Anterior Approach Surgical Technique

2013-06-11

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The Anterior
Approach
as described by Joel Matta, M.D.

Surgical Technique

Table Of Contents

Introduction2
hana® Table

Pre-Operative Set-Up

Incision and Initial Exposure

Exposure10
Capsular Exposure

Dislocation14
Dislocation and Femoral Head Resection

Femoral Head Resection

Acetabular Reaming

Femoral Preparation

Femoral Broaching and Trialing

Femoral Trialing

Final Implantation

Hints and Tips

Preventing Infection in Obese Patients

Ordering Information

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction

Introduction

Anterior Approach Philosophy
Minimally invasive or tissue-sparing orthopaedic procedures
have gained attention as patients demand shortened recovery time and accelerated rehabilitation. Development
of efficient, repeatable, tissue-sparing total hip replacement procedures is important.
The Anterior Approach Surgical Technique for Total Hip
Replacement is described by Joel Matta, M.D., who has
brought the Anterior Approach technique as it is known
today into the United States. This approach is an advanced
application of the Smith-Petersen approach using the
PROfx®, hana® or hana SSXT® tables from Mizuho OSI®.
These tables help to streamline the technique, creating a
reproducible procedure that minimizes soft-tissue releases
and eliminates the need for secondary incisions to accommodate instrumentation or the femoral component. The
technique does not cut any muscles, but separates them
to allow access into the hip joint. The result is that muscles are spared during surgery. With these advantages,
the Anterior Approach provides the potential for a quicker
recovery compared to traditional hip replacement surgery.

Anterior Approach Education Program
DePuy Synthes Joint Reconstruction has collaborated with
Joel Matta, M.D., to build a comprehensive training and education program around the Anterior Approach. This program features Anterior Approach Courses offering hands-on
cadaveric training, didactic lectures and interactive discussion. Surgical technique papers, surgical technique videos,
specially designed Anterior Approach instrumentation, marketing materials and a field specialist further augment DePuy
Synthes Joint Reconstruction’s comprehensive Anterior Approach program.
Anterior Approach Resources
Additional resources for surgeons, patients and OR Staff
can be found at www.DePuy.com/AnteriorApproach including an interactive 3D animation for surgeon and OR
staff education.

*The hana® table is not a DePuy Synthes Joint Reconstruction product, nor is it the only table that can be used for this approach. This surgical technique still applies when
using other tables.

2 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

About Joel Matta, M.D.
Joel Matta, M.D., brought the Anterior Approach to the
United States from Europe and has advanced the technique through training and education. The CORAIL® Total
Hip System and the Anterior Approach surgical instruments were designed in conjunction with Dr. Matta and a
team of other surgeons. Having performed over 3,000
plus, Anterior Approach hip replacements, Dr. Matta has
also been instrumental in the training of many orthopaedic surgeons in the technique, and serves as chairman of
DePuy Synthes Joint Reconstruction’s Anterior Approach
Courses.
Dr. Matta is founder and chairman of the Anterior Total
Hip Arthroplasty Collaborative (ATHAC, www.athac.org),
the founder and director of the Hip & Pelvis Institute at
Saint John’s Health Center in Santa Monica, CA, and the
author of over 100 publications and videos and hip replacement and pelvic surgery.
Dr. Matta is a consultant for DePuy Synthes Joint
Reconstruction, and receives royalties as the designer
of the PROfx®, hana® or hana SSXT® tables which are
manufactured by Mizuho OSI.

Joel Matta, M.D.

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 3

Introduction

hana® Table
Allows Precise Control of Patient Position, Manipulation and Traction
Proven performance for Anterior Approach to total hip procedures.
Allows bilateral hip replacement for qualified patients.

Extensive Imaging Capability
Un-restricted C-Arm access.
Radiolucent 35 inch (89 cm) cantelevered top section.
Radiolucent leg spars for uninterrupted imaging.

The hana® table allows the surgeon to perform Total Hip Arthroplasty through a single anterior approach incision, without detachment of muscle from the pelvis, or femur. The table allows hyperextension, abduction, adduction and external rotation of the hip for femoral component placements, a positioning option not possible with conventional tables.
Minimizing the disturbance to the lateral and posterior soft tissues provides immediate stability of the hip after surgery.

4 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

OR Team Engineered
Facilitates OR Team performance.
Proprietary features make pre-operative and intra-operative protocol easier than a standard OR table
Suited to the Newest Technologies
Supports tissue-sparing techniques for MIS procedures.
Provides new level of surgical assistance
for surgeon and OR team.

Rotation Lock

Fine Traction

Gross Traction

Internal/External Rotation

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 5

Pre-Operative Set-Up

Patient Set-up and Draping
Before transferring the patient to the hana® table, it is
recommended that the patient’s feet be secured into the
boots. Apply web roll around the foot, then self-adherent
wrap (Coban™) around the upper ankle. With the boot
liner out of the shell, position the foot inside the liner. Secure the tongue and the Velcro® strap then place the foot
into the boot. Ensure that the heel drops down into the
shell. Affix the buckle straps and securely tighten the foot.
Test the stability of the boot on the foot by holding the
ankle while pulling on the boot handle.
Position the patient on the hana table in preparation for
surgery. Typically, the patient’s arms are placed roughly
perpendicular outward and not over the chest. Arms placed
on the chest can interfere with femoral preparation later
in the procedure.

Extra large drape

Clear drape

Figure 1

1. Use a clear U drape (non sterile) around operative area
and towards the foot (Figure 1). A towel wrapped over
each boot reduces the chance of perforation through
the curtain.

Extra large drape

2. Place two extra large drapes over the lower extremities
starting distal to operative area. Place two large drapes
across the top of the patient (Figure 2).
3. Staple three towels around operative area, one on each
side of the incision area and one medial to the incision
area (Figure 3).

Figure 2
Split drape

Figure 3

6 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Towels

Split drape

4. Apply an impervious U drape with adhesive around the
operative area and extending over the legs. Apply another in the opposite direction over the head.
5. Place a split drape with adhesive proximal and distal to
the operative area.
6. Cover exposed skin with iodine incise drape (Figure 4).
7. Cut a small hole in the drape for the femoral hook lift,
place the hook bracket on the lift and seal with iodine
incise drape (Figure 5).
Figure 4

Figure 5

Room Set-up
The OR is set up such that the instruments are on the operative side of the patient. Generally, the use of 2 back tables (A), 1 Mayo stand (B) and 1 basin stand (C) is sufficient, creating an L-shaped area.
D

The C-Arm (D) is positioned on the non-operative side,
perpendicular to the patient. A typical OR team will consist of the surgeon, physician’s assistant, anesthesiologist,
scrub nurse, circulating nurse/table operator and X-ray
technician (Figure 6).

Surgeon

A
B

C
Figure 6
A

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 7

Incision and Initial Exposure

Mark the locations of the iliac crest, greater trochanter and
the anterior superior iliac spine (ASIS) (Figure 7). Start the incision approximately 3 cm lateral and 1 cm distal to the ASIS,
and continue in a posterior and distal direction toward the
anterior border of the femur. The incision will be 8-9 cm and
parallels the fibers of the tensor fascia lata muscle.

Incision

Proximal Femur

Iliac Crest

Greater Trochanter

Figure 7

The tensor fibers are visible through the translucent fascia
(Figure 8).

Volkman’s Retractor

Figure 8

8 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

ASIS

A soft tissue protector (Protractor®) may be inserted into
the wound. Incise the fascia over the tensor and parallel
to its fibers. Extend the fascial split beneath the skin proximal (toward the ASIS) and distal (Figure 9).

Protractor®
ASIS

Figure 9

Coagulate the vessel that perforates the fascia.

Protractor®

The fascial incision is typically between the anterior twothirds and posterior one-third of the tensor muscle (Figure
10). Avoid splitting the iliotibial band, which lies along the
posterior border of the tensor. Splitting this will lead to
the muscle interval posterior to the tensor commonly
known as the Watson-Jones approach.

Figure 10

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 9

Exposure

Lift the anterior tensor flap with an Allis Clamp and using
your finger, bluntly dissect inside the tensor sheath, anterior and medial to the tensor muscle.

Allis Clamp

Hibbs Retractor

The location and obliquity of the incision along with the
deep dissection within the tensor sheath, protects the lateral femoral cutaneous nerve.
Place a Hibbs Retractor (Cat. No. 2598-07-180) medially
to aid visualization. Palpate the ASIS and move your finger
distal and lateral to palpate the anterior hip capsule. Place
a blunt-tipped Cobra Retractor (Cat. No. 37-4106) lateral
to the hip capsule and locate the origin of the rectus femorus. Retract the tensor and gluteus minimus laterally. Use
the Hibbs Retractor and retract the sartorius and rectus
femorus muscles medially (Figure 11).

Cobra Retractor
Figure 11

To elevate the iliopsoas and rectus femorus muscles from
the anterior capsule, pass a Key/Cobb elevator posterior
to the origin of the rectus femorus and anterior to the hip
capsule, directing it medial and distal (Figure 12).

Key/Cobb Elevator

Hibbs Retractor

Rectus

Cobra Retractor

Figure 12

11 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Place the tip of the MI Narrow Curved Hohmann Retractor (Cat. No. 2598-07-190) on the antero-medial hip capsule to retract the rectus femorus and sartorius medially.
As the Hohmann and Cobra retract medially and laterally,
use your finger to tease the fascia lata off the distal tensor to enhance exposure and avoid rupture of the tensor
fibers (Figure 13).

MI Narrow Curved
Hohmann Retractor

Cobra Retractor

Hibbs Retractor

Clamped Circumflex Vessels
Figure 13

MI Narrow Curved
Hohmann Retractor

Retract the tensor laterally with a Hibbs Retractor to facilitate visualization of the anterior capsule. Dissect distally
to enhance exposure. The lateral femoral circumflex vessels are also now visualized distal to the hip capsule. Cut
and tie, or cauterize both sides of the vessel, taking care
to cauterize all of the branches (Figure 14).

Cauterized
Circumflex Vessels

Hibbs Retractor

Figure 14

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 11

Capsular Exposure

For more mobility of tensor muscle, release the fascia
layer distal to the cauterized vessels. Retract the tensor to
visualize the fibers of the vastus lateralis muscle.

Hibbs
Retractor

MI Narrow Curved
Hohmann Retractor

Cut the capsule parallel to the neck at the junction of the
anterior and lateral/superior capsule; continue down to the
base of the neck, until reaching the inter-trochanteric line.
Ensure that the lateral shoulder (saddle) of the neck is visible where the lateral portion of the neck joins the tip of
the greater trochanter (Figure 15).

Figure 15

Cobra Retractor

Anterior Capsule Tag

To retract the capsule, position a suture tag into the lateral
edge of the anterior capsule (Figure 16). From the distal extent of the capsular incision, cut at a right angle medially
along the intertrochanteric line (junction of the anterior
capsule and the origin of the vastus lateralis muscle).
Cut the anterior capsule off the base of the neck. This ensures visualization and mobility of the femur during femoral preparation. Place a sharp-tipped Cobra Retractor (Cat
2598-07-200) under the anterior capsule and around the
anterior neck. Detach the capsule from the intertrochanteric line area.

Hibbs
Retractor

Figure 16

11 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Cobra Retractor

Lateral Capsule Tag

Watch for and cauterize bleeders along the intertrochanteric line. Place a tag suture on the cut edge of the lateral
capsule, near the greater trochanter. Place the lateral
cobra inside the lateral capsule along the lateral neck.
Slide the tip of a small Hohmann Retractor (Cat. No.
2598-07-190), under the anterior capsule and over the
anterior rim.

Labrum removed
from Acetabulum

Femoral Head

Locate and remove the labrum to visualize the bony rim
of the acetabulum. The labrum is often ossified (acetabular osteophyte), if so, excise with an osteotome, failing to
do so may make inserting the Bone Skid difficult. Request
gross traction be applied and lock. Using approximately
3-4 turns of fine traction, the femoral head will pull away
from the acetabulum (Figure 17).

Lock
gross
traction
Figure 17

Cobra
Retractor

3 or 4 turns of fine traction

Push the Murphy Bone Skid (Cat. No. 2004-00-000)
between the superior head and acetabular roof and
“lever” to loosen the soft tissues. Remove the Skid.
Request the operator to remove 2 turns of fine traction.
Place the Murphy Bone Skid between the femoral head
and anterior rim (Figure 18). Mobilize the head and externally rotate the hip approximately 20 degrees.

Cobra
Retractor
Murphy Bone Skid

Figure 18

Cobra Retractor

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 11

Dislocation

Under power, insert the Modular Head Ball Remover (Cat.
No. 2125-00-600), or Corkscrew, into the femoral head in
an anterior to posterior direction and attach the Excel THandle (Cat. No. 2001-42-000) (Figure 19).

Corkscrew

Murphy Bone Skid

Cobra
Retractor
Figure 19

Cobra Retractor

Unlock the rotation on the table. Using leverage from
the Murphy Bone Skid and by pulling and rotating with
the corkscrew dislocate the head anterior and lateral
(Figure 20).

Murphy Bone Skid
Unlock

Corkscrew
Figure 20

11 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Dislocation and Femoral Head Resection

Remove the Murphy Bone Skid and place Cobra Retractors medial and lateral to the neck. Using a small Hohmann Retractor to slide under the muscle, with the tip
around the lesser trochanter, retract the vastus origin. Release the capsule off the medial and posterior-medial
neck (Figure 21). This dislocation and capsular release will
later enhance femoral mobility and access.

Small Hohmann
Cobra Retractor
Retractor

Capsular Release
Posterior/Medial Neck

Identify and coagulate bleeders near the base of the neck.
Unlock the table rotation and internally rotate the leg to
reduce the hip. The neck cut should be based on the preoperative templating. Most often, the lateral portion of
the neck cut comes near the lateral shoulder of the neck,
by the junction of the greater trochanter. This can be used
as an indicator for the neck cut.
Figure 21

Unlock rotation and
internally rotate

Corkscrew

Completing Neck Cut

Osteotome

Using a Hibbs Retractor to protect the tensor from the
Oscillating Saw Blade, aim in a medial direction so the excursion of the saw does not come into contact with the
posterior greater trochanter. Make the cut using the saw.
Use an Osteotome with the blade parallel to the long axis
of the body to finish the cut (between the greater trochanter and the base of the neck) (Figure 22).

Saw

Note: An in-situ neck cut may also be performed,
if preferred. A neck cut following dislocation is
described here since dislocation can aid with femoral mobility.
Hibbs Retractor

Cobra Retractor

Figure 22

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 11

Femoral Head Resection

Prevent sharp edges from catching on muscles by rotating
the head to bring the uncut side out first (Figure 23).

Corkscrew

Externally rotate the hip about 45 degrees. Pull up on the
tag suture attached to the anterior capsule and place an MI
Narrow Curved Hohmann Retractor under the capsule and
over the inferior part of the anterior rim. Place a Cobra Retractor over the mid-portion of the posterior rim with the
tip outside of the labrum, but inside of the capsule.
Hibbs
Retractor

Figure 23

Slight external rotation

Inferior Capsule

MI Narrow
Curved Hohmann

Cut the inferior capsule transversely to allow a little release, excising inferior capsule if needed. With a knife,
excise residual posterior, and if present, anterior labrum
(Figure 24).

Figure 24

11 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Posterior Labrum

Acetabular Reaming

Begin reaming the acetabulum by aiming the reamer anterior to posterior, and proximal. Medialize with the
reamer aimed medial and slightly posterior and superior
(Figure 25). Sequentially ream in 1-2 mm increments.
Check progress by visualizing the acetabulum and by
checking with the C-Arm. Look for and control bleeding
near the obturator foramen.
Before reaming to the final templated size, it is recommended that the reamer position be checked with fluoroscopy. Generally, the cup should be placed at the patient’s anatomic center of rotation. Rotate the C-Arm
image (A/P view) on the screen until the pelvis image appears level (when the transverse anatomic line is horizontal). With the image centered over the midline, the coccyx
should be pointing right at the symphysis, and the obturator foramina should look identical. You may need to orbit and rainbow the C-Arm to accomplish this.

C-Arm

Figure 25

Reamer

After leveling the image and pelvis, center the image over
the operative acetabulum. The image of the reamer
shows where the cup will be centered (Figure 26). The
cup should have a good circumferential fit.
Tip: A cup that is too large may lack purchase and
an overhanging anterior edge may impinge on the iliopsoas tendon.

Figure 26

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 11

Acetabular Reaming

When you have reamed to the appropriate size, you can
insert the PINNACLE® Trial or Cup (trial liner optional). After confirming alignment and position, remove the trial
and insert the final prosthesis. For surgeons unaccustomed to the supine position, it is common to place the
cup with too much inclination and anteversion. The correct insertion orientation is typically more parallel to the
floor and long axis of the body than expected. Check for
proper placement of the final component with the CArm. Aim for a targeted 40-45 degrees of inclination and
15-20 degrees of anteversion (Figure 27).
The angle and proportions of the image of the ellipse of
the rim of the cup indicates inclination and anteversion.

Cup Inserter

Note: See front pocket for transparency of an ellipse
for comparison.
Figure 27

Cobra Retractor

Place the final component into position and impact the
Cup. Before inserting the Cup Liner, check the Acetabular
Retractors. A Cobra Retractor should be placed over the
mid-portion of the posterior rim. Detach the Cup and insert the Liner into the Cup, seating it into the Cup
(Figure 28). Impact the Liner and perform a final check of
the Cup and Liner placement under X-ray.

Cobra Retractor
Figure 28

11 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Femoral Preparation

Femoral Preparation
Internally rotate the femur to the neutral position. Palpate
the vastus tubercle, and place the tip of the bone hook
(either the right or left, corresponding to the operative
hip) just distal to the vastus tubercle and around the posterior femur (Figures 29 -30).

Bone Hook

Rotate from
45˚ to 0˚

Do not force external rotation of the femur. Very forceful external rotation can cause a lower extremity fracture. If the patient is elderly and osteoporotic, it is often
safest for the surgeon to grasp the foot boot with its
overlying drape. The surgeon then applies extremity
torque that he or she is comfortable with and the unscrubbed table operator locks the position. In many
cases, initial femoral external rotation is short of 90 degrees, but subsequent soft tissue releases will allow 90
degrees of femoral external rotation.
Figure 29

View 3
Figure 30

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 11

Femoral Preparation

Lift up on the femur with the bone hook and pull laterally
away from the acetabulum. From the table, unlock the
gross traction – using no traction at this stage. Externally
rotate the foot approximately 110-120 degrees, this will
result with the femur rotating approximately 90 degrees.
Lock the rotation wheel, unlock gross traction and extend
and adduct the leg (Figure 31).

Foot EXTERNALLY rotated 110-120 degrees
(Rotation of femur 90 degrees)

Extend the leg to the
floor and adduct

Gross Traction Unlocked
Figure 31

22 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Place a Cobra or Muller Retractor (Cat. No. 2176-10-000)
along the posterior cortex of the femur. Next, place a
Trochanteric Retractor (Cat No. 2598-07-240) over the tip
of the greater trochanter, and outside the hip capsule
(Figure 32).

Cobra Retractor

Trochanteric
Retractor

Place the bone hook into the bracket on the table and
manually lift the Hook. Lift the femur and raise the jack to
bring the bracket up to hold the Hook.
Note: Use the table bracket as a shelf, not as a lift for
the bone hook and femur.

Figure 32

Bone Hook

Anterior Capsule Suture

Cobra Retractor

Trochanteric
Retractor

Detach the lateral capsule anterior to posterior from the
inside of the greater trochanter, into the piriformis fossa.
Pull up on the suture attached to the anterior capsule to
facilitate this (Figure 33).

Figure 33

Lateral Capsule

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 22

Femoral Preparation

Cauterize the region of the retinacular vessels along the
posterior superior neck. The piriformis and obturator internus tendons insert on the anterior portion of the
greater trochanter. Typically, the piriformis tendon lies superior to the anterior greater trochanter. The obturator internus tendon typically lies medial to the tip of the greater
trochanter. Further release of the capsule from the medial
trochanter tip and partial or total release of the internus
tendon provides full exposure of the medial trochanter tip
and enhanced femoral mobility
At this point you will see some fibers of the capsule and
may see some of the obturator internus tendon. If you
need to see more of the inside of the greater trochanter,
incise along the inner surface of the greater trochanter to
enhance visualization (Figure 34).
A manual lateral and anterior pull on the Bone Hook (after
soft tissue release) can give further femoral exposure. This
position is maintained by raising the hook bracket. At this
point, further femoral rotation, if necessary, may be possible. The strong insertion of the obturator externus tendon
is seen in the piriformis fossa and should be preserved. The
obturator externus pulls the femur in a medial direction
and thereby has an important anti-dislocation function.

Cobra Retractor

Figure 34

Bone Hook

Cobra Retractor

Hohmann Retractor

Rongeur

Use a Long-Handled Rongeur (Cat. No. 2598-07-690),
to remove the lateral neck remnant and if necessary, to
get more lateral into the inside of the greater trochanter
(Figure 35).

Figure 35

22 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Lateral Neck Remnant

Bone Hook

Femoral Broaching and Trialing

Broaching
Start the CORAIL® Total Hip System broach insertion near
the calcar, by pushing the smallest size compaction
broach by hand (Figure 36).

Cobra or Muller Retractor

Broach Handle

Trochanteric
Retractor

Orient the broach such that the plane of the broach is
parallel to the posterior cortex. Sequentially broach to the
proper size with the broach attached to the selected
broach handle. This will progressively enlarge the metaphyseal cavity by compacting and shaping the cancellous
bone until the level of the neck resection is reached.
Check the depth of broach insertion in relation to the tip
of the greater trochanter and match this to the templated
pre-operative plan.
Broaching should continue until complete stability
is achieved with the last size broach used without reaching cortical contact in the femoral canal, ensuring cancellous bone preservation. The size of each CORAIL broach is
the same as the corresponding implant without the 155μ
thick HA (hydroxyapatite) coating.

Figure 36

Bone Hook

Tip: If you impact a broach and it does not fully seat
in the canal, it is recommended that you go back to
the previous size broach and re-establish the broach
envelope of cancellous bone to accept the smaller
size implant. The CORAIL implant’s design allows
you to go back to the smaller size if needed.

Trialing
Place the appropriate trial neck and head onto the broach
(Figure 37). Lower the bracket and take out the retractors
and femoral hook. Use the table to bring the leg back to
neutral position. Pull back on the gross traction and internally rotate the leg to reduce the hip.

Hohmann Retractor

Figure 37

Cobra or Muller Retractor

Trochanteric Retractor

Bone Hook Trial Head

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 22

Femoral Trialing

Check the leg length and offset with the X-ray. Position
the hips identically to get accurate comparison views. The
table is very helpful for making and holding small adjustments of abduction and rotation to maximize the accuracy of comparison X-rays. Take an X-ray of the non-operative hip to be used as a control. Then take a picture of
the operative hip for comparison (Figure 38).

Figure 38

With the two prints, check femoral offset and leg length
by overlaying the X-rays (Figure 39).
Tip: Take a distal X-ray to check stem direction and
correct sizing in the canal.

Figure 39

22 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Final Implantation

Return the femur to the preparation position (dislocate,
externally rotate, extend and adduct). Re-establish the
femoral exposure with the retractors and elevate the femur with the bone hook. If the trial reduction was satisfactory, with good broach size and position, and accurate
length and offset, then plane the calcar. Place the MI Calcar Planer (assemble Shaft 2570-04-500, and Mill Disc2001-47-000 Small, 2001-48-000 Medium, or 2001-49000 Large) onto the broach trunion and mill the calcar to
the broach face, allowing the implant collar (if used) to
seat flush against the calcar. Make certain the calcar
planer is rotating before engaging the calcar to prevent
the planer from binding on the calcar.
If during trial reduction, it was determined that adjustments
were needed, make the necessary adjustments to correct
broach size, inserter depth, neck length or offset. Significant
adjustments should be checked with another trial.

Cobra or Muller Retractor
Final Head

Figure 40

Place the final CORAIL implant by hand into the prepared
canal until 1-2 cm of HA coating is visible.
Impact the stem with light blows until it is seated using
the Anterior Inserter (Cat. Nos. 2598-07-460, Modular Inserter Handle, and 2598-07-440, CORAIL/TRI-LOCK Bone
Preservation Stem Anterior Inserter Shaft). Place the final
head onto the stem and impact. Using the hana table,
complete the final reduction (Figure 40).
Take a final X-ray and perform wound closure by tying the
two sutures together and irrigating out. Close the fascia,
subcutaneous tissue and skin (Figure 41).

Figure 41

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 22

Hints and Tips

CORAIL Tips
• The use of the collared CORAIL stem can help control
for subsidence, especially in Type C bone.
• The CORAIL is a cancellous impaction broach and stem,
and it does not fit and fill. You should not have to use
aggressive mallet blows to seat the broach or the stem,
wrist motion is usually sufficient. Be particularly careful
in Type A bone where the cancellous bone is usually
dense, and do not try to force too large of a size in this
type of bone.
Approach Tips
• For your first Anterior Approach cases, select your patients carefully. The most difficult patients are the
heavy, muscular males that have short femoral necks,
or morbidly obese patients. As you become more comfortable with the technique, you will find that you can
expand your patient selection. Many surgeons use the
Anterior Approach on all patients, once they are
through the initial learning curve.
• Orthopaedic surgeons are accustomed to palpating
bone, cutting to the bone and following it. The Anterior Approach may produce some initial unfamiliarity
because it is more of a pure soft tissue approach and
relies on recognition of soft tissue landmarks.
• Be meticulous with exposure of the lateral neck/top of
the trochanter. It improves access to the femur and
makes it easier to avoid varus implant placement.
• Early in the learning curve, the main difficulty is mobilization of the femur. Some surgeons recommend excising the anterior capsule, which may help with a large
patient. Some surgeons will do this routinely and it
may help early in the learning curve.
• Some surgeons start the case with the hip in slight flexion, which can help to relax the rectus.
Incision Tips
• For the surgeon unfamiliar with the approach, the incision will appear more lateral than expected. The incision should go over the belly of the tensor fascia lata

muscle and lateral to the interval between the tensor
and sartorius. This preserves the lateral cutaneous
nerve of the thigh and allows access inside the tensor
sheath. If you are too medial to the tensor sheath,
there is the potential for damage due to muscle enervation. If you are too lateral, the operation can still be
performed through a different interval. The tensor may
be split, which is an approach used by Keggi. The Watson-Jones interval is further lateral and posterior to the
tensor.
• If the incision is too distal, the first Cobra may not be
placed correctly. You should be able to feel the anterior
innominate bone through the incision, and this generally requires that the proximal incision cross the groin
crease. To find the superior lateral neck for the first retractor placement, feel with your finger as you dissect
the medial border of the tensor off its sheath proximally until you can feel the anterior border of the
bone. Follow it deep until you feel the superior neck,
and place the cobra here.
• Make sure the lateral circumflex vessels are cauterized
during the approach.
Dislocation Tips
• Excise the anterior hip capsule in a trapezoidal shape,
with the wide part of the trapezoid along the femoral
inner trochanteric line and the narrow part at the acetabular rim.
• With the hip skid, start superiorly between the roof and
the head. Generally, four turns of traction are needed.
The next step is to re-insert the skid between the anterior wall and the head, and take off two turns of traction to relax the anterior structures. Use a curved osteotome or a long, curved scissor to sever the ligamentum if
you experience difficulty placing the hip skid.
• Posterior capsule release followed by an internus and
piriformis release will expose most hips.
• Externus releases are rarely needed, and are difficult
because of the intimate contact with the fossa and
posterior bone.

22 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Neck Cut Tips

Head Removal Tips

• Cutting the neck from anterior to posterior introduces
the possibility of the saw inadvertently cutting the posterior greater trochanter. Guard against this by aiming
the saw somewhat medial and cutting the calcar area
first. Next, cut only the anterior neck more lateral and
finally cut the lateral shoulder of the neck with an osteotome in a posterior and medial direction. A small
bridge of the bone in the posterior neck near the
greater trochanter may be left uncut but it will fracture
and the spike left can easily be trimmed later.

• Some surgeons remove the head with a segmental cut
in the femoral neck without dislocating the hip.

• It is difficult with the Anterior Approach to re-cut the
neck. With other techniques, you may have learned
that if the neck cut is long, you can always come back.
With the Anterior Approach, a long neck cut will challenge you the rest of the case, making it difficult to get
reamers and the cup into the acetabulum. Take your
time, cut the neck at the right length the first time
through, which means you must know where the inferior trochanter is before the osteotomy.
• While cutting the neck, take care not to cut the greater
trochanter, which is a posterior structure. If the hip is
slightly externally rotated, it can endanger the trochanter when the saw comes through the posterior cortex.
Some surgeons finish the superior lateral cut with the
osteotome to protect against cutting the trochanter.

• When removing the head, use a Hibbs retractor and a
Cobra to protect the tensor from the sharp, cut edge
of the neck.
Acetabular Preparation Tips
• When reaming, keep traction on, with the leg externally rotated about 60 degrees to help keep the femoral neck out of the way.
• If you are having difficulty getting the acetabular reamers into the acetabulum, make sure the femoral neck
cut is not too long.
• Be careful reaming the acetabulum, as the tendency is
to ream too anteriorly. You can reduce anterior retractor tension when inserting reamer, and during reaming, to allow centralization of reamer and avoid preferential anterior reaming.
• If needed, you can place the reamer into the acetabulum, and then attach the power.

• To help avoid fracture of the greater trochanter, some
surgeons release the capsule when extended, and rotate the femur to mobilize better for rotation and elevation before releasing external rotators.
• Once the hip is dislocated anteriorly, you can use a
small Hohmann to retract the vastus lateralis from the
calcar and then release the inferior medial capsule from
the neck. With the corkscrew still in place and the hip
dislocated anteriorly, perform a sub-capital femoral
neck resection with a long, narrow saw blade.
• Because the corkscrew is still attached to the head and
the head is anterior, you simply remove the head and
internally rotate the hip to about 30 degrees of external rotation. Next, complete the neck cut and remove
the remaining neck segment at the desired level of
neck resection.
Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 22

Hints and Tips

Cup Insertion Tips
• Cup insertion is straightforward, and it is recommended that you use fluoroscopy, starting with a true
A/P pelvis view to verify your landmarks.
• Most of the errors in positioning the acetabular component are placing it too abducted and too anteverted.
After proper placement, the correctly positioned acetabulum will often appear in the wound to be more
horizontal and less anteverted than expected. This effect is accentuated if the patient’s lumbar lordosis increases when supine under anesthesia on the orthopaedic table, as is often the case. An increase in
lordosis is easily identified with an image view of the
obturator foramina showing a decreasing superior-inferior dimension.
Femoral Preparation Tips
• Some surgeons recommend incising the piriformis to
expose the femur and get to the true piriformis fossa
for the starting point into the femur.
• Access to the femur requires patience and a stepwise
approach. Many surgeons release the capsule from the
medial femoral neck after dislocating the head. If you
choose to not dislocate and cut the neck in situ, this
capsular release can be performed after head removal
and with the femur externally rotated. Release the
band of capsule just inferior to the acetabulum. The femur is placed in the preparation position with the table
with successive external rotation (approximately 120
degrees), hyperextension, adduction, and proximal elevation with the hook. First, the lateral capsule is released from the lateral neck remnant and medial
greater trochanter, which is typically enough to allow
the femur to displace lateral and anterior. The bone
hook is progressively raised as the femur mobility allows. Do not force the bone hook up, because it will
risk a fracture of the greater trochanter.

• If further femoral displacement is needed you can progressively release the tendons of the obturator internus, piriformis, and obturator externus. An obturator
externus tendon release is rarely necessary and is least
desirable because it has the most medial anti-dislocation pull on the femur. At times the femur will not initially rotate externally to 90 degrees but will after release of the lateral capsule.
• The femoral elevation hook should not be thought of
as a strong traction device. The hook is a support that
keeps the femur from falling posterior from a position
that you can manually create by pulling on the hook.
Feel the tension on the hook and make sure that you
can still manually lift the femur a little higher than the
hook supports it.
• Ensure that all traction is off the operative leg before
placing it in extension and external rotation.
• Do not force the proximal femur up if it resists. Instead,
release the posterior superior capsule, and try to pull
the femur away from the acetabulum. The posterior
part of the greater trochanter tends to get caught on
the posterior rim of the acetabulum. If you try to force
it up, you will risk fracture of
the trochanter.
• You can enter the femoral canal with a Kuntcher Awl
or the Canal Finder (Cat. No 9400-80-001). It has just
the right bend and gets the entry in the right alignment under fluoro. It has helped some surgeons when
they first started on the learning curve and may help
avoid violation of the canal.

22 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Femoral Broaching Tips
• Broaching is straightforward, but be cautious of a patient with a flexion contracture, as the femur may be sitting straight out instead of down, and you can broach
out the back of the femur if you are not careful.
• Femoral anteversion is judged by palpation of the patella and visualization of the neck cut. The plane of the
broach should be roughly parallel to the plane of the
posterior neck cortex. Most femurs have very little anatomic anteversion.
• The broach handle should be up against the patient’s
side to avoid having the broach perforate the posterior
part of the proximal femur.
C-Arm Tips
• The purpose of the image intensifier is to enhance the
accuracy of the cup placement and femoral length and
offset compared to standard techniques. Use your
standard cues for orientation of the acetabular component and use the image as your check. Place the femoral trial according to the pre-operative template and intra-operative bony landmarks (greater and lesser
trochanter) and then make a check with the C-Arm.
• Capture a true A/P pelvis view and note how many degrees of orbit are present. Once the acetabular component is impacted, view the hip using continuous fluoro
while orbiting the fluoro laterally. When the posterior
rim of the acetabular component is superimposed on
the anterior rim of the shell lock the orbit. Note how
many degrees of orbit are present. This number minus
the initial number from the A/P will be the anteversion
angle of the cup. It is very important to start the procedure with a balanced pelvis where the coccyx lines up
with the symphysis pubis.

• Check your stem version with the femur as the reference. Using the final broach as your guide, reduce the
hip and balance the pelvis under fluoro to assure the
center of the coccyx is in line with the symphysis. Orbit
the fluoro beam to obtain an A/P of the hip and proximal femur. Using continuous fluoro, unlock the table
rotation, manipulate the operative leg at the knee or
foot while viewing the image screen. When rotating
from external to internal you will observe the femoral
stems anterior surface is at its maximum medial to lateral diameter (when using a tapered stem) and relative
foot position. If the foot is externally rotated, then your
stem is retroverted. If the foot is internally rotated 10
to 15 degrees, then your stem is well-rotated. If, however, you have the foot extremely internally rotated,
then your femoral stem is excessively anteverted.
Stability Checking Tips
• Check hip stability with 60 degrees of external rotation
and 50-60 degrees of extension.
• Take the boot out of the spar, grasp the foot with the
sterile drapes that are covering it and put the leg in a
ROM test, and/ or your preferred checks.
Retractor Tips
• Use a Sorrel Retractor (2598-07-210) placed over a lap
sponge over the tensor muscle and attach it to a weight
(2598-07-230). It obviates the need for an assistant to
retract the tensor posteriorly with a Hibbs retractor.
• The long-handled Cobras are good for obese patients
and allow the hands of the assistant to be out of the
way while broaching.
• Take care when using the anterior acetabulum retractor
– do not use a long pointed tip, and stay on the bone
to avoid injury to the femoral nerve.

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 22

Preventing Infection in Obese Patients
Joel Matta, M.D.

There has been concern expressed regarding the possibility
of wound infection for obese patients undergoing Anterior
Total Hip Arthroplasty (ATHA). I will give my thoughts
which may be useful because my personal series documents only one deep infection in over 1350 primaries. This
patient was not particularly obese but had psoriatic arthritis
with skin lesions adjacent to the operative site.
Obesity by itself is of course an infection risk because of
the thick, poorly vascularized sub-cutaneous layer. Posterior and lateral approaches with their fat layer - thicker
than anterior - certainly pose their own risks. The major
concern and observed problem from anterior, however,
has been an overhanging pannus with
a deep skin crease.
Surgery should not be performed, particularly ATHA, if
the skin fold has observed inflammation, skin breakdown,
or evidence of fungal infection. “Goopy stuff” in the fold
and redness are obvious warning flags. I have had patients that needed a dermatologic consult pre-op. This led
to topical medications and dressing material in the fold.
I think prepping and draping methodically and carefully is
very important. In extreme cases the abdomen can be
taped toward the opposite side. Assuming the skin is
clean and in good condition, I shave local and adjacent
pubic hair. The main goal is to have adhesive vinyl drapes
that stick and remain stuck during the prep and throughout the procedure.
I don’t think that vinyl drape application is as simple as it
seems to many in the OR and I harp on the details of this
to nurses and assistants. Another principle is that making
your drape border far from the wound edges enhances
sterility because there is less likelihood that unsticking of
the drapes will make a window to surrounding unsterile
areas. I make an outline of tincture of benzoin where the
sticky edge drapes. Allow the benzoin to dry prior to vinyl
border drape application. Proximal this outline is above or
at the iliac crest and distal at mid thigh, and posterior,
posterior to the greater trochanter by 7 to 10 cm. The

medial border should be as medial as possible without being deep in the skin crease between the pubic prominence and the thigh.
I find if the medial drape is too medial it is very difficult to
keep it firmly attached during the prep. When the border
vinyl drapes are placed on the benzoin border they should
not be placed under tension. If anything, place the skin
under slight tension so that the vinyl edge will sit down
and in the concavities and folds and stay there. The biggest problem I see is that the person applying pulls the vinyl drape and it does not go into and firmly attach to the
depths of the concavities and folds. No tension during application! The prepping must also not create detachment
of the vinyl drape border.
Once the vinyl drape border is established I don’t let the
subsequent drapes make the exposed surgical area
smaller. After placing some sheets above and below, I staple towels to the skin along the vinyl border and then apply split sheets above and below. The splits are not placed
on the skin but on the bordering towels and leave a small
margin of the towel border visible.
The most important step follows, which is getting the Betadine® impregnated skin vi drape properly applied. The
prepped area must be dry. Again don’t stretch the drape,
stretch the skin. An assistant needs to pull the pannus
proximally to flatten out the fold as much as possible. The
vi drape is then patted first into the concavities and then
outward over the convexities. At the completion the vi
drape if applied properly should look wrinkled not tense
and smooth. If pulled under tension, it will pull away from
the concavities during the case and open the widow to
unsterile areas. You may need a bigger vi drape than you
think because of stretching out the skin and following the
concavities of the obese. If there are air bubbles under the
vi drape, puncture them. Don’t “walk them to the side”
with your fingers. When you do this you unstick and restick areas of the vinyl making it lose some of its adhesiveness which makes it more likely to detach during the surgery and open a window to groin or other bacteria.

33 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Probably my details, like the towel border and U drapes,
are individual to my routine and not essential. However, a
firmly attached border with benzoin and maintaining intimate vi drape attachment during the surgery is essential.
An additional benefit of this technique is that the vi drape
usually turns the fold into a more gentle concavity and
helps hold the pannus up.
Begin the incision lateral enough and you will usually avoid
the worst of the pannus fold. Usually my incision is not longer than 10 cm, but make it as long as necessary. I prefer
the Protractor because it helps protect the skin and sub
cut. Like any other surgery, being gentle with soft tissues
and hemostasis is important in preventing infection. I have
started using the Tissue Link AquaMantis which I think
helps down in corners and hard to reach bleeders. I think it
helps with capsule bleeding. Get adequate femoral mobilization so that the tensor doesn’t get ripped. Femoral mobilization combined with adequate incision length will also
limit broach and handle trauma to the tissues.

After surgery, it is probably best to keep a dressing in the
skin fold to help prevent maceration. Do not allow the
nurses to place tape on the Steri-Strips or the tape will
pull them off.
I think that some obese patients will inevitably get some
proximal wound maceration and the skin may open some
in this area but the problem seems to remain superficial
and it gradually heals. If the wound opens a little in this
area, I do not try to close it.
No tubs or swimming pool (just showers) for the first 2
weeks and possibly longer if there is a wound problem.

Deep and sub cut drains are optional according to preference and bleeding at the end. After closing the fascia, I like
to put only one running layer of 2-0 in the sub cut. I don’t
like to try to approximate the dermis at this point because
the wound tends to split sub cut sutures that are very superficial. For the sub cut I think that usually less is better
because a lot of suture just crushes the fat leading to drainage. I then prefer a running sub cut that is resorbable. Secure the suture ends well with benzoin and Steri-Strips™
pinching the free ends of the suture. Dermabond® is the
last layer, then a dressing after the Dermabond dries.

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 33

Ordering Information

TSS Core Case 1
1

1. 2598-07-460 Universal Stem Insert Handle
2.

Trial Heads – Two Sets Per Case

3. 2598-07-570 Retaining Stem Inserter (2 pcs)
4. 2598-07-530 Modular Box Osteotome

Insert

1. Any two handles:

2570-00-000 SUMMIT® Universal Broach Handle
9522-10-500F CORAIL AMT Straight Broach Handle
9522-11-500 CORAIL AMT Curved Broach Handle
2598-07-540 Long Posterior Broach Handle
2001-97-000 Optional Version Control Rod
(for Posterior Broach Handle)
2598-07-550 Extra Curved Broach Handle
2598-07-350 Anterior Broach Handle - Left
2598-07-360 Anterior Broach Handle - Right

2. 2598-07-470 CORAIL/TRI-LOCK
Posterior Stem Insert Shaft

7
2
3

Base

3. 2598-07-480 SUMMIT Posterior Stem Insert Shaft
4. 2598-07-435 Bullet Tip Stem Insert Shaft
5. 2598-07-430 Standard Straight Stem Insert Shaft
6. 2598-07-450 SUMMIT Anterior Stem Insert Shaft
7. 2598-07-440 CORAIL/TRI-LOCK Anterior Stem Insert Shaft

2598-07-390

Tissue Sparing Femoral Core Case 1
Complete

2598-07-410 Lid
2598-07-411 Insert
2598-07-400 Base

33 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Modular Box Osteotome 2598-07-530

Dual Offset Anterior Approach Broach Handle
Left 2598-07-350, Right 2598-07-360

Extra-Curved Broach Handle 2598-07-550
Suitable for multiple surgical approaches.

Other broach handle options:
2570-00-000

SUMMIT Universal Broach Handle

9522-10-500F CORAIL AMT Straight Broach Handle
9522-11-500 CORAIL AMT Curved Broach Handle
Technique-specific femoral component inserters:
2598-07-460 Universal Stem Inserter Handle
2598-07-440 CORAIL/TRI-LOCK Bone Preservation
Stem Anterior Inserter Shaft
2598-07-450

SUMMIT Anterior Inserter Shaft

2598-07-430

Standard Straight Inserter Shaft

2598-07-470 CORAIL/TRI-LOCK Bone Preservation
Stem Posterior Inserter Shaft
2598-07-480

SUMMIT Posterior Inserter Shaft

2598-07-435 Bullet Tip Inserter Shaft

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 33

Ordering Information

TSS Core Case 2

1. 2354-10-000 Muller Awl Reamer w/Hudson End

5
2

2. 2001-42-000 Excel T-Handle
3. 2001-80-501 IM Initiator Sized
4. 9400-80-007 MI Calcar Reamer Small (Shielded)
5. 85-3927

Femoral Rasp

6. 9400-80-001 Canal Finder
7. 2001-65-000 Femoral/Humeral Head Impactor

2598-07-420 Tissue Sparing Femoral Core Case 2
Complete
2598-07-422 Lid
2598-07-421 Base
Optional Replacement Part:
2001-66-000 Replacement Tip
for Femoral Head Impactor

Calcar Planer
2570-04-500 MI Calcar Reamer Shaft
2001-47-000 Calcar Mill Discs – Small
2001-48-000 Calcar Mill Discs – Medium
2001-49-000 Calcar Mill Discs – Large

33 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

3
4

Anterior Approach Instrumentation
7

1. 37-4106 Blunted Serrated Cobra (2)
1

2. 2598-07-200 MI 2-Incision Sharp Cobra (Serrated Point)

3. 2598-07-260 Blunted Cobra

2
3

4. 2598-07-240 Single Prong Soft Tissue Retractor

4
5

5. 2181-10-000 Hohmann Retractor Narrow/Curved
(120 degree)

Insert

6. 2001-42-000 Excel T-Handle
7. 2125-00-600 Modular Head Ball Remover

1. 2598-07-180 Right Angle Posterior Capsular Retractor
(Hibbs)

2. 2598-07-230 Sorrel Retractor Weight 2lbs

3. 32598-07-210 Sorrel Incision Retractor Blade Wide
8

4. 2004-00-000 Murphy Bone Skid

5
6
7

5. 2598-07-190 MI Narrow Curved Hohmann
Base

6. 2598-07-110 MI Gluteus Medius Retractor
(Right Angle Hohmann)
7. 2176-10-000 Muller Type Retractor
8. 2598-07-220 Sorrel Retractor Weight 2.5 lbs

2598-07-310 Anterior Approach Case Complete
2598-07-320 Lid
2598-07-340 Insert
2598-07-330 Base

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 33

Ordering Information

MI Retractor Kit

1
2

1. 2598-07-650 MI XL Femoral Neck Elevator

2. 2598-07-625 Inferior Posterior Capsular Retractor Right
3. 2598-07-626 Inferior Posterior Capsular Retractor Left

4. 2598-07-180 Right Angle Posterior Capsular Retractor
5. 2598-07-120 Blunt Right Angle
Posterior Capsular Retractor

7
8

Insert

6. 2598-07-150 Sciatic Nerve Retractor
7. 2598-07-140 Superior Capsular Retractor
8. 2598-07-170 Anterior Hohmann

1. 2598-07-130 MI Cobra Retractor with Armrest
2. 2598-07-190 MI Narrow Curved Hohmann
3. 2598-07-160 MI Narrow Cobra
2

4. 2598-07-110 MI Gluteus Medius Retractor
(Right Angle Hohmann)

3
4
1

Base

2598-07-500 MI Retractor Case Complete
2598-07-520 Lid
2598-07-515 Insert
2598-07-510 Base

33 DePuy Synthes Joint Reconstruction Anterior Approach Surgical Technique

Lighted Retractors

1. 2598-07-940 Cable with Olympus Adaptor
2. 2598-07-930 Cable with Storz Adaptor
3. 2598-07-910 Cable with ACMI Adaptor
3

4. 2598-07-920 Cable with Wolf Adaptor

5. 2598-07-900 Lightstrips (Package of 5)

MAcS Acetabular Set

1. 9200-10-024 Impactor Tip 22.225 mm

6
2

2. 9200-10-025 Impactor Tip 26 mm

4
5

7
9

8
7

3. 9200-10-026 Impactor Tip 28 mm
4. 9200-10-027 Impactor Tip 32 mm

5. 9200-10-028 Impactor Tip 36 mm
6. 2598-08-160 Angled Drive Shaft Dual Coupling
7. 9200-10-029 Angled Acetabular Inserter
8. 9200-10-023 Bantam Adaptor
9. 2598-08-150 Angled Reamer Driver Housing Assembly

9200-10-017

MAcS Case Complete

Inserter Replacement Parts (not shown):

Optional Impactor Tips (not shown):

9200-10-088

Spring

2217-50-060 Impactor Tip 40 mm

9200-10-089

Button

2217-50-061 Impactor Tip 44 mm

9200-10-091

Lock Catch

2217-50-062 Impactor Tip 48 mm

9200-10-093

Standard Adapter

Anterior Approach Surgical Technique DePuy Synthes Joint Reconstruction 33

Total Hip Prostheses, Self-Centering™ Hip Prostheses and Hemi-Hip Prostheses
Important

Contraindications

This Essential Product Information sheet does not include all of
the information necessary for selection and use of a device. Please
see full labeling for all necessary information.

THA and hemi-hip arthroplasty are contraindicated in cases of:
active local or systemic infection; loss of musculature, neuromuscular compromise or vascular deficiency in the affected limb,
rendering the procedure unjustifiable; poor bone quality; Charcot’s or Paget’s disease; for hemi-hip arthroplasty – pathological
conditions of the acetabulum that preclude the use of the natural acetabulum as an appropriate articular surface. Ceramic
heads without inner titanium sleeves are contraindicated in revision surgery when the femoral stem is well fixed and is not being replaced.

Intended Use/Indications
Total Hip Arthroplasty (THA) is intended to provide increased patient mobility and reduce pain by replacing the damaged hip
joint articulation in patients where there is evidence of sufficient
sound bone to seat and support the components.
THA is indicated for a severely painful and/or disabled joint
from osteoarthritis, traumatic arthritis, rheumatoid arthritis or
congenital hip dysplasia; avascular necrosis of the femoral head;
acute traumatic fracture of the femoral head or neck; failed previous hip surgery; and certain cases of ankylosis.
Porous-coated Pinnacle Acetabular Cups are indicated for cementless applications. Self-Centering Hip Prostheses and HemiHip Prostheses are intended to be used for hemi-hip arthroplasty
where there is evidence of a satisfactory natural acetabulum and
sufficient femoral bone to seat and support the femoral stem.
The Cathcart is not intended for use in total hip arthroplasty.
Hemi-hip arthroplasty is indicated
in the following conditions:
Acute fracture of the femoral head or neck that cannot be reduced and treated with internal fixation; fracture dislocation of
the hip that cannot be appropriately reduced and treated with
internal fixation; avascular necrosis of the femoral head; nonunion of femoral neck fractures; certain high subcapital and
femoral neck fractures in the elderly; degenerative arthritis involving only the femoral head in which the acetabulum does not
require replacement; and pathology involving only the femoral
head/neck and/or proximal femur that can be adequately
treated by hemi-hip arthroplasty.

Warnings and Precautions
Ceramic coated femoral stem prostheses are indicated for
uncemented press fit fixation. CAUTION: DO NOT USE
BONE CEMENT FOR FIXATION OF A CERAMIC
COATED PROSTHESIS.
Components labeled for “Cemented Use Only” are to be implanted only with bone cement. The following conditions tend
to adversely affect hip replacement implants: excessive patient
weight, high levels of patient activity, likelihood of falls, poor
bone stock, metabolic disorders, history of infections, severe deformities leading to impaired fixation or improper positioning,
tumors of the supporting bone structures, allergic reactions to
materials, tissue reactions, and disabilities of other joints.
Adverse Events
The following are the most frequent adverse events after hip arthroplasty: change in position of the components, loosening of
components, wear or fracture of components, dislocation, infection, peripheral neuropathies, tissue reaction.

Limited Warranty and Disclaimer: DePuy Synthes Joint Reconstruction products are sold with a limited warranty to the original purchaser against defects
in workmanship and materials. Any other express or implied warranties, including warranties of merchantability or fitness, are hereby disclaimed.
WARNING: In the USA, this product has labeling limitations. See package insert for complete information.
CAUTION: USA Law restricts these devices to sale by or on the order of a physician.
Not all products are currently available in all markets.

DePuy Orthopaedics, Inc.
700 Orthopaedic Drive
Warsaw, IN 46582
T. +1 (800) 366-8143

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History When                    : 2010:08:31 10:21:21+01:00, 2010:08:31 10:21:21+01:00, 2010:08:31 10:22:20+01:00, 2010:10:14 16:03:13+01:00, 2010:10:14 16:21:41+01:00, 2010:10:14 16:31+01:00, 2010:10:14 16:31+01:00, 2010:10:15 11:47:47+01:00, 2010:10:20 14:41:20+01:00, 2010:10:20 14:41:20+01:00, 2010:10:22 16:23:15+01:00, 2010:10:22 16:25:55+01:00, 2010:10:22 16:25:55+01:00, 2010:10:25 10:45:52+01:00, 2010:11:18 11:41:23Z, 2010:11:18 11:41:23Z, 2010:11:18 11:47:07Z, 2010:11:18 12:45:58Z, 2010:11:18 12:46:17Z, 2010:11:18 14:19:44Z, 2010:11:18 14:43:21Z, 2010:11:18 15:39:24Z, 2010:11:18 15:46:52Z, 2010:11:18 15:57:02Z, 2010:11:18 16:17:29Z, 2010:11:18 16:27:44Z, 2010:11:18 16:29:19Z, 2010:11:18 17:03:10Z, 2010:11:18 17:15:04Z, 2010:11:18 17:25:22Z, 2010:11:18 17:28:42Z, 2010:11:18 17:39:37Z, 2010:11:19 10:00:42Z, 2010:11:19 10:00:42Z, 2010:11:19 10:51:57Z, 2010:11:19 10:54:50Z, 2010:11:19 10:59:16Z, 2010:11:19 11:00:36Z, 2010:11:19 11:06:20Z, 2010:11:19 11:22:28Z, 2010:11:19 11:37:11Z, 2010:11:19 11:59:33Z, 2010:11:19 12:01:18Z, 2010:11:19 12:09:51Z, 2010:11:19 12:24:42Z, 2010:11:19 12:33:10Z, 2010:11:19 13:41:28Z, 2010:11:19 13:45:18Z, 2010:11:19 13:52:47Z, 2010:11:19 14:10:50Z, 2010:11:19 15:04:17Z, 2010:11:19 15:10Z, 2010:11:19 15:16:25Z, 2010:11:19 15:16:45Z, 2010:11:19 15:48:17Z, 2010:11:19 16:30:32Z, 2010:11:19 16:38:38Z, 2010:11:19 17:01:24Z, 2010:12:13 17:27:02Z, 2010:12:13 17:27:03Z, 2010:12:13 17:39:12Z, 2010:12:14 09:48:06Z, 2010:12:14 09:48:06Z, 2010:12:14 11:37:23Z, 2010:12:14 11:56:14Z, 2010:12:16 15:28:37Z, 2010:12:16 15:28:37Z, 2010:12:16 15:37:31Z, 2010:12:16 15:38:43Z, 2010:12:16 15:45:22Z, 2010:12:16 16:02:02Z, 2010:12:17 15:19:34Z, 2010:12:17 15:19:35Z, 2010:12:17 16:51:38Z, 2010:12:17 17:22:09Z, 2010:12:20 11:23:21Z, 2010:12:20 11:23:21Z, 2010:12:20 12:10:02Z, 2010:12:20 12:51:46Z, 2010:12:20 12:59:19Z, 2010:12:20 14:28:44Z, 2010:12:20 14:57:05Z, 2010:12:20 17:38:44Z, 2010:12:21 09:24:53Z, 2010:12:21 09:24:53Z, 2010:12:21 17:30:11Z, 2010:12:23 10:24:41Z, 2010:12:23 10:24:42Z, 2010:12:23 10:41:11Z, 2010:12:23 11:09:22Z, 2010:12:23 11:10:50Z, 2010:12:23 11:19:31Z, 2010:12:23 11:24:08Z, 2010:12:23 12:06:26Z, 2010:12:23 14:11:55Z, 2010:12:23 17:11:58Z, 2010:12:24 09:42:37Z, 2010:12:24 10:45:08Z, 2010:12:24 10:49:53Z, 2010:12:24 10:52:20Z, 2010:12:24 11:04:37Z, 2010:12:24 11:15:46Z, 2010:12:24 11:22:29Z, 2011:01:10 11:38:48Z, 2011:01:10 11:38:48Z, 2011:01:10 14:18:07Z, 2011:01:10 14:46:43Z, 2011:01:10 15:23:14Z, 2011:01:10 15:52:34Z, 2011:01:10 16:21:38Z, 2011:01:10 16:24Z, 2011:01:10 16:26:53Z, 2011:01:10 16:57:57Z, 2011:01:10 17:00:04Z, 2011:01:10 17:03:05Z, 2011:01:10 17:04:39Z, 2011:01:10 17:08:58Z, 2011:01:11 09:29Z, 2011:01:11 16:54:28Z, 2011:01:11 17:12:31Z, 2011:01:11 17:25:22Z, 2011:01:11 17:29:58Z, 2011:01:11 17:35:18Z, 2011:01:11 17:35:55Z, 2011:01:18 17:12:53Z, 2011:01:18 17:12:54Z, 2011:01:18 17:59:56Z, 2011:01:20 15:48:28Z, 2011:01:20 15:48:28Z, 2011:01:20 16:33:29Z, 2011:01:20 17:38:38Z, 2011:01:21 10:56:29Z, 2011:01:21 11:27:06Z, 2011:01:21 11:27:06Z, 2011:01:21 12:12:25Z, 2011:01:21 12:12:25Z, 2011:01:21 12:26:24Z, 2011:01:21 12:28Z, 2011:01:21 12:38Z, 2011:01:21 15:59:27Z, 2011:02:02 16:11:02Z, 2011:02:02 16:11:02Z, 2011:02:02 16:58:31Z, 2011:02:02 17:02:34Z, 2011:02:02 17:32:47Z, 2011:02:03 09:46:18Z, 2011:02:03 09:46:19Z, 2011:02:03 10:43:16Z, 2011:02:04 09:35:18Z, 2011:02:04 17:20:18Z, 2011:02:04 17:20:18Z, 2011:02:07 17:30:51Z, 2011:02:07 17:30:51Z, 2011:02:08 09:52:31Z, 2011:02:08 09:52:32Z, 2011:02:08 10:46:11Z, 2011:02:08 11:00:26Z, 2011:02:08 11:10:08Z, 2011:02:08 11:20:33Z, 2011:02:08 11:22:01Z, 2011:02:08 11:26:10Z, 2011:02:08 15:44:35Z, 2011:02:08 16:20:11Z, 2011:02:09 10:40:20Z, 2011:02:09 10:44:14Z, 2011:02:09 10:44:14Z, 2011:02:09 10:46:29Z, 2011:02:09 10:53:18Z, 2011:02:09 10:57:59Z, 2011:02:09 11:34:16Z, 2011:02:09 11:56:45Z, 2011:02:09 13:29:54Z, 2011:02:09 13:43:43Z, 2011:02:10 11:51:34Z, 2011:02:10 11:51:34Z, 2011:02:10 12:00:13Z, 2011:02:14 10:11:48Z, 2011:02:14 10:11:48Z, 2011:02:14 10:21:49Z, 2011:02:14 10:53:27Z, 2011:02:14 11:01:16Z, 2011:02:14 11:19:23Z, 2011:02:14 16:47:39Z, 2011:02:16 17:52:06Z, 2011:02:16 18:06:20Z, 2011:02:17 10:39:10Z, 2011:02:17 11:06:10Z, 2011:02:17 11:06:10Z, 2011:02:17 15:37:40Z, 2011:02:21 13:49Z, 2011:02:21 13:49:21Z, 2011:02:21 13:49:21Z, 2011:02:21 13:49:42Z, 2011:02:21 17:56:04Z, 2011:02:23 16:02:05Z, 2011:02:23 16:06:42Z, 2011:02:23 16:35:51Z, 2011:02:23 16:41:14Z, 2011:02:23 16:47:21Z, 2011:02:23 16:48:28Z, 2011:02:23 16:48:29Z, 2011:02:24 09:55:14Z, 2011:02:24 09:58:51Z, 2011:02:28 10:29:36-05:00, 2011:02:28 10:29:36-05:00, 2011:02:28 14:54:22-05:00, 2011:02:28 15:41:43-05:00, 2011:02:28 16:11:35-05:00, 2011:03:08 14:32:44-05:00, 2011:09:09 08:22:42-04:00, 2011:09:09 08:22:43-04:00, 2011:09:09 08:25:54-04:00, 2011:09:13 13:17:53-04:00, 2011:09:21 08:17:15-04:00, 2011:09:21 08:17:15-04:00, 2011:09:21 08:19:03-04:00, 2011:10:10 13:27:05-04:00, 2011:10:10 13:37:17-04:00, 2011:10:10 13:43:57-04:00, 2011:10:10 14:36:28-04:00, 2012:07:25 13:27:35-04:00, 2012:07:25 13:27:35-04:00, 2012:07:25 14:08:24-04:00, 2012:07:25 14:08:24-04:00, 2012:07:25 14:13:17-04:00, 2012:07:26 08:41:25-04:00, 2012:07:26 11:47:06-04:00, 2012:07:26 11:48:10-04:00, 2012:07:26 11:48:45-04:00, 2012:07:26 11:49:56-04:00, 2012:07:26 11:52:03-04:00, 2012:07:26 11:52:03-04:00, 2012:07:26 11:59:58-04:00, 2012:08:13 14:42:12-04:00, 2012:08:13 14:42:24-04:00, 2012:08:24 14:01:22-04:00, 2012:08:24 14:01:42-04:00, 2012:08:24 14:10:29-04:00, 2012:08:27 15:44:01-04:00, 2012:08:27 15:44:21-04:00, 2012:08:28 08:48:43-04:00, 2012:08:28 08:49:14-04:00, 2012:08:28 08:50:07-04:00, 2012:08:28 08:50:07-04:00, 2012:08:28 08:52:13-04:00, 2012:08:29 09:20:30-04:00, 2012:08:29 09:20:30-04:00, 2012:08:29 10:32:12-04:00, 2012:08:29 10:33:12-04:00, 2012:08:29 10:39:35-04:00, 2012:08:29 11:03:57-04:00, 2012:08:29 11:04:58-04:00, 2012:08:29 11:44:50-04:00, 2012:08:29 14:29:13-04:00, 2012:09:18 07:21:06-04:00, 2013:03:27 11:49:55-04:00, 2013:03:27 12:05:19-04:00, 2013:03:27 12:35:47-04:00, 2013:03:27 13:37:42-04:00, 2013:03:27 13:40:25-04:00, 2013:03:27 14:03:32-04:00, 2013:03:27 14:15:50-04:00, 2013:03:27 14:29:36-04:00, 2013:03:27 15:04:23-04:00, 2013:03:27 15:12:06-04:00, 2013:03:27 15:16:47-04:00, 2013:03:27 15:22:26-04:00, 2013:03:27 15:38:39-04:00, 2013:03:27 15:47:30-04:00, 2013:03:27 16:00:55-04:00, 2013:03:28 08:24:20-04:00, 2013:03:28 08:38:49-04:00, 2013:03:28 08:56:27-04:00, 2013:03:28 09:19:22-04:00, 2013:03:28 10:15:31-04:00, 2013:03:28 10:16:24-04:00, 2013:03:28 10:21:59-04:00, 2013:03:28 10:31:07-04:00, 2013:04:16 11:34:16-04:00, 2013:04:16 11:39:59-04:00, 2013:04:16 11:49:36-04:00, 2013:05:03 15:02:26-04:00, 2013:05:03 15:07:29-04:00, 2013:05:03 15:13:09-04:00, 2013:05:03 15:15:25-04:00, 2013:05:03 15:25:31-04:00, 2013:05:03 15:32:18-04:00, 2013:05:03 15:38:25-04:00, 2013:05:03 15:49:32-04:00, 2013:05:03 15:51:29-04:00, 2013:05:03 15:55:47-04:00, 2013:05:03 16:01-04:00, 2013:05:03 16:03:59-04:00, 2013:05:03 16:05:21-04:00, 2013:05:06 12:33:05-04:00, 2013:05:06 12:35:08-04:00, 2013:05:07 09:12:11-04:00
History Software Agent          : Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe 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Anterior Approach Surgical Technique

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