning the o�setnumber with its position, using the fin of the implant stemas a reference (fig. 31).

IMPORTANT NOTETHE HEAD SHOULD BE ASSEMBLED TO THE IMPLANT STEM

WITH CLEAN GLOVES IN A DRY ENVIRONMENT.

Should a humeral head ever have to be removed, positionthe Humeral Head Removal instrument below the inferiorpart of the head and firmly tap with the mallet to loosenthe head.


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10 Humeral implant assembly and positioning

After removing the trial humeral prosthesis, the final stemand head are chosen using the same parameters fordiameter and inclination of the stem size and o�set of thehead.The head is positioned on the stem,aligning the o�setnumber with its position, using the fin of the implant stemas a reference (fig. 31).

IMPORTANT NOTETHE HEAD SHOULD BE ASSEMBLED TO THE IMPLANT STEM

WITH CLEAN GLOVES IN A DRY ENVIRONMENT.

Should a humeral head ever have to be removed, positionthe Humeral Head Removal instrument below the inferiorpart of the head and firmly tap with the mallet to loosenthe head.


Figure 31

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The head is impacted onto the stem using the impaction support (Figure 32) with the head impactor and the mallet. Take care not to damage the articulating surface of the implant head.

At this stage, the long head of the biceps is cut from the superior glenoid and tenodesed into the groove. Three subscapularis sutures are preplaced through the lateral subscapularis and lesser tuberosity (Figure 33).

The prosthesis is then inserted. Proper orientation of the prosthesis during insertion is assured by positioning the fin into the groove prepared with the retroversion osteotome (Figure 34).

The prosthesis has to be impacted carefully into the medullary canal to avoid metaphyseal fracture.

11. Reduction of the glenohumeral joint and closure

Following reduction of the glenohumeral joint, the stability and mobility of the shoulder are tested. The joint is closed by reinsertion of the subscapularis to the coracohumeral ligament, and to the subscapular remnant, allowing slight slippage of the subscapularis upwards. The wound is closed in layers over an aspiration drain.

Postoperatively the arm is immobilized in a simple sling.

Figure 32: The impactor must be aligned with the morse taper.

Figure 33

Figure 34

Bone graft

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The head is impacted onto the stem using the impactionsupport (fig. 32) with the head impactor and the mallet.Take care not to damage the articulating surface of theimplant head.

11 Reduction of the glenohumeral joint and closure

Following reduction of the glenohumeral joint, thestability and mobility of the shoulder are tested. The jointis closed by reinsertion of the subscapularis to the coraco-humeral ligament, and to the subscapular remnant,allowing slight slippage of the subscapularis upwards.The wound is closed in layers over an aspiration drain.

Postoperativelythe arm is immobilized in a simple sling.

At this stage, the long head of the biceps is cut from thesuperior glenoid and tenodesed into the groove. Threesubscapularis sutures are preplaced through the lateralsubscapularis and lesser tuberosity (fig. 33).

The prosthesis is then inserted. Proper orientation of theprosthesis during insertion is assured by positioning thefin into the groove prepared with the retroversionosteotome (fig. 34).The prosthesis has to be impacted carefully into themedullary canal to avoid metaphyseal fracture.

Note: In case of impingement of the stem in the medullarycanal, the stem should be removed and a stem of asmaller diameter should be cemented.


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Note: In case of impingement of the stem in the medullary canal, the stem should be removed and a stem of a smaller diameter should be cemented.

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Instruments

50 cm RulerRef. MWA123

AwlRef. MWA024

Humeral Cutting GuideRef. MWB065

3 mm Guide PinsRef. MJU051

2 mm Humeral Re-Cutting GuideRef. MWB066

Cylindrical Reamers

Inclination GuideRef. MWB058

Retroversion OsteotomeRef. MWA101

Monobloc Compactors

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INSTRUMENTS

Cylindrical Reamers

Ø 7 Ref. MWB059Ø 9 Ref. MWB060Ø 11 Ref. MWB061Ø 13 Ref. MWB062Ø 15 Ref. MWB063

Inclination Guide Ref. MWB058

Ref.

Monobloc Compactors

Ø 7 Ref. MWB 050Ø 9 Ref. MWB 051Ø 11 Ref. MWB 052Ø 13 Ref. MWB 053Ø 15 Ref. MWB 054

50 cm Ruler Ref. MWA 123

AwlRef. MWA 024

Humeral Cutting GuideRef. MWB 065

3 mm Guide Pins Ref. MJU 051

2 mm HumeralRe-Cutting Guide Ref. MWB 066

2 3 4 5 6 7 8 9 10 1112 13 14 15 16 17 18 19 20 21 22 23 24 25 30 35 40

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INSTRUMENTS

Cylindrical Reamers


Inclination Guide Ref. MWB058

Ref.

Monobloc Compactors

Ø 7 Ref. MWB 050Ø 9 Ref. MWB 051Ø 11 Ref. MWB 052Ø 13 Ref. MWB 053Ø 15 Ref. MWB 054

50 cm Ruler Ref. MWA 123

AwlRef. MWA 024

Humeral Cutting GuideRef. MWB 065

3 mm Guide Pins Ref. MJU 051

2 mm HumeralRe-Cutting Guide Ref. MWB 066

2 3 4 5 6 7 8 9 10 1112 13 14 15 16 17 18 19 20 21 22 23 24 25 30 35 40

9


Ø 7 Ref. MWB059

Ø 9 Ref. MWB060

Ø 11 Ref. MWB061

Ø 13 Ref. MWB062

Ø 15 Ref. MWB063

Ø 7 Ref. MWB050

Ø 9 Ref. MWB051

Ø 11 Ref. MWB052

Ø 13 Ref. MWB053

Ø 15 Ref. MWB054

23

Trial Stems

Trial Necks

Hexagonal Screwdriver 4.5 mmRef. MWB012

T. handle Trial Stem HolderRef. MWA106

Trial Stem ImpactorRef. MWA109

Trial Heads

Trial Head Template

CaliperRef. MWA102

Trial Head ClampRef. MWA103

Instruments

Ø 7 Ref. MWB020

Ø 9 Ref. MWB021

Ø 11 Ref. MWB022

Ø 13 Ref. MWB023

Ø 15 Ref. MWB024

37 x 13.5 mm Ref. MWA237

39 x 14 mm Ref. MWA239









125° Ref. MWB016

130° Ref. MWB017

135° Ref. MWB018

140° Ref. MWB019

25

INSTRUMENTS

Trial Heads

37 x 13.5 mm Ref. MWA237

39 x 14 mm Ref. MWA23941 x 15 mm Ref. MWA24143 x 16 mm Ref. MWA24346 x 17 mm Ref. MWA24648 x 18 mm Ref. MWA24850 x 16 mm Ref. MWA25050 x 19 mm Ref. MWA25152 x 19 mm Ref. MWA25252 x 23 mm Ref. MWA253

Trial Head Template

CaliperRef. MWA102


Trial Stems

Ø 7 mm Ref. MWB 020

Ø 9 mm Ref. MWB 021Ø 11 mmRef. MWB 022Ø 13 mmRef. MWB 023Ø 15 mmRef. MWB 024

Trial Necks

125° Ref. MWB016

130° Ref. MWB017135° Ref. MWB018140° Ref. MWB019

Hexagonal Ref.

T. handle Ref. MWA106

TrialRef.

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20


25

INSTRUMENTS

Trial Heads

37 x 13.5 mm Ref. MWA237


Trial Head Template

CaliperRef. MWA102


Trial Stems



Trial Necks

125° Ref. MWB016


Hexagonal Ref.


TrialRef.

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20


25

INSTRUMENTS

Trial Heads

37 x 13.5 mm Ref. MWA237


Trial Head Template

CaliperRef. MWA102


Trial Stems



Trial Necks

125° Ref. MWB016


Hexagonal Ref.


TrialRef.

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20


25

INSTRUMENTS

Trial Heads

37 x 13.5 mm Ref. MWA237


Trial Head Template

CaliperRef. MWA102


Trial Stems



Trial Necks

125° Ref. MWB016


Hexagonal Ref.


TrialRef.

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20


25

INSTRUMENTS

Trial Heads

37 x 13.5 mm Ref. MWA237


Trial Head Template

CaliperRef. MWA102


Trial Stems



Trial Necks

125° Ref. MWB016


Hexagonal Ref.


TrialRef.

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20


25

INSTRUMENTS

Trial Heads

37 x 13.5 mm Ref. MWA237


Trial Head Template

CaliperRef. MWA102


Trial Stems



Trial Necks

125° Ref. MWB016


Hexagonal Ref.


TrialRef.

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20


24

Humeral Broaches(for cemented use only)

Humeral Broach Handle(for cemented use only)Ref. MWB015

Humeral Cut Protectors

Extractor HammerRef. MWA118

Humeral Prosthesis ImpactorRef. MWA108

Impaction SupportRef. MWB013

MalletRef. MWA122

Head Removal InstrumentRef. MWB067

Instruments

Ø 7 Ref. MWB034

Ø 9 Ref. MWB035

Ø 11 Ref. MWB036

Ø 13 Ref. MWB037

Ø 15 Ref. MWB038

125° Ref. MWB025

130° Ref. MWB026

135° Ref. MWB027

140° Ref. MWB028

26

Humeral Ref. MWA108

Impaction Ref. MWB013

MalletRef. MWA122

Head Ref. MWB 067

Humeral Broaches (for cemented use only)




125° Ref. MWB025130° Ref. MWB026135° Ref. MWB027140° Ref. MWB028

Extractor HammerRef.

INSTRUMENTS


26

Humeral Ref. MWA108


MalletRef. MWA122

Head Ref. MWB 067







INSTRUMENTS


26

Humeral Ref. MWA108


MalletRef. MWA122

Head Ref. MWB 067







INSTRUMENTS


25

Implants

125° 130° 135° 140° Lengths

Ø 7 DWB701 DWB702 DWB703 DWB704 115 mm






Humeral Stems

Heads

Extended Sizes (available upon request only)

Heads

Size Ref.

37 x 13.5 mm DWB237

39 x 14 mm DWB239

41 x 15 mm DWB241

43 x 16 mm DWB243

46 x 17 mm DWB246

48 x 18 mm DWB246

50 x 16 mm DWB250

50 x 19 mm DWB251

52 x 19 mm DWB252

52 x 23 mm DWB253

Size Ref.

54 x 23 mm DWB254

54 x 27 mm DWB255

IMPLANTS

Heads

Size Ref.37 x 13.5 mm DWB 23739 x 14 mm DWB 23941 x 15 mm DWB 24143 x 16 mm DWB 24346 x 17 mm DWB 24648 x 18 mm DWB 24650 x 16 mm DWB 25050 x 19 mm DWB 25152 x 19 mm DWB 25252 x 23 mm DWB 253

Heads

Size Ref.54 x 23 mm DWB25454 x 27 mm DWB255

Extended sizes(available upon special request only)

The length is given fromthe top of the fin to the distalend of the stem.

Humeral Stems

ø 125° 130° 135° 140° Lengths7 DWB 701 DWB 702 DWB 703 DWB 704 115 mm

9 DWB 711 DWB 712 DWB 713 DWB 714 115 mm 11 DWB 721 DWB 722 DWB 723 DWB 724 115 mm 13 DWB 731 DWB 732 DWB 733 DWB 734 125 mm 15 DWB 741 DWB 742 DWB 743 DWB 744 125 mm 17 DWB 751 DWB 752 DWB 753 DWB 754 125 mm

This surgical technique has been developedin conjunction with TOM NORRIS, M.D.,

(SAN FRANCISCO)

IMPLANTS

Heads

Size Ref.37 x 13.5 mm DWB 23739 x 14 mm DWB 23941 x 15 mm DWB 24143 x 16 mm DWB 24346 x 17 mm DWB 24648 x 18 mm DWB 24650 x 16 mm DWB 25050 x 19 mm DWB 25152 x 19 mm DWB 25252 x 23 mm DWB 253

Heads

Size Ref.54 x 23 mm DWB25454 x 27 mm DWB255

Extended sizes(available upon special request only)

The length is given fromthe top of the fin to the distalend of the stem.

Humeral Stems

ø 125° 130° 135° 140° Lengths7 DWB 701 DWB 702 DWB 703 DWB 704 115 mm

9 DWB 711 DWB 712 DWB 713 DWB 714 115 mm 11 DWB 721 DWB 722 DWB 723 DWB 724 115 mm 13 DWB 731 DWB 732 DWB 733 DWB 734 125 mm 15 DWB 741 DWB 742 DWB 743 DWB 744 125 mm 17 DWB 751 DWB 752 DWB 753 DWB 754 125 mm

This surgical technique has been developedin conjunction with TOM NORRIS, M.D.,

(SAN FRANCISCO)

The length is given from the top of the fin to the distal end of the stem.

26

Notes

27

1023 Cherry RoadMemphis, TN 38117800 238 7117901 867 9971www.wright.com

10801 Nesbitt Avenue SouthBloomington, MN 55437888 867 6437952 426 7600www.tornier.com

Proper surgical procedures and techniques are the responsibility of the medical professional. This material is furnished for information purposes only. Each surgeon must evaluate the appropriateness of the material based on his or her personal medical training and experience. Prior to use of any Tornier implant system, the surgeon should refer to the product package insert for complete warnings, precautions, indications, contraindications, and adverse effects. Package inserts are also available by contacting Wright. Contact information can be found in this document and the package insert.

™ and ® denote Trademarks and Registered Trademarks of Wright Medical Group N.V. or its affiliates.©2016 Wright Medical Group N.V. or its affiliates. All Rights Reserved.

CAW-4702 Rev A ECN 160681 21-Jun-2016

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