Zimmer Biomet Arcos Modular FemoralRevision System User manual

Arcos®Modular Femoral
Revision System
Broach and Calcar Proximal Bodies
Surgical Technique

Table of Contents
Pre-operative Planning .......................................................................................2
Patient Positioning and Surgical Approach..........................................................2
Removal of a Cemented Component ...................................................................3
Removal of a Cementless Stem ...........................................................................3
Calcar/Broach Proximal Bodies & PPS®Distal Stems Sterile Field Technique ........4
Preparation of the Diaphysis ................................................................................ 4
Preparation of the Metaphysis ............................................................................. 4
Broaching the Metaphysis ................................................................................... 5
Calcar Resection ................................................................................................. 6
Trial Reduction .................................................................................................... 7
Implant Assembly................................................................................................ 8
Implant Insertion ................................................................................................. 8
Inserting the Locking Screw................................................................................. 9
Final Reduction ................................................................................................... 9
Calcar/Broach Proximal Bodies & STS Distal Stems Sterile Field Techinque........10
Preparation of the Diaphysis .............................................................................. 10
Trialing the Distal Stem...................................................................................... 10
Preparation of the Metaphysis ........................................................................... 11
Broaching the Metaphysis ................................................................................. 12
Calcar Resection ............................................................................................... 13
Trial Reduction .................................................................................................. 14
Implant Assembly.............................................................................................. 15
Implant Insertion ............................................................................................... 16
Inserting the Locking Screw............................................................................... 16
Final Reduction ................................................................................................. 17
Trochanteric Reattachment Technique .............................................................. 18
Attaching the Trochanteric Bolt Guide ............................................................... 18
Preparing For Auxiliary Implant Attachment ...................................................... 19
Final Attachment of the Auxiliary Implant........................................................... 21
In-Femur Assembly...........................................................................................22
Implant Assembly.............................................................................................. 22
Inserter Disassembly......................................................................................... 25
Inserting the Locking Screw............................................................................... 26
Final Reduction ................................................................................................. 27
Taper Compression Assembly...........................................................................28
Proximal Body Insertion .................................................................................... 28
Inserter Disassembly......................................................................................... 30
Inserting the Locking Screw............................................................................... 31
Disengaging the Taper Junction ........................................................................32
Disengaging the Proximal Body from the Distal Stem Implant............................ 32

2 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 2Figure 1
Patient Positioning
and Surgical Approach
Patient position should be determined by the
surgeon’s preferred approach. The goal of the surgical
approach is to establish adequate visualization of the
anatomy (Figure 2).
Pre-operative Planning
When planning a hip revision utilizing the Arcos
Modular Femoral Revision System, carefully review
the indications and contraindications for use
referenced within the package insert.
The Arcos Modular Femoral Revision System is not
designed for use in a fully unsupported proximal
femur. Bone stock of adequate quality must be
present and appraised at the time of surgery. The
use of medial and/or lateral strut grafts may be
necessary to support the taper junction in cases of
severe proximal deficiency.
Utilizing A/P and M/L X-rays and implant templates
will assist in determining the correct implant size,
offset and position for a stable reconstruction
(Figure 1). Final determination frequently cannot be
made until the actual time of surgery. However, with
appropriate planning, a consistent operative plan
with alternatives can be formulated.

3 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 3 Figure 5Figure 4
Removal of a Cementless Stem
Removal of a cementless stem may be dicult due to
thebiologicfixationthatmayexist between the implant
and bone. When removing a proximally porous coated
stem, it may be necessary to perform an osteotomy
of the femur just below the level of the porous coating
to assist in stem removal (Figure 4).
Note: An extended trochanteric osteotomy may be
necessary if removing an extensively coated stem.
Sectioning the stem and utilizing trephine reamers
can assist in the removal of the porous coated distal
segment of a cementless stem (Figure 5).
Removal of a Cemented Component
Once the stem has been removed from the cement
mantle by utilizing universal extraction instruments or
manufacturerspecificinstruments,ensureallcementis
removed prior to preparation of the femur for the Arcos
femoral components (Figure 3). This can be achieved
using the Ultra-Drive®cement removal system or
cement removal tools. An osteotomy of the femur may
be necessary to facilitate removal of the cement.

4 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 6 Figure 7 Figure 8
Proximal Reamer
Transition Reamer
Calcar/Broach Proximal Bodies & PPS Distal Stems
Sterile Field Technique
Preparation of the Metaphysis
To prepare the proximal femur for the tapered region
of the PPS distal stem and proximal body, assemble
the transition reamer that is the same size as the
desired distal stem into the proximal reamer and press
down on the collar at the top of the proximal reamer to
securely lock the two instruments together (Figure 7).
Ream the proximal femur with the modular (transition/
proximal)reamer,sequentiallyincreasingthesizeofthe
proximal reamer, until the desired size (A–F) and the
60 mm proximal body height is achieved. The 60 mm
etch mark of the proximal reamer should align with the
tip of the greater trochanter (Figure 8).
Preparation of the Diaphysis
To prepare the femur for a PPS coated distal stem,
select flexible or thin shaft reamers and sequentially
ream the femur two cortical diameters or 2–3 cm
below the distal defect, increasing size until cortical
“chatter” is achieved (Figure 6).
Note: When utilizing flexible reamers, ream the
canal in 0.5 mm increments until cortical “chatter”
is achieved. The final reamer diameter should be
line-to-line or 0.5 mm larger than the diameter of
the desired implant, depending on bone quality.
Note: Reaming over a guide is recommended.
The Arcos distal reamers are designed to prepare
the femur for a bowed distal stem and are
cannulated to accommodate a guide wire.

5 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 9 Figure 10 Figure 11
Broach the proximal femur sequentially, until the final
broach size matches the last proximal reamer used
(Figure 10). Verify that the broach is advanced into the
femur, oriented to the desired anteversion, and the
60 mm etch mark on the broach handle is aligned with
the tip of the greater trochanter.
Once the desired broach size is obtained, remove
the broach handle and tighten the broach’s captured
screw with the 3.5 mm hex driver to lock the broach
into place (Figure 11).
Note: Locking the broach and stem trial together
will aid in matching the orientation of the trial to the
final implant.
Broaching the Metaphysis
Once the desired size and 60 mm proximal body
height has been achieved utilizing the modular
reamer, loosely assemble the proximal broach and the
distal stem trial together using the 3.5 mm hex driver
(Figure 9).
Note: Assemble the proximal broach and distal
stem trial loose to allow the distal stem to find the
appropriate position in the femur.

6 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 12 Figure 13
+0
+10
+20
Calcar/Broach Proximal Bodies & PPS Distal Stems
Sterile Field Technique
Note: The large platform should be utilized for a
+0 resection level and the small platform should be
utilized for the +10 or +20 resection levels.
Reattach the broach handle to the assembled trial and
insert the trial into the femur to verify it seats to the
desired level.
Calcar Resection
If utilizing the calcar proximal body implant, determine
the level of deficiency in the proximal femur, align the
resection guide to the broach and mark the desired
resection with a saw (Figure 12). Remove the broach
and stem trial with the broach handle and complete
the calcar resection.
Insert either the large or small platform trial into the
slot corresponding with the calcar resection level
(Figure 13).

7 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 14 Figure 15
Standard Offset
High Offset
Once the desired oset, leg length and joint stability
have been achieved, remove the modular neck
and head trials. Reattach the broach handle to the
assembled trial and remove the trial from the femur.
Detach the broach handle from the assembled trial.
Trial Reduction
Utilizing the modular neck and head trials, perform a
trial reduction of the hip and determine if the selected
oset, leg length and joint stability are appropriate
(Figures 14 and 15). When performing the trial range
of motion, ensure the absence of impingement of
the neck on the rim of the acetabular component or
acetabular liner.
Note: The gold modular trials indicate standard
oset and the black trials indicate high oset.

8 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 18Figure 16 Figure 17
Calcar/Broach Proximal Bodies & PPS Distal Stems
Sterile Field Technique
Implant Insertion
With the proximal inserter still assembled to the
implant, ensure the anti-rotation tabs are properly
locked and insert the implant into the femur until the
desired depth is achieved (Figure 18).
Implant Assembly
With the trial still assembled in the sterile field,
assemble the distal stem and proximal body implants
to match the orientation of the assembled trial
(Figure 16).
Note: If utilizing a slotted stem, a straight
osteotome can be used in the slot of the trial and
implant to properly orient the distal stem in relation
to the proximal body.
When the desired orientation of the implants has
been achieved, thread the green proximal body
inserter to the assembled implant and impact the
taper junction with at least three blows of the mallet
on the back table (Figure 17).

9 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 19 Figure 20
Torque Limiting Position
Final Reduction
If desired, another trial reduction can be accomplished
prior to selecting final head size and impacting the
modular head onto the stem (Figure 20). Provisional
heads in seven neck lengths allow an additional trial
reduction using the actual implant to ensure proper
leg length and stability. After fully seating the femoral
component, impact the appropriate modular head
onto the clean, dry taper.
Inserting the Locking Screw
To lock the distal and proximal body implants, thread
the locking screw into the top of the proximal body
using the 3.5 mm hex driver and the T-handle in
torque limiting position until a “click” is felt and heard
(Figure 19).
Note: The screw can be used to lock the proximal
body and distal stem together before the implants
are inserted into the femur. If this is done, check
the security of the screw once the implant has been
fully seated.

10 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 21 Figure 22
Locked Position
Calcar/Broach Proximal Bodies & STS Distal Stems
Sterile Field Technique
Trialing the Distal Stem
When distal femoral reaming is complete, select the
stem trial that is the same diameter as the final reamer
and the necessary length for stem stability. Thread the
black distal trial inserter into the stem trial and insert
the stem trial into the femur, matching the etched
depth mark on the inserter to the depth achieved from
the last STS reamer used (Figure 22).
Note: The stem trial and reamer are the same size.
Both are 1 mm smaller than the femoral implant.
Preparation of the Diaphysis
To prepare the femur for an STS distal stem, select
the STS reamers (silver reamers for 150 mm stem
length and gold reamers for a 190 mm stem length).
Assemble the STS reamer to the T-handle and turn the
handle from torque limiting to the locked position.
Ream the femur in 1 mm increments by hand until the
reamer advances to the 60 mm mark, referencing the
tip of the greater trochanter (Figure 21).
Note: The final depth of the implant may vary from
the depth of the reamer. How aggressively the
femur is prepared and the quality of the bone
may impact the depth that the final implant will
seat. If the final implant sits proud of the desired
ream depth, note the dierence between these and
utilize the last reamer used to ream deeper into the
femur. Reaming the femur by hand may help avoid
any discrepancy between the reamed depth and
the final depth of the implant.

11 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 23 Figure 24
Proximal Reamer
STS Reamer
Preparation of the Metaphysis
To prepare the proximal femur, assemble the final
STS reamer into the proximal reamer and press
down on the collar at the top of the proximal reamer
to securely lock the two instruments together
(Figure 23). Ream the proximal femur, sequentially
increasing the size of the proximal reamer, until
the desired size (A–F) and the 60 mm proximal body
height is achieved (Figure 24).

12 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 26Figure 25
Calcar/Broach Proximal Bodies & STS Distal Stems
Sterile Field Technique
Broach the proximal femur sequentially, until the
final broach size matches the last proximal reamer
used (Figure 26). Verify that the broach body is
advanced into the femur, oriented to the desired
anteversion and the 60 mm etch mark on the
broach handle is aligned with the tip of the greater
trochanter. Once the broach has been seated to the
desired level, remove the broach handle from the
assembled trial.
Broaching the Metaphysis
Once the desired size and 60 mm proximal body
height has been achieved utilizing the STS/proximal
reamers, assemble the proximal broach body and the
distal stem trial together using the 3.5 mm hex driver
(Figure 25).
Note: To keep the broach aligned with the femur,
utilize the distal stem trial previously used.

13 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 27 Figure 28
+0
+10
+20
Note: The large platform should be utilized for a
+0 resection level and the small platform should be
utilized for the +10 or +20 resection levels.
Reattach the broach handle to the assembled trial and
insert the trial into the femur to verify that it seats to
the desired level.
Calcar Resection
If utilizing the calcar proximal body implant, determine
the level of deficiency in the proximal femur, align the
resection guide to the broach and mark the desired
resection with a saw (Figure 27). Remove the broach
and stem trial with the broach handle and complete
the calcar resection.
Insert either the large or small platform trial into the
slot corresponding with the calcar resection level
(Figure 28).

14 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 29 Figure 30
Standard Offset
High Offset
Calcar/Broach Proximal Bodies & STS Distal Stems
Sterile Field Technique
Once the desired oset, leg length and joint stability
have been achieved, remove the modular neck
and head trials. Reattach the broach handle to the
assembled trial and remove the trial from the femur.
Detach the broach handle from the assembled trial.
Trial Reduction
Utilizing the modular neck and head trials, perform a
trial reduction of the hip and determine if the selected
oset, leg length and joint stability are appropriate
(Figures 29 and 30). When performing the trial range
of motion, ensure the absence of impingement of
the neck on the rim of the acetabular component or
acetabular liner.
Note: The gold modular trials indicate standard
oset and the black trials indicate high oset.

15 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 31 Figure 32
When the desired orientation of the implants has been
achieved, thread the green proximal body inserter to
the assembled implant and impact the taper junction
with at least three blows of the mallet on the back table
(Figure 32).
Implant Assembly
With the trial still assembled in the sterile field,
assemble the distal stem and proximal body implants
to match the orientation of the assembled trial
(Figure 31).
Note: If utilizing the 190 mm stem, ensure the bevel
at the distal tip of the stem is oriented anteriorly.

16 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 33 Figure 34
Torque Limiting Position
Calcar/Broach Proximal Bodies & STS Distal Stems
Sterile Field Technique
Inserting the Locking Screw
To lock the distal and proximal body implants, thread
the locking screw into the top of the proximal body
using the 3.5 mm hex driver and the T-handle in
torque limiting position until a “click” is felt and heard
(Figure 34).
Note: The screw can be used to lock the proximal
body and distal stem together before the implants
are inserted into the femur. If this is done, check
the security of the screw once the implant has been
fully seated.
Implant Insertion
With the proximal inserter still assembled to the
implant, ensure the anti-rotation tabs are properly
locked and insert the final implant into the femur until
the desired depth is achieved (Figure 33).
Note: The final depth of the implant may vary
from the depth of the reamer in this step. How
aggressively the femur is prepared and the quality
of the bone may impact the depth that the final
implant will seat. If the final implant sits proud
of the desired ream depth, note the dierence
between these and utilize the last reamer used to
ream deeper into the femur. Reaming the femur by
hand may help avoid any discrepancy between the
reamed depth and the final depth of the implant.

17 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 35
Final Reduction
If desired, another trial reduction can be accomplished
prior to selecting final head size and impacting the
modular head onto the stem (Figure 35). Provisional
heads in seven neck lengths allow an additional trial
reduction using the actual implant to ensure proper
leg length and stability. After fully seating the femoral
component, impact the appropriate modular head
onto the clean, dry taper.

18 | Arcos Broach/Calcar Proximal Body Surgical Technique
Figure 36 Figure 37
Use the 5.0 mm hex driver to thread the trochanteric
bolt guide into the insertion hole on the proximal
body, ensuring the anti-rotation tabs are locked to
the proximal body implant. Place the trochanteric
fragment between the implant and the trochanteric
bolt guide (Figure 37).
If utilizing the trochanteric claw use the claw trials
(large or small) to select the needed width.
Note: Guide may be easier to attach before hip is
reduced.
Attaching the Trochanteric Bolt Guide
All proximal body designs accept a bolt and claw
except the 50A Cone and 50A Calcar bodies.
Once the final implant has been reduced, the
osteotomy can be repaired and stabilized by choosing
one of the auxiliary options available in the Arcos
System and attaching it directly to the implant.
Depending on the surgical approach and operative
hip, select the appropriate trochanteric bolt guide
instrument (Figure 36).
Trochanteric Reattachment Technique