Surgical Technique Total Hip Arthroplasty
Contents
1. with a small screw or Bovie so that it can be easily reproduced Hold the tip of the Pointer steady on the marked point When the point is successfully taken a beep will sound This point will be used at the end of the procedure to measure change in leg length and offset ob wnitinaphew Ps Mark a point on the patella with an EKG lead non sterile sphere etc so that it can be easily reproduced Hold the tip of the Pointer steady on the marked point When the point is successfully taken a beep will sound This point will be used to determine the orientation of the femur when measuring leg length and offset Notes Measuring leg length and offset does not require navigation of the stem or placement of a femoral array Measurements are taken in reference to a single pelvic array Do not dislocate the femoral head before completing this step The greater trochanter and patella landmarks must be taken before dislocation to establish preoperative leg length and offset Acetabulum Registration 16 Points Option Locate Gastar of Acetaubers Skp as lt Hold the tip of the Pointer steady on 16 random points on the acetabular surface Each time a beep sounds move to the next point Each point must be at least 8mm away from the last point The 16 points should be taken around the entire hemisphere of the acetabular surface to create a more accurate acetabular sphere When the 16 points are comp2. Instrument Array to the selected Cup Impactor Attach the selected REFLECTION Cup to the Cup Impactor Enter the Cup diameter size on the screen Align the Cup to selected target values When the Cup is in the desired position impact the Cup Press the Lock command and remove the Cup Impactor from the seated Cup When Lock is pressed the computer will digitize the permanent position of the seated Cup The screen will display the abduction and anteversion angles of the implanted Cup as well as the Superior Inferior Medial Lateral and Anterior Posterior position in millimeters of the implants acetabular center relative to the digitized preoperative acetabular center Press the forward arrow to continue Note The Lock button must be pressed before the Cup Impactor is removed from the seated Cup Locking the seated Cup position is required in order to measure postoperative leg length and offset Media Onbortor S SE man If the Adjusted Anteversion option is used the screen will display adjusted anteversion in addition to regular anteversion on all navigation screens When positioning the Reamer and Cup Impactor the target value should be obtained in the regular Anteversion field not in the Adjusted Anteversion field When the Lock command is pressed the computer records the Cup as being permanently seated in the displayed position To verify that the Cup has not moved re attach the
3. can be used to save a screenshot at any time during the procedure z Archive Surgery Gata Eit LEESE km The Archive Surgery Data screen is used to save the surgery data on a CD The surgery data includes all screen snapshots taken during the procedure the position of bony landmarks and the surgical input parameters used for the procedure Insert a blank CD into the disk drive Press the Start command to burn a CD with surgery data The saved information can be viewed on any computer 22 Appendix Actions button The Actions button can be used at any time to access various menus 1 An Aim Camera function to verify arrays and accompanying instruments 2 A Snapshot function to capture the screen display and save it to a picture file 3 A Checkpoints function to acquire and check up to four landmarks on the pelvis at specific locations The location of the landmarks can be verified at any point during the surgery to confirm the stability of the bone references 4 An Acetabular Rim Plane function to measure and verify the inclination and version of the acetabular rim or the implanted Cup Six points are taken around the rim to establish a plane and the screen displays the orientation of the measured plane 5 A Range of Motion function to measure range of motion requires Femoral Array 6 An Archive On CD function to write data to a blank CD 7 An Abort Exit function to quit the application Acetab Rim Plan
4. tracked instruments on the patient Note Line of sight is essential to the proper use of the optical tracking system Patient in supine position Patient in lateral position General Precautions The AchieveCAS system should only be used by trained surgeons Do not proceed any further in the surgery if there are any doubts about the quality of the registration The registration process should be restarted The AchieveCAS system should only be used with the instruments provided by Smith amp Nephew for the given application Before every surgery 1 Verify that the instruments have been sterilized 2 Verify that the instruments are in good condition to perform the surgery Always use instruments inside the field of the optical tracking system The AchieveCAS system should not be used in the presence of strong infrared sources within the vicinity of the arrays This could cause interference with the system Start Up gt smith amp nephew paces AchieveCAS Support Computer Assisted Surgery TY Shut Down Turn the AchieveCAS unit on via the power switch on the back of the computer Press the Hip icon on the touchscreen to begin the AchieveCAS operation Select Surgeon Profile Use this profile hil Profiles pees Select a profile from the list provided or press the Create button to create a new Surgeon Profile see next screens z gt smith nephew E Erber Hew Profile
5. AchieveCAS Computer Assisted Surgery AchieveCAS Computer Assisted Surgery Smith amp Nephew is proud to present the AchieveCAS system for hip arthroplasty The AchieveCAS system offers the surgeon accurate real time imageless computer navigation and facilitates precise implant placement The accurate alignment and placement of a Smith amp Nephew implant may extend its lifespan by reducing uneven wear thus preventing future corrective surgeries In addition precise implant placement may help reduce the risk of postoperative dislocation and contribute to long term implant stability and increased range of motion The AchieveCAS system also enhances the use of MIS techniques With computer assisted technology smaller incisions made possible for joint replacement surgery mean less muscle is cut and less blood is lost In turn this leads to shorter hospital stays and shorter rehabilitation for patients The increased vision from the AchieveCAS system advances and strengthens minimally invasive surgery This surgical technique will guide you through the software and instrument workflow for an AchieveCAS hip arthroplasty The interface and workflow of the AchieveCAS system are extraordinarily simple and user friendly The surgeon only sees the values and images that he or she needs no extraneous bells and whistles that serve to distract rather than help All told the AchieveCAS system is compact simple and inexpens
6. Cup Impactor with the Instrument Array attached to the screw hole in the bottom of the implanted Cup and press the highlighted Lock button This will deactivate the Lock function and will allow the camera to read the current orientation of the Cup using the array on the Cup Impactor If the Cup does not need to be adjusted or repositioned press the Lock button again before removing the Cup Impactor Locking the seated Cup position is required in order to measure postoperative leg length and offset Press the forward arrow to continue 18 Leg Length Verification Vartty Leg Length Skip MITE oo Align lemur along kengiudinal mi Salegi makaj larararks Insert trial components Enter the type of liner standard or lateralized being used All anteverted liners are lateralized Warthy Leg Length Skip ooh mH k 2i Flex the knee to 90 as depicted on the screen to reproduce the position used for preoperative leg length measurement Hold the tip of the Pointer steady on the marked greater trochanter point used during the anatomical landmarking step Reproduce the point exactly as done before femoral head dislocation Note Measuring leg length and offset does not require navigation of the stem or placement of a femoral array Measurements are taken in reference to a single pelvic array 20 Lincs Type Hold the tip of the Pointer steady on the marked patella point used during the anatomical l
7. Mama Type in a name for the new profile e Cree Mew Profile Smg Input appropriate Surgical Plan variables a set of options chosen to configure the flow of the application for the new Surgeon Profile Follow all screen instructions to complete the new Surgeon Profile Inset Matena Hip Canter Capture Mock Femoral Tracking Press the appropriate button to choose the operative side as directed by the screen instructions Calibration ewan Tente e peman gt Pomler oe 2 Cup impactor Calibrate the Pointer by inserting it into the Calibration Block Open the lever and ensure that the Pointer is fixed between the block s lever and metal structure see figure above Push the Pointer down until the tip of the Pointer rests on the base of the Calibration Block Orient the spheres of the Calibration Block and the instrument towards the camera When the calibration is complete a beep will sound The Calibration Block should be set on a stable immobile surface within view of the camera Verify that the Pointer Tip is firmly tightened to the Pointer Handle Make sure that no other arrays or spheres are visible to the camera If the screen prompts the user to Retry do not move the Pointer or the Calibration Block Simply press the Retry button on the touchscreen without touching the instruments When the calibration is successfully completed a beep will sound Note T
8. andmarking step Reproduce the point exactly A Verily Leg Langth F Liner Type STD Longer S Lateral w a DD The screen will display the measured leg length and offset in millimeters relative to preoperative measurements Press Clear All to re measure leg length and offset for actual implants or for different trials if adjustments are made Rim Plane Measurement Locate Aialak ier Flaws Ces Rim plane orientation abduction and anteversion can be checked at any time using the Acetabular Rim Plane function Press the Actions button at the bottom right and then press Acetabular Rim Plane on the resulting menu Hold the tip of the Pointer steady on six random points around the Acetabular Rim Plane A beep will sound each time a point is successfully taken Locate Restates kin Bir Flares cons When all six points have been registered the abduction and anteversion values of the measured plane will be displayed This function can be used to measure preoperative abduction and anteversion of the natural acetabular rim as well as to measure the orientation of the seated Cup 21 fbchachion r mamion Sct furlewrsion lt n ip io a When the procedure is complete the screen displays the key results To save a screenshot of the displayed results press the Actions button at the lower right and then the Snapshot button from the resulting menu This function
9. e Range of Motion Archive On CD Abort Exit Settings Button The Settings Button is used to access various menus 1 An Input Surgical Plan function to view modify various surgical options 2 A Language function to select different user languages 3 A System Information function to view system specifications 2 Button Press the button for a comprehensive User s Manual 23 Orthopaedics Smith amp Nephew Inc www smith nephew com 1450 Brooks Road www achievecas com Memphis TN 38116 USA Telephone 1 901 396 2121 Information 1 800 821 5700 Orders and Inquiries 1 800 238 7538 2006 Smith amp Nephew Inc Printed in USA Trademark of Smith amp Nephew Registered US Patent and Trademark Office 43740102 7448 7087 05 06
10. f the Pelvic Reference Array will be level to the coronal plane This will reduce visibility conflicts when the patient is moved to lateral position Place the Modular Reference Base over the pins Firmly tighten the set screws using the hex Screwdriver Handle Place three reflective spheres on all arrays Each sphere is properly seated when it clicks into place To clean spheres intraoperatively wipe first with a wet cloth and immediately wipe again with a dry cloth Place the Pelvic Reference Array on the Modular Reference Base and tighten firmly The Pelvic Reference Array may be removed and replaced during the procedure The same array cranial or lateral must be used in the same orientation throughout the procedure 8 BlockPelwis Removable array Pointer Digitizer Femur hamithdnephew Using the Camera Field screen make sure the Pelvic Reference Array can be seen by the camera This screen can be obtained at any time by pressing the Actions button on the lower right and then the Aim Camera button from the resulting menu Cannot be seen by camera Can be seen by camera If at any time an array cannot be seen by the camera a shaded circle will appear behind the array s representative icon at the bottom of the applicable screen Anatomical Landmark Acquisition Supine Position idenbh Pehk Coordinate Satan TETT With the patient in supine position hold the tip of the Pointer steady on the ind
11. he Pointer and the selected Cup Impactor Standard or MIS must be calibrated at each surgery before their use Calibration of the Reamer may be skipped if reaming will not be navigated Standard Instruments To calibrate the Straight Cup Impactor firmly attach the Quick Lock Instrument Array to the Straight Cup Impactor Insert the Straight Cup Impactor into the Calibration Block in the same manner used to calibrate the Pointer When calibration is complete a beep will sound To calibrate the Reamer first insert the Reamer into the black Reamer Calibration Sleeve Firmly attach the Quick Lock Instrument Array to the Reamer Insert the Reamer into the Calibration Block in the same manner used to calibrate the Pointer If reaming will not be navigated simply press the forward arrow to skip this step When calibration is complete a beep will sound and the screen will indicate that all instruments have been successfully calibrated Press the forward arrow at the top of the screen to continue MIS Instruments The MIS Cup Impactor because of its offset shape does not fit directly into the Calibration Block To calibrate the MIS Cup Impactor firmly attach the Offset Cup Impactor Calibration Tool to the screw threads on the end of the Impactor Attach the Quick Lock Instrument Array to the MIS Impactor Insert the Offset Cup Impactor Calibration Tool and attached Impactor into the Block as directed on the scree
12. icated anterior superior iliac spine ASIS The ASIS on the operative side will always be taken first Hold the tip of the Pointer steady on the opposite ASIS Hold the tip of the Pointer steady on either of the pubic tubercles it does not matter which one Sman GE Note The reading of each point is triggered automatically based on a stability criterion When the Pointer is held steady the computer will record a point Each time a point is successfully acquired a beep will sound 10 Handling Sterile and Non sterile Instruments During the registration of the pelvic plane and table plane lif selected see next page the Pointer Tip and the surgeon s hand used to steady the Pointer Tip may touch non sterile areas The Pointer Handle and the surgeon s hand used to hold the Pointer Handle must remain sterile With the non sterile hand When registration in the supine position is complete remove the non sterile Pointer Tip from the Pointer Handle and hand it to a non sterile assistant Do not touch the Pointer Handle or the Pelvic Reference Array with the non sterile hand With the sterile hand After the non sterile tip has been removed hand the sterile Pointer Handle to a sterile assistant Remove the Pelvic Reference Array and hand it to the sterile assistant The instrument set contains a second Pointer Tip The sterile assistant will firmly attach the sterile Pointer Tip to the Pointer Handle to be used fo
13. ip of the Pointer to the digitized acetabular surface Place the tip of the Pointer in the bottom of the fossa to estimate reaming distance for the acetabulum Navigation Reamer Abduction Ae eaasrgic Firmly attach the Quick Lock Instrument Array to the Reamer Select the size of the first Reamer Dome that will be used Align the Reamer to desired position and ream to desired depth Each time the size of the Reamer Dome is increased adjust the Reamer Size on the screen to match the size of the Reamer Dome being used Press the Position button to advance to the Cup Placement screen The Ream button can be pressed at any time to return to the Reaming screen All navigation screens make use of a target circle and target values to guide navigation When a navigated instrument is on target the target circle becomes green and a beep will sound When the abduction and anteversion values are within 5 of the target value the boxes in which the values are displayed also become green Note Do not use the pictoral representation of the pelvic bones for component positioning purposes They are provided solely to visualize Cup orientation and do not represent the actual bony anatomy Navigation Cup Placement Navigate Acetabulum gt pn CE E EE ka Abduction 4nteversian superior Medial Anternar Cup 0 0 Viewer AP Viewrr LAT amm enithsnephew BE SO Actions Attach the Quick Lock
14. ive A simply brilliant concept Turn it on Nota bene The technique in this book is to be used as product information only It is not intended to be employed as a user manual as it does not contain warnings that have to be considered for the use of the system Operating Room Setup Given that the size of the operating field is limited appropriate positioning of the optical tracking equipment is crucial A specific camera location must be selected to allow an unobstructed camera view of the operation field Care must be taken to ensure that no operating room OR equipment obstructs the field between the camera and the navigated instruments An appropriate camera placement should allow for the calibration of instruments and the navigation to be carried out with a single rotation of the camera This will facilitate handling during surgery The optical stand can easily be positioned in the OR using the ergonomic handles A minimum distance of 4 7 must be maintained between the camera and the calibration navigation areas The OR setup must be determined according to the side of the operated hip left or right the specifications of the optical system and the standard instrument setup Due to the orientation of the arrays the camera should be placed medially to the operative side approximately even with the patient s upper torso The exact camera position depends on the OR setup the surgeon s preferences and the position of the
15. lete the system will display the diameter of the digitized acetabular sphere as well as the distance from the tip of the Pointer to the digitized acetabular surface Place the tip of the Pointer in the bottom of the fossa to estimate reaming distance for the acetabulum Note Final results depend on accurate acquisition of landmarks For accurate results ensure that points are taken on the acetabular sphere Do not take points in damaged areas or in the fossa below the acetabular surface Acetabulum Registration Trial Cup Option If the quality of the acetabulum does not allow accurate taking of points on the acetabular surface a Trial Cup option may be used to locate the acetabular center To use this option it must be selected preoperatively in the Surgical Plan r tele Arita bulir a Seip Firmly attach the Quick Lock Instrument Array to the selected Cup Impactor Estimate acetabular size and attach the corresponding size Trial Cup to the Impactor Place the Trial Cup in the acetabulum as directed on the screen If the Trial Cup does not fit adjust the size of the Trial Cup and repeat until a fit is achieved Enter the selected Trial Cup size on the screen With the Trial Cup seated in the acetabulum press the Acquire button on the touch screen Aana BE A Ban When the acetabular center has been registered the system will display the input diameter of the digitized acetabular sphere as well as the distance from the t
16. n When calibration is complete a beep will sound When using MIS instruments make sure they are selected in the surgical plan Note When each step in the software workflow is complete the screen will automatically display results or advance to the next screen in the workflow Press the forward or back arrow at the top of the screen at any time to move manually to the next or previous screen Beginning the Procedure Notes In order to ensure proper system accuracy the Modular Reference Base must remain firmly secured on the pins Always use unblemished reflective spheres Always ensure that reflective spheres are firmly seated Always ensure that the Pointer Tip is firmly tightened on the Pointer Handle Always minimize handling of the spheres since errors may result from the non uniform reflection of the surface of the spheres Pelvic Reference Array position With the patient in supine position insert one 3 2mm cove point pin into the iliac crest anterolaterally The patient should be minimally draped and the surgeon gowned but not necessarily scrubbed sterile The patient will be fully prepared for surgery in lateral position Attach the Screwdriver Handle to the Modular Reference Base Insert a second 3 2mm cove point pin using the Modular Reference Base and Screwdriver Handle as a drill guide To ensure maximum visibility of the camera insert the pins with no more than 45 of anteversion so that the face o
17. r the remainder of the procedure The surgeon may now leave the room to prepare for surgery while the OR staff repositions the patient to lateral position and prepares the patient for surgery Adjusted Anteversion anian UE If the surgeon wishes to view adjusted anteversion anteversion relative to the table plane instead of relative to the pelvic plane the table plane must be registered Hold the Pointer Tip steady on three points on the flat surface of the operating table The points must be at least 30mm apart and must not be linear The Pointer Tip and the surgeon s hand used to steady the Pointer Tip may touch non sterile areas If the surgeon does not wish to view adjusted anteversion simply press the Skip button at the upper right to continue ee When the table plane has been registered the screen will display the angle of the pelvic plane in relation to the table plane Note On every screen where there is a list of points to acquire two buttons will become available when at least one point is digitized Clear All and Clear Last The last acquired point may be deleted by pressing Clear Last Pressing Clear All deletes all points acquired on the screen 12 Anatomical Landmark Acquisition Lateral Position Once exposure of the joint is achieved but before dislocation of the femoral head flex the knee to 90 as directed by the screen Mark a point on the greater trochanter
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