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CEMENT TECHNIQUE A

34

CEMENT TECHNIQUE

Insert a cement restrictor in each canal thanks to cement
restrictor inserter.
Using a cement gun, antibiotic laden bone cement is injected
retrograde into the humeral canal, and antegrade into 
the ulnar and radial canals. The stems of the ulnar and radial
components are precoated with cement to improve 
the implant cement bond. The components are placed into
position, removing all excess cement, particularly around 
the bipolar radial head component. Depending on preference,
the radial and ulnar components can be cemented first 
and then the humerus or all three can be cemented
simultaneously.

TIP
When using the radial head component, cement both radial
head and ulnar stem at the same time. To ensure that both
components are seated at the same level, use the trial
humeral stem and spool as a visual guide to correct insertion
(fig. 57).

Anterior Flange Bone Graft 

A cancellous bone fragment from the resected bone of the
distal humerus is fashioned to fit between the humeral shaft
and the anterior flange of the humeral component.
The bone graft is wedged firmly in place (fig. 58).

Unlinked 

• The supplied ulnar screw is left in the ulnar component. 
• Proceed with ligament repair and closure. 

11. FINAL IMPLANT ASSEMBLY

(fig. 57)

(fig. 58)

Bone graft

Latitude Elbow Prosthesis Surgical Technique UCLT101

After all trial components have been removed, lavage and dry all medullary canals. 
Cement restrictors should be considered. 

ASSEMBLY OF FINAL COMPONENTS

The humeral stem (side and size) is assembled to the appropriate spool (side, size and offset). 
The implant humeral screw (cannulated) is firmly tightened with the 4.5 mm hex screwdriver (fig. 56a-c).

Check that the spool sits properly on the humeral component. 

(fig. 56a)

(fig. 56b)

(fig. 56c)

1

2

3

12. CEMENT TECHNIQUE AND BONE GRAFT

Latitude Elbow Prosthesis

TO LATITUDE INT UCLT101.qxd:Mise en page 1  7/07/10  15:01  Page 33

Summary of Contents for Latitude

Page 1: ...UCLT101 Latitude Elbow Prosthesis www tornier com S u r g i c a l Technique ...

Page 2: ...reaming for standard stem 9 ULNAR TRIAL AND RADIUS PREPARATION 10 TRIAL AND REDUCTION 1 Unlinked 2 Linked 11 FINAL IMPLANT ASSEMBLY 12 CEMENT TECHNIQUE AND BONE GRAFT 13 SUTURE TECHNIQUE AND CLOSURE 14 RADIO ULNAR TRICEPS ON CUTTING GUIDE 15 REVISION INSTRUMENTATION The Latitude surgical technique has been developed in conjunction with Shawn O Driscoll MD PhD Mayo Foundation Ken Yamaguchi MD Washi...

Page 3: ...nctive right and left anatomical components Precision instrumentation Intraoperative flexibility to utilize linked or unlinked Accurate implant positioning referenced on the flexion extension axis Ease of assembly Optimal bone preservation Anatomic distribution of loads on polyethylene CLINICAL OBJECTIVES Latitude for use in a wide range of indications Latitude to reproduce patient flexion extensi...

Page 4: ... to 9 fig 01 The flexion extension axis has a variable offset relative to the axis of the diaphysis varying between 4 and 8 mm with a mean of 6 mm fig 02 This variability necessitates a modular design with different articular offsets There is a consistent relationship between the distance from the center of the capitellum to the trochlear groove and the diameter of the capitellum The distance vari...

Page 5: ...meral spools have been designed with a concave barrel shaped trochlea to preserve linear contact throughout 7 of valgus varus movement with the ulnar component fig 05 5 Latitude Elbow Prosthesis Latitude Elbow Prosthesis Surgical Technique UCLT101 fig 05 2 ANATOMICAL DESIGN VALIDATION Anterior flange for bone graft to prevent posterior migration Stem in CoCr for cemented use Square shape for rotat...

Page 6: ...ution of joint reactive forces The Latitude Total Elbow offers intraoperative flexibility The decision to use the implant in a linked or unlinked mode is made following the examination of the surrounding soft tissues The ulnar cap has been designed to capture the humeral component to convert the implant to a linked semi constrained device In the event that an unlinked construct was initially perfo...

Page 7: ...f heads Ø 18 20 22 and 24 mm and 2 stem diameters 5 0 mm and 6 5 mm The Latitude Elbow radial component enables the surgeon to maintain the radio humeral joint when anatomical alignment is adequate The radial component has been designed to replicate the radio ulnar articulation The radial component is a bipolar design with 10 of motion to balance load transfer fig 11 The cobalt chrome ring of the ...

Page 8: ...s Ulnar diaphysis drill guides Bell saws Ulnar rasps The Latitude Elbow instruments bring precision and reproducibility to elbow arthroplasty in the setting where there has been some preservation of normal anatomy The instruments are designed to offer a reproducible step by step procedure Each jig uses anatomic landmarks to insure replication of the natural anatomy The flexion extension axis is ea...

Page 9: ...niques Same indications for Latitude Anatomic Hemi Elbow Prosthesis The prosthesis is for cemented use only 2 Contraindications Refer to the instruction for use delivered with the implant Latitude Elbow Prosthesis Surgical Technique UCLT101 UMENTATION 3 PRECISION INSTRUMENTATION INDICATIONS AND CONTRAINDICATIONS 4 INDICATIONS AND CONTRAINDICATIONS Ulnar and radial trial components Large components...

Page 10: ...nt be necessary full revision of the humeral components stem spool screw with Latitude 2nd generation humeral components is recommended The spool and screw revision only is still possible In that instance please contact the Custom Products Department 6 weeks before surgery Département des produits spéciaux TORNIER 161 rue Lavoisier Montbonnot 38334 Saint Ismier Cedex France Tél 33 0 4 76 61 35 00 ...

Page 11: ...ote The Latitude Anatomic Prosthesis does not take spool offset into consideration Refer to page 33 for the cement and bone graft technique Refer to page 36 for the suture technique and closure Note The Latitude Anatomic Prosthesis components are Humeral stem the one used for Total Elbow Prosthesis DKY181 to DKY186 fig 14 Anatomic spool different than the one used for the Total Elbow Prosthesis fi...

Page 12: ...e and just medial to the tip of the olecranon fig 16a Full thickness medial and lateral flaps are elevated on the deep fascia fig 16b Ulnar Nerve transposition The medial aspect of the triceps mechanism is identified and the ulnar nerve is isolated using loupe magnification fig 16c The medial intermuscular septum is excised The ulnar nerve is mobilized and transposed anteriorly into the subcutaneo...

Page 13: ...al humerus is bone deficient using a triceps sparing approach Triceps splitting approach The triceps tendon is split centrally ascending 8 cm proximal from the tip of the olecranon The tendon is then reflected medially and laterally off the olecranon by dividing Sharpey s fibers The medial and lateral portions of the tendon are kept in continuity with the flexor carpi ulnaris and anconeus respecti...

Page 14: ...d fig 17b The size of the capitellum may be confirmed with the gauge fig 17c Choose the final implant size based on these measurements This determination will be used throughout the procedure TIP Should the patient s humeral condyle size fall between two anatomical sized trial spools pick the smaller one for the remainder of the procedure Latitude Elbow Prosthesis Surgical Technique UCLT101 fig 17...

Page 15: ...ent of the lateral ligaments to the lateral epicondyle If the capitellum is imagined to be a circle when viewed from the lateral side the flexion extension axis is located at the center point of this circle The circular gauge is a useful tool to visually estimate this location Note The key to a successful outcome is the accurate determination of the flexion extension axis Remove the central portio...

Page 16: ...ly 45 anteriorly The center of the medial notch should be roughly at the center of the medial ridge of the trochlea such that an axis pin would appear to exit at the anterior and inferior edge of the medial epicondyle s intersection with the trochlea fig 20a Drill the flexion extension axis and then remove the guide fig 20c As a check reinsert the flexion extension pin to confirm correct alignment...

Page 17: ...mination Insert the pointed intramedullary alignment rod into the shaft of the humerus Anterior to the rod insert the flexion extension axis pin through the previously drilled holes fig 24a Select the offset gauge of the previously determined humeral size small medium large Determine spool offset by placing offset gauge between the flexion extension axis pin and the intramedullary alignment rod fi...

Page 18: ...stal Preparation Assemble the appropriate size humeral trochlea cutting block to the trochlear cutting guide support with the assembly screw Do not fully tighten the assembly screw at this time fig 25a Position the cutting guide on the flexion extension axis pin and align with the medullary alignment rodas shown fig 25b 18 Latitude Elbow Prosthesis Latitude Elbow Prosthesis Surgical Technique UCLT...

Page 19: ...ameter drill bit drill 2 holes at the inferior portion of the humeral trochlea cutting block and place 2 stabilizing pins as shown fig 27 TIP Size and side designations on all instruments always face the surgeon Remove the cutting support the flexion extension axis pin and the intramedullary alignment rod Drill with the 3 mm drill bit through the remaining holes on the cutting block as shown fig 2...

Page 20: ...ine figured on the block is correctly positioned Remove the bony bridge between the drill holes with a straight osteotome microsaggital saw or rongeur as necessary fig 30 If the medial trochlea has been excised mark where the flexion extension axis was using a marking pen Smooth the cut surface with a humeral broach or burr fig 31 Latitude Elbow Prosthesis Surgical Technique UCLT101 Instruments to...

Page 21: ...gn the jig Make distal and anterior capitellar cuts with an oscillating saw on the marked surface as shown fig 33 Broach the humeral canal with the starting broach and then proceed sequentially to the selected size of the humeral component fig 34a TIP The indication of side right or left should point posteriorly so that it can be read by the surgeon fig 34b Instruments to use fig 33 fig 34a fig 34...

Page 22: ...for a left trial on the right for a right trial stem Place the appropriate size trial humeral screw from medial to lateral Tighten using the 4 5 mm hex screwdriver Select the corresponding spool side size and offset according to the following table fig 36 left right anterior center posterior LEFT LEFT LARGE LARGE ASSEMBLY SPOOL TOTAL ELBOW PROSTHESIS LATITUDE ANATOMIC SMALL SMALL PLUS Anatomic onl...

Page 23: ...1 ASSEMBLY HUMERAL TRIAL STEM 7 HUMERAL TRIAL STEM Instruments to use Position the trial stem assembly in the humeral shaft Use the impactor to seat the implant flush with the bone fig 37 fig 37 Trial humeral stem Trial spool Trial humeral screw Impactor 4 5 hexagonal screwdriver L ...

Page 24: ...g guide Sliding block Forearm axis guide 3 locking screws flat trochar cannulated Ø 2 mm Choose the appropriate size and side cutting guide Assemble the cutting guide as shown see assembled cutting guide fig 38a d fig 38d fig 38a fig 38b fig 38c Screw the forearm axis guide into the cutting guide Screw the desired type screws cannulated trochar or flat into the cutting guide Slide the block onto t...

Page 25: ...r First tighten the posterior screw on the flat spot of the ulna to ensure that the spool will sit correctly in the sigmoid cavity of the olecranon Then tighten the remaining two screws Make sure that the forearm axis guide points towards the ulnar styloid fig 40a Make sure that the anatomical spool seats properly into the ulna and is anatomically aligned with the radial head fig 40b TIP The corre...

Page 26: ...collar of the saw sits on the lateral ring fig 42 Ensure the ulnar nerve is protected fig 41 fig 42 Instruments to use Anatomical spool Bell saw 8 ULNAR PREPARATION triceps splitting approach Bell saw collar Ulnar radial cutting guide Note Slot thickness is 1 4 mm Latitude Elbow Prosthesis Latitude Elbow Prosthesis Surgical Technique UCLT101 ULNAR PREPARATIO ...

Page 27: ... L ulnar diaphysis drill guide fig 44a Place the drill guide in the sigmoid cut and drill the ulnar canal with the 4 5 mm drill bit to the depth of the mark corresponding to the size of the implant fig 44b The tip of the olecranon can be removed with a rongeur if necessary Note The position of the guide should be aligned as shown with reference to the tip of the coranoid and olecranon Instruments ...

Page 28: ...ach in the ulnar canal respecting the radial inclination of the shaft fig 46 Use the orientation of the flat spot on the posterior surface of the ulna to assist in correctly rotating the ulnar broach 28 Instruments to use fig 45 fig 46 Ulnar broaches 8 ULNAR PREPARATION triceps splitting approach Latitude Elbow Prosthesis Latitude Elbow Prosthesis Surgical Technique UCLT101 ...

Page 29: ...ate seating of the trial and implant fig 47b Should a standard ulnar stem be desired ream the canal for the final implant with the ulnar reamer fig 47c or a flexible boring 3 Ulnar canal reaming for standard stem Assemble the reamer to the handle Gently ream the canal making sure not to penetrate the lateral or dorsal cortex fig 47c Flexible reamers not included can be used if preferred fig 47a In...

Page 30: ...Surgical Technique UCLT101 ULNAR TRIAL Select the appropriate ulnar trial according to side size and desired length Position the trial stem in the ulnar canal and then seat it flush with the ulna using the impactor fig 48a b Instruments to use fig 48a fig 48b Trial ulnar stems Impactor Trial radial stem impactor ...

Page 31: ... the resected surface If a larger stem is desired broach next with the 6 5 mm broach fig 50 Upon completion unscrew the handle leaving the broach seated in the canal fig 51a Using the same color code select the appropriate size trial radial head and place the trial head on the stem fig 51b TIP The radial head trial seats freely on the stem and is not a snap fit Instruments to use Trial radial stem...

Page 32: ...at the trial implants are correctly positioned and that no soft tissue impingement has occurred In case of an unstable elbow use the trial cap to link the implant 2 Linked Assemble the trial ulnar cap as shown fig 53a d to the ulnar stem and tighten the trial locking screw Confirm appropriate component placement and perform another trial reduction Perform the initial trial reduction by placing the...

Page 33: ...ormed After the trial reduction is complete remove the trial stems To remove the trial radial stem screw the radial trial handle into the screw hole of the radial trial stem Gently tap with a mallet to extract the stem Remove the ulnar trial stem using the ulnar stem extractor tool fig 54 To remove the humeral component grasp the humeral trial spool with the humeral extractor clamp fig 55 Then gen...

Page 34: ...al stem and spool as a visual guide to correct insertion fig 57 Anterior Flange Bone Graft A cancellous bone fragment from the resected bone of the distal humerus is fashioned to fit between the humeral shaft and the anterior flange of the humeral component The bone graft is wedged firmly in place fig 58 Unlinked The supplied ulnar screw is left in the ulnar component Proceed with ligament repair ...

Page 35: ... the components Assemble the 2 5 mm screwdriver with the torque handle When cement has completely set remove the protecting ulnar screw with the 2 5 mm hex screw driver and discard Reduce humeral and ulnar components to approximately 140 of flexion insert ulnar cap into the ulnar stem fig 59 Tighten the screw until the torque release is reached fig 60 35 Latitude Elbow Prosthesis E AND BONE GRAFT ...

Page 36: ...61b 12 CEMENT TECHNIQUE AND BONE GRAFT Instruments to use Torque handle Cement restrictor inserter Torgue screwdriver adaptator Mallet Ulnar cap lug bending tool fig 61a fig 61b Latitude Elbow Prosthesis Latitude Elbow Prosthesis Surgical Technique UCLT101 CEMENT TECHNIQUE AND BONE GRAFT ...

Page 37: ...supination is performed with the elbow in flexion A collar and cuff or sling is used between exercises for the first 6 weeks Extension splinting at night may be used to assist in regaining elbow extension after four weeks Light strengthening is initiated 10 weeks postoperatively Linked TEA The elbow is splinted in full extension with a well padded splint for 24 48 hours Active flexion and prosupin...

Page 38: ...s guide into the cutting guide Assemble the spool support to the jig on either side depending on whether the ulnar cut is to be made from lateral or medial Slide the screw support onto the cutting guide Medial Lateral Right Left The radial head cut is performed at the level of the notch on the side of the triceps on guide Screw the 4 desired type screws cannulated trochar or flat into the cutting ...

Page 39: ...y remove the pin from the plastic metal interface picture 3 Step 5 Once the pin has been removed the ulnar plastic bushing can be slide off the ulnar stem It can be helpful to use a tapered tool and a hammer to remove the plastic part as shown on pictures 4 and 5 Step 6 Position the new plastic bushing on the ulnar stem and rotate it on the slide channel until it is flush fully engaged picture 6 S...

Page 40: ...Ref MKY058 Humeral diaphysis reamer Ø 6 Ref MKY007 Offset determination Axis Ø 2 8 L180 flexion extension Ref MKY018 Humeral diaphysis axis Ref MKY019 Offset determining gauge Small size Ref MKY008 Medium size Ref MKY009 Large size Ref MKY010 Humeral trochlea cut Humeral trochlea cutting block Small size Ref MKY012 Medium size Ref MKY013 Large size Ref MKY014 Humeral trochlea cutting guide support...

Page 41: ...e left Ref MKY090 Large size right Ref MKY088 Large size left Ref MKY091 Large size right Ref MKY139 Large size left Ref MKY140 Trial spool centered offset Small right Ref MKY098 Small left Ref MKY101 Medium right Ref MKY099 Medium left Ref MKY102 Large right Ref MKY100 Large left Ref MKY103 Large right Ref MKY141 Large left Ref MKY142 Trial spool posterior offset Small right Ref MKY092 Small left...

Page 42: ...l cutting guide sliding block Ref MKY047 Locking screw Ref MKY054 Bell saw Small size Ref MKY037 Medium size Ref MKY038 Large size Ref MKY039 Ulnar diaphysis drilling Ulnar diaphysis drill guide handle Ref MKY048 Ulnar diaphysis drill guide Small size right Ref MKY051 Small size left Ref MKY069 Medium size right Ref MKY050 Medium size left Ref MKY067 Large size right Ref MKY049 Large size left Ref...

Page 43: ...130 Torque handle Ref MKY121 Torque screwdriver adaptor hexagon 2 5 mm Ref MKY122 Trial ulnar cap Small size Ref MKY113 Medium size Ref MKY114 Large size Ref MKY115 Spare M5 ulnar screw implant Ref DKY066 Ulnar cup lug bending tool Ref MKY124 Trial radial head Small size Ref MKY055 Medium size Ref MKY056 Large size Ref MKY057 Large size Ref MKY134 Triceps on jig Right size Ref MKY135 Left size Ref...

Page 44: ...all left DKY076 Standard ulnar stem medium left DKY077 Standard ulnar stem large left Short Ulnar Stem Ref Component information DKY081 Ulnar stem small right DKY082 Ulnar stem medium right DKY083 Ulnar stem large right DKY085 Ulnar stem small left DKY086 Ulnar stem medium left DKY087 Ulnar stem large left Posterior Anterior Centered 161 rue Lavoisier Montbonnot 38334 Saint Ismier Cedex France Tel...

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