CA2112108C

CA2112108C - System for performing hip prosthesis revision surgery

Info

Publication number: CA2112108C
Application number: CA002112108A
Authority: CA
Inventors: W. E. Michael Mikhail; James J. Elting; Robin S. M. Ling; Graham A. Gie; Tom J. J. H. Slooff
Original assignee: Individual
Current assignee: Individual
Priority date: 1990-08-10
Filing date: 1992-07-21
Publication date: 1995-09-26
Anticipated expiration: 2012-07-21
Also published as: ES2123565T3; EP0595956A4; EP0595956B1; AU2328795A; DE69226868D1; AU8089291A; ATE170394T1; US5192283A; JP2525551B2; CA2112108A1; AU675392B2; AU658440B2; EP0595956A1; US5047035A; JPH07500027A; US5470336A; AU2393592A; WO1993001773A1; DE69226868T2; WO1992002183A1

Abstract

A method and apparatus for performing hip prosthesis revision surgery in-cludes preparation of the cavity (57) left after removal of the original prosthesis (11).
A tamp (70) having a longitudinal passageway (74) extending longitudinally through the stem portion (71) thereof and a guidewire (62) positioned in the cavity (57) func-tion to compact bone graft material (65) in the cavity (57) and form a precisely con-toured new hip prosthesis receiving cavity (78).

Description

2ll2lo~

SYSTEM FOR PERFORMING HIP PROSTHESIS
REVISION SURGERY
BACKGROUND ART
The present lnventlon ls dlrected to a method for performlng revlslon surgery to replace a hlp prosthesls havlng a stem portlon prevlously lmplanted ln the lntramedullary canal of a femur and to a system for performlng such surgery.
As ls well known, lt ls frequency necessary to replace a hlp ~olnt prosthesls. Thls ls usually done several years after the orlglnal lmplantatlon ln order to replace dlsfunctlonal ~olnts or to obtaln the beneflts of one of newer deslgn whlch resulted from advancements ln medlcal technology.
In the course of hlp revlslon surgery, lt ls necessary to remove the femoral component lncludlng lts stem from the intramedullary canal of the femur. If cement materlal was used to flx the stem wlthln the lntramedullary canal, lt must be removed prlor to lmplantatlon of the new prosthesls thereln.
Removal of the cement ls accompllshed by drllllng or reamlng.
Durlng such drllllng or reamlng procedure, lt ls lmportant that the drlll or reamer be properly allgned and gulded to avold accldental performatlon of the cortex of the femur.

B

W O 93/01773 PC~r/US92/06039 21121~8 .

A number of prior art devices have been utilized for nligninE
drills or reamers in the performance of revision hip surgery. U.S.
Patent No. 4,860,735 relates to a drill alignment guide for osteoplastic surgery in which an alignment rod is supported on a clamp element affixed to the femur. The drill is mounted for 10 movement with an alignment rod which is parallel to snd ~ po~ed a predetermined distance from a shaft of the drill. As the drill is moved forward, the forward end of the alignment rod moves through an aperture of the clamp element thereby insuring that drilling occurs along a predetermined drilled path extending along the bone 1 5 ~xis.
U.S. Patent No. 4,686,972 relates to a surgical deflector and drilling guide for guiding a drill bit, awl or reamer into a bone. The boring-tool guide assembly comprises a sleeve having a T-shaped nib whlch can be detachably inserted into a corresponding bracket 20 permanently mounted against a tool having teeth designed to anchor the tool on a boney tissue. The surgeon can insert the tip of a drill bit, awl or reamer into the sleeve of the guide assembly when the teeth are anchored onto the boney tissue to obtain means for guiding the boring tool.
A method of economically removing cement from the femoral canal during revision surgery appeared in the publication "Orthopedics Today", September 1989, pages 18 and 19. Under the procedure described therein, a side cut and end cut reamer positioned in a guide sleeve is utilized to remove the cement.
A catalog entitled "Omniflex TM Femoral System Surgical Protocol Press-Fit" copyright 1988 by Osteonics Corp., describes a cement removal system utilizing a tapered axial reamer.
U.S. Patent No. 4,919,673 is directed to a femoral head prosthesis having a fixing stem with a longitudinal bore utilizing a 35 centering rod extending therethrough and engaged to a barrier at the lower end of the bone cavity.

W O 93/01773 PC~r/US92/06039 211210~8 Following removal of 811 of the old plastic cement and any cement restricter or plug which may have been used, the cavity rem~ininE in the femur will be substantially larger than is necessary or desirable to accomodate the new femoral hip prosthesis.
Accordingly, it is generally accepted procedure to place crushed cancellous bone graft in the enlarged cavity or femoral canal. Prior to positioning the new prosthesis in the femoral canal, the crushed cancellous bone graft is tamped in order to compact it and have it tightly packed in the femoral canal. The stem of the new prosthesis is then placed in the femoral canal with bone cement if the prosthesis 5 is of a type intended for use with bone cement or without bone cement if such prosthesis is of a type intended to be used without such bone cement. If the crushed cancellous bone graft is tightly compacted prior to insertion of the stem of the new prosthesis therein, it may be necessary to enlarge the new cavity in the 20 compacted crushed cancellous bone graft to receive the new prosthesis or use a smaller prosthesis than was intended. As is well known by those skilled in the art, it is necessary that the crushed cancellous bone graft be tightly compacted to provide for strong boney structure around the prosthesis and, if it is not compacted 25 sufficiently tightly prior to introduction of the prosthesis, attempts must be made to further compact it after placement of the new prosthesis in the femoral canal.
The foregoing prior art references are incorporated herein by reference and copies are herewith enclosed.

DISCLOSUR~; OF INVENTION
The parent application of the present continuation-in-part application provides for a new method of performing revision surgery utilizing improved means for insuring proper centering and guidance 3 5 for of the reamer utilized for removing old bone cement. Such centering and guidance means insures proper positioning of the WO 93/01773 PCr/US92/06039 revision prosthesis with an adequate thickness of bone cement there around and assists in avoiding accidental perforation of the cortex of the femur. Under such invention, the original femoral component is removed and then replaced by a cannulated trial femoral component of similar size and shape to the original prosthesis which has been removed. X-rays taken prior to removal of the original prosthesis can be used to confirm that the original prosthesis is still properly aligned in the femoral canal and did not subside within the original cement mantle into varus. Assuming that the original prosthesis as removed was properly aligned, the cannulated trisl femoral component is then inserted into the cavity left by the removal of the original prosthesis. An elongated drill is then inserted through the cannulated stem and, using the passageway of the cannulated stem as a guide, is utilized to drill through the cement and cement restricter at the bottom of the cavity thus forming a pilot hole in the cement, restricter and bone marrow therebelow. The pilot hole is sufficiently large to permit insertion of a bullit guidewire having a slightly enlarged head at its free end. Following insertion of the bullit guide wire, cannulated reamers of progressively increasing size are placed over the bullit guidewire and utilized to prog~e;.~ively increase the size of the prepared canal to (1) remove all of the old bone cement, centralizer and restricter and (2) reach a size suitable for receiving new bone cement and the stem of the new femoral hip joint prosthesis.
As previously discussed, removal of the old bone cement will result in formation of a cavity in the femur significantly larger than required or desired to receive the new prosthesis and a portion of such cavity should be filled with crushed cancellous bone graft which is then tightly commpacted therein.
According to the present invention, a method is provided using a cannulated tamp of the present invention to compact crushed cancellous bone graft placed in such enlarged cavity to the density or 2112108 22236-59l tlghtness deslred for optlmum graftlng wlth the remainlng bone whlle at the same tlme formlng a new cavlty of the deslred shape and slze to recelve the new prosthesls wlth the approprlate amount of bone cement. The present lnventlon utllizing the cannulated tamp and guldewlre may be used ln revlslon surgery performed uslng alternate methods of removing bone cement as well as the method of removlng bone cement dlsclosed ln the parent of the present appllcation.
Accordingly, lt ls an ob~ect of the present lnventlon to provide a method and apparatus for performing revlslon surgery lncludlng speclflcally a method and apparatus for placement and compactlng of crushed cancellous bone graft ln an enlarged cavlty ln a manner whlch forms a cavlty of the shape and size desired to receive the stem of a hip prosthesls.
Accordlng to a broad aspect of the lnventlon there ls provided a method of performlng revlslon surgery to replace a prevlously lmplanted hlp prosthesls havlng a stem portlon previously implanted ln a medullary canal of a femur wlth a new hip prosthesls having a stem portion of predetermlned conflguratlon comprising the steps of:
~ a) removing sald prevlously lmplanted hlp prosthesls from sald femur thereby leavlng a space ln sald femur;
(b) enlarglng said space in sald femur prevlously occupied by said previously lmplanted hlp prosthesls to form a cavlty larger than the stem portlon of the new hlp prosthesls to be lmplanted thereln, sald cavlty havlng a bottom and an open top;
(c) placlng a restricter at the bottom of said cavlty, sald restrlcter havlng a gulde wlre engaged thereto, sald gulde 5a 2112l0 22236-591 wlre extendlng from sald restrlcter to a polnt beyond sald open top;
(d) placing bone graft materlal in sald cavlty;
(e) provldlng a tamp havlng a stem extendlng from a proxlmal end to a dlstal end and havlng a conflguratlon slmllar to sald predetermlned conflguratlon and havlng a passageway extendlng through sald tamp stem from sald dlstal end to sald proxlmal end;
(f) placlng sald tamp over sald guldewlre wlth the guldewlre extendlng through sald passageway;
(g) lmpactlng sald tamp whlle gulded by sald guldewlre to compact sald bone graft materlal and to form a prosthesls recelvlng cavlty larger than and slmllar ln shape to sald predetermlned conflguratlon.
Accordlng to another broad aspect of the lnventlon there ls provlded a method of preparlng a medullary canal of a femur for lmplantatlon of a hlp prosthesls havlng a stem portlon of predetermlned conflguratlon comprlslng the steps of:
(a) formlng a cavlty larger than sald predetermlned conflguratlon, sald cavlty havlng a bottom and an open top;
(b) placlng a restrlcter at the bottom of sald cavlty, sald restrlcter havlng a guldewlre engaged thereto, sald guldewlre extendlng from sald restrlcter to a polnt beyond sald open top;
(c) placlng bone graft materlal ln sald cavlty;
(d) provldlng a tamp havlng a stem extendlng from a proxlmal end to a dlstal end and havlng a conflguratlon slmllar to sald predetermlned conflguratlon and havlng a passageway B

_ 5b 2112108 22236-591 extendlng through sald stem from sald dlstal end to sald proxlmal end;
(e) placlng sald tamp over sald guldewlre wlth the guldewlre extendlng through sald passageway;
(f) lmpactlng sald tamp whlle gulded by sald guldewlre to compact sald bone graft materlal and to form a prosthesls recelving cavlty larger than and slmllar ln shape to sald predetermlned conflguratlon.
Accordlng to another broad aspect of the lnventlon there ls provlded apparatus for use ln preparlng a femoral cavlty to recelve bone graft materlal and a femoral hlp prosthesls comprlslng:
(a) a guldewlre;
(b) means for supportlng sald guldewlre longltudlnally ln sald cavlty; and (c) cannulated tamp means havlng a stem extendlng from a proxlmal end havlng a relatlvely large cross-sectional slze and taperlng to a dlstal end havlng a relatlvely small cross-sectlonal slze, sald stem having a passageway slzed to slldeably recelve sald guldewlre, sald passageway extendlng from sald proxlmal end to sald dlstal end.
Accordlng to another broad aspect of the lnventlon there ls provlded apparatus for performing revislon surgery to replace a prevlously lmplanted hip prosthesls havlng a stem portlon previously lmplanted ln a medullary canal of a femur wlth a new hlp prosthesls havlng a stem portlon of predetermlned conflguratlon comprlslng:
(a) a tamp havlng a stem extendlng from a proxlmal end to 211~ 8 5c 22236-591 a dlstal end and havlng a conflguratlon slmllar to sald predetermlned conflguratlon and havlng a passageway extendlng through sald stem from sald dlstal end to sald proxlmal end;
(b) a guldewlre extendlng through sald passageway; and (c) means for supportlng sald guldewlre ln sald medullary canal;
said tamp being movable over sald guldewlre lnto and out of sald medullary canal to compact bone graft materlal placed thereln.
Accordlng to another broad aspect of the lnventlon there ls provlded a system for preparlng an lmplantatlon cavlty ln a medullary canal of a femur to recelve a hlp prosthesls havlng a stem portlon of predetermlned slze and conflguratlon comprlslng:
(a) means for formlng ln sald medullary canal a flrst cavlty larger ln slze than the deslred slze of sald lmplantatlon cavlty;
(b) bone graft materlal;
(c) a tamp havlng a stem extendlng from a proxlmal end havlng a relatlvely large cross-sectlonal slze and taperlng to a smaller dlstal end and havlng a slze larger than and a conflguratlon slmllar to sald predetermlned slze and conflguratlon and havlng a passageway extendlng through sald stem from sald distal end to sald proxlmal end;
(d) a guldewlre extendlng through sald passageway;
(e) means for supportlng sald guldewlre ln sald medullary canal;
(f) a handle; and 5d 2 112 108 22236-591 (g) engagement means on said proxlmal end ln offset relatlon to sald guldewlre for retalnlng sald handle;
sald tamp belng movable over sald guldewlre lnto and out of sald medullary canal to compact sald bone graft materlal placed thereln.
The lnventlon wlll be more fully understood and other ob~ects and advantages wlll become apparent from the followlng detalled descrlptlon ln con~unctlon wlth the attached drawlngs.
BRIeF D~-~CRTPTION OF THe DRAWINGS
Fig. 1 ls an elevatlonal vlew, partlally ln sectlon, showlng a femoral hlp ~olnt prosthesls lmplanted ln the femoral canal of a patlent.
Flg. 2 ls a vlew slmllar to Flg. 1 showlng the femur wlth the prevlously lmplanted femoral hlp ~olnt prosthesls removed.
Flg. 3 ls a vlew slmllar to Flgs. 1 and 2 showlng the cannulated trlal femoral component of the present lnventlon posltloned wlthln the cavlty prevlously occupled by the orlglnal femoral hlp ~olnt prosthesls.
Flg. 4 ls a vlew slmllar to Flg. 3 but showlng the drllllng of a pllot passageway utlllzlng the cannulated trlal femoral component as a gulde.
Flg. 5 ls a vlew slmllar to Flg. 4 followlng removal of the elongated drlll blt and lnsertlon of the guldewlre wlth lts enlarged B

3 PCr/US92/06039 2 1 ~ ~1 08 bullit hesd through the guide passageway of the cannulated trial femoral component and into the newly drilled pilot hole.
Fig. 6 is a view similar to Fig. 5 but slightly enlarged for clarity, showing the reaming of the canal following removal of the cannulated trial stem and showing the first of several proE;Le.,.,ively 0 larger reamers being utilized with the bullit guidewire as a guide to control the path of the reamer.
Figs. ~ and 8 are view similar to Fig. 6 showing the femur as the canal is pro~le~ively enlarged with still larger reamers utilizing the bullit guidewire as a guide.
Fig. 9 is a sectional view of a femur prepared for revision surgery with the old cement removed and the guidewire removed.
Fig. 10 is a sectional view of n femur prepared for revision sul~e,y showing plncement of a new cement restricter.
Fig. 11 is a view similar to Fig. 10 showing the next step of 2 0 revision ~ . y.
Fig. 12 is an elevational view of the cannulated tamp of the present invention.
Fig. 13 is a view showing the guidewire to be used with the cannulated tamp in performing the method of the present invention.
Fig. 14 is a sectional view showing the tamp with the guidewire extending therethrough positioned to compact bone graft material in the femur.
Fig. 15 is a sectional view showing a new prosthesis implanted in the femur.

BEST MODE OF CARRYING OUT INVENTION
Referring now to Fig. 1, there is shown a femur generally designated by the number 10 having implanted therein a hip joint prosthesis 11 having a stem 12 implanted within the intramedullary 35 canal 13 of the femur. The stem extends from a lower distal end 14 to an upper portion which includes an enlarged shoulder 15 and a neck portion 16 disDosed at an obtuse angle relative to the stem 12.

W O 93/01773 PC~r/US92/06039 The prosthesis 11 is typically secured in the femoral intramedullary canal 13 by a cement mantle 17 of polymethylmethacrylate (PMMA) or other suitable bone cement. A
restricter 18 is placed in the intramedullary canal 13 prior to introduction of the bone cement 17 therein. The distal end 14 of the stem may be engaged in a centralizer 19 which assists in centering the distal end 14 during the step of implantation of the prosthesis 11 in the cement 17. The prosthesis 11 may be provided with an aperture 20 or other suitable grasping means to assist in its removal.
As shown in Fig. 2, the removal of the prosthesis 11 leaves a cavity 25 conforming to the shape of the removed stem 12. Obviously, prior to removal of the prosthesis 11, any portion of the cement mantle 17 such as that overlying the enlarged shoulder 15 as indicated by the numeral 26 in Fig. 1, must be removed. As can be seen in Fig. 2, the restricter 18 and centralizer 19 remain within the intramedullary canal 13 following removal of the prosthesis 11 as does the cement mantle 17 which retained the prosthesis 11.
It is desirable that all of the old cement 17 be removed prior to implantation of a new prosthesis in the intramedullary canal 13. In order to effect such cement removal efficiently and with minim~l 25 risk to the patient, guide means for the drill and reamer are utilized for such removal. Referring to Fig. 3, there is shown a cannulated trial femoral component 30 following its insertion into the cavity 25 left by removal of the original prosthesis 11. The cannulated trial femoral component 30 preferably has a stem 31 which is shaped 30 substantially the same as the shape of the stem of the original - prosthesis 11. The stem 31 extends from a distal end 32 to an enlarged upper end 34 extending out of the cavity 25. The stem 31 has a longitudinally extending passageway 33 which extends from the distal end 32 to the upper end 34 where it forms an outlet opening 35.

WO 93/01773 PCl/US92/06039 21 ~ f l~8 Prior to removal of the original prosthesis 11, X-rays should be taken to determine that the stem 12 of such original prosthesis was properly aligned in the intramedullary canal 13 and that it did not - shift into varus as a result of subsidence within the cement mantle.
Such subsidence within the cement mantle is known to occur over a period of time.
As shown in Fig. 4, there is provided a drill 40 having an elongated drill bit 41. The drill bit 41 has a length permitting it to extend completely through the longitudinal passageway 33 of the cannulated trial femoral component 30 and a substantial distance beyond. Thus, as shown in Fig. 4, the drill bit 41 is of sufficient length to drill, using the longitudinal passageway 33 as a guide, through the centralizer 19, restricter 18 and a substantial distance into the intramedullary csnal 13 forming a new rhnn~el 42 below the restricter 18.
Referring now to Fig. 5, there is shown a bullit guidewire 43 having an enlarged head 44 positioned in the newly drilled t~hnnn~l 42.
- Thus, following drilling of the channel 42 through the centralizer 19, restricter 18 and further into the intramedullary canal 13, the drill bit 41 is removed therefrom while leaving the cannulated trial femoral component 30 positioned therein. Thereafter, the guide wire 43 with its enlarged head 44 is inserted through the longitudinal passageway 33 and into the ch~nnel 42. Following insertion of the guidewire 43, the cannulated trial femoral component 30 is removed leaving the guidewire 43 in position.
Referring now to Fig. 6, following removal of the cannulated trial femoral component 30, a reamer 50 having a hollow stem 51 terminating in an enlarged cutting head 52 is provided. A
longitudinal passageway 53 extends through the cutting head 52 and the stem 51. The reamer S0 is telescoped over the bullit guidewire 3 5 43 and may be power rotated by any standard well known power means.

W O 93/01773 PC~r/US92/06039 211210~

As can be seen in Figs. 7 and 8, progressively larger reamers 50' (Fig. 7) and 50" (Fig. 8) with pro~les~ively larger cutting heads 52' and 52" are utilized to progressively enlarge the opening of the cavity 25 and remove the old cement 17, the centralizer 19 and the restricter 18 and to pro~le~ively enlarge the opening until all of the old cement 17 has been removed and in doing so to utilized the bulllt guidewire 43 to guide it. If desired, as progressively larger reamers 50, 50' and 50" are used, larger diameter guidewires may be Inserted, replacing the small guidewire 43 used for the drill bit 41. The larger guidewires will give additional rigidity in guiding the path of the 1 5 reamers.
Referring to Fig. 9, following reaming of the old cement 17 in the lower portion of the femur and reaming of the centralizer 19 and restricter 18, the reamer and guidewire 43 may be removed.
Although there will be additional old cement 17 still present in the 20 upper, larger femur portion, it can be readily removed by conventional techniques.
Referring now to Figs. 10-15, there is shown the method and apparatus for preparing a newly reamed cavity 57 of femur 56 preparatory to receiving a new femoral hip prosthesis for 25 implantation. Although not limited to such use, the method and apparatus disclosed and claimed herein is ideally suited for preparing, in revision ~ ery, a femur to receive a collarless polished tapered femoral prosthesis of the type manufactured and sold by Zimmer, Inc., Warsaw, Tntljnn~ as shown in its brochure entitled "The 30 CPT TM Hip System" (copy enclosed) which is incorporated herein by reference.
Following removal of the old prosthesis, old cement and old restricter, a new cement restricter or plug 60 is placed at or near the bottom of the cavity 57. Preferably the restricter 60 is formed of 35 plastic and has a central threaded cavity 61 formed therein. A
guidewire 62 having external threads 63 on its free end is threadedly WO 93/01773 PCr/US92/06039 engaged to the restricter 60. A removable T-bar 64 of conventional design may be secured to the end of the guidewire 62 extending out of the cavity 57 of femur 56. One such T-bar is one manufactured and sold by Zimmer, Inc., under the name of T-Handle (Zimmer Shank) Item No. 6551-60 of the above referenced brochure. The T-bar 64, when engaged to the guidewire 62 threadedly engaged to the restricter 60 may be used to position the restricter 60 in the cavity 57. While still attached to the guidewire 62, the T-bar 64 is impacted to drive the restricter 60 to its proper position in the cavity 57. The T-bar 64 is then removed from the guidewire 62 leaving the guidewire in place threadedly engaged to the restricter 60.
Referring now to Fig. 11, with the guidewire 62 and restricter 60 in place, crushed cancellous bone graft material 65 is then loosely packed in the cavity 57.
Referring now to Figs. 12 and 14, there is shown a cannulated tamp generally designated by the numeral 70 which, in Fig. 14, is shown positioned in the cavity 57 of the femur 56 being prepared to receive a new femoral prosthesis. The tamp includes a stem portion 71 extending from an upper proximal end 72 to a lower distal end 73.
The tamp 70 should have its stem 71 shaped similar to the shape of the femoral prosthesis intended to be implanted; however, ideally a series of tamps each of varying size will be utilized in performing a single revision surgery. Smaller sized tamps will be used initially with pro~l e3~ively larger ones used thereafter until the crushed cancellous bone graft material is compacted to the desired density and the new cavity thus formed will be of the desired size. The largest size tamp will be larger than the prosthesis intended to be implanted by an amount which will permit new bone cement used to implant such prosthesis to have a thickness of two to four millimeters in all portions of the stem. Thus, if the surgeon intends to use an implant of the type shown in the above-referenced Zimmer, Inc.
brochure as a "CPT Hip Stem" the tamp 70 will have a stem W O 93/01773 PC~r/US92/06039 i 2112108 configuration similar to that of the CPT Hip Stem. Preferably all portions of the stem 71 are polished to a smooth finish.
The tamp 70 has a longitudinal passagewsy 74. The upper or proximal end 72 of the tamp includes a protrusion 75 and knob 76 intended to be engaged by a rasp handle 77 of any desired type such as that disclosed in the above-referenced Zimmer, Inc. brochure as item no. 6601-OS. It should be understood that since the longitudinal passageway 74 extends through the distal end 73 of the tamp 70, the tamp 70 may be slightly shorter than the prosthesis to be used in the revision. The passageway 74 must be large enough to permit the tamp 70 to move freely over the guidewire 62.
Referring to Fig. 13, there is shown a detailed view of the guidewire 62. The guidewire 62 is approximately 2-5mm in size, and in addition to the threads 63, may have a series of lines 67 for measuring depth to which the restricter is positioned.
Referring to Fig. 14, with the rasp handle 77 engaged to the tamp 70 by means of the protrusion 75 and knob 76, the tamp 70 is positioned to be driven into the cavity 57 by means of the rasp handle 76 being impacted by a hammer or other impacting device. With the tamp 70 positioned as indicated in Fig. 14 and with the guidewire 62 extending through the longitudinal passageway 74, the position of the tamp 70 is precisely controlled as it is driven to the desired position within the cavity 57. As will be appreciated by those skilled in the art, from time to time it may be necessary to completely remove the tamp 70 to place additional bone graft material 65 therein in order to provide the sufficient quantity of materiul for impacting to the proper density. Additionally, as previously noted, it may be desirable to utilize a series of tamps 70 beginning with a smaller tamp and working up plo~.e;.aively to one which is larger than the desired prosthesis to permit an adequate amount of bone cement around such prosthesis on implantation.

Following tamping of the cancellous bone graft material 65 to the desired density and the resultant formation of a cavity of the proper size and shape the tamp may be removed from the newly formed cavity 78, the rasp handle 77 removed therefrom, and the guidewire 62 may be unscrewed and removed from the restricter 60.
The new cavity 78 is now ready to receive the new prost~
Fig. 15 shows the completed revision surgery with a new prosthesis 81 having a distal end 82 positioned in a support element 83 implanted in bone cement 88. The support element 83 is formed of material suitable for implantation in a human body (such as PMMA) and has nn annulnr sidewall 84 with a closed end 85 and an open top 86 in which the distal end 82 of the new prosthesis 81 is posltioned. The distal end 82 is spaced from the closed end 85 to allow space for movement of such distal end 82 therein as the prosthesis 81, over time, subsides within the cement mantle 88 in which the new prosthesis is implanted. As will be appreciated and as can be seen in Fig. 15, the cement mantle 88 fills the cavity left by removal of the guidewire 62 from the restricter 60 and compacted bone graft.
The present inYention may be used in revision surgery irrespective of whether the prosthesis to be replaced was implanted with bone cement or was one designed and used without cement. The new prosthesis should be implanted in cement following completion of bone graft as described above.
It is to be understood that the above detailed description of a preferred embodiment of the invention is provided by way of example only. Various details of design and construction and steps in the procedure may be modified without departing from the true spirit and scope of the invention as set forth in the appended claims.

Claims

THE EMBODIMENTS OF THE INVENTION IN WHICH AN EXCLUSIVE
PROPERTY OR PRIVILEGE IS CLAIMED ARE DEFINED AS FOLLOWS:

1. A method of performing revision surgery to replace a previously implanted hip prosthesis having a stem portion previously implanted in a medullary canal of a femur with a new hip prosthesis having a stem portion of predetermined configuration comprising the steps of:
(a) removing said previously implanted hip prosthesis from said femur thereby leaving a space in said femur;
(b) enlarging said space in said femur previously occupied by said previously implanted hip prosthesis to form a cavity larger than the stem portion of the new hip prosthesis to be implanted therein, said cavity having a bottom and an open top;
(c) placing a restricter at the bottom of said cavity, said restricter having a guide wire engaged thereto, said guide wire extending from said restricter to a point beyond said open top;
(d) placing bone graft material in said cavity;
(e) providing a tamp having a stem extending from a proximal end to a distal end and having a configuration similar to said predetermined configuration and having a passageway extending through said tamp stem from said distal end to said proximal end;
(f) placing said tamp over said guidewire with the guidewire extending through said passageway;
(g) impacting said tamp while guided by said guidewire to compact said bone graft material and to form a prosthesis receiving cavity larger than and similar in shape to said predetermined configuration.

2. The method according to claim 1 further including the steps of :
(h) placing new bone cement in said prosthesis receiving cavity; and positioning said new hip prosthesis in said prosthesis receiving cavity with said new bone cement having interfacial contact with the stem portion of said new hip prosthesis.

3. The method according to claim 2 wherein said stem portion of said new hip prosthesis extends from a proximal end of maximum cross-sectional size to a distal end of minimum cross-sectional size and said distal end has positioned thereover a support element having sidewalls engaged by said stem adjacent said distal end and a closed end, said stem distal end being spaced from said closed end.

4. A method of performing revision surgery to replace a hip prosthesis having a stem portion previously implanted in a cement mantle in a medullary canal of a femur with a new hip prosthesis having a stem portion of predetermined configuration comprising the steps of:
(a) removing said previously implanted hip prosthesis from said femur;
(b) removing substantially all of said cement mantle to form a cavity larger than the stem portion of the new hip prosthesis to be implanted therein, said cavity having a bottom and an open top;
(c) placing a restricter at the bottom of said cavity, said restricter having a guidewire engaged thereto, said guidewire extending from said restricter to a point beyond said open top;
(d) placing bone graft material in said cavity;
(e) providing a tamp having a stem extending from a proximal end to a distal end and having a configuration similar to said predetermined configuration and having a passageway extending through said stem from said distal end to said proximal end;
(f) placing said tamp over said guidewire with the guidewire extending through said passageway;
(g) impacting said tamp while guided by said guidewire to compact said bone graft material and to form a prosthesis receiving cavity larger than and similar in shape to said predetermined configuration.

5. The method according to claim 4 further including the steps of:
(h) placing new bone cement in said prosthesis receiving cavity; and (i) positioning a new hip prosthesis in said prosthesis receiving cavity with said new bone cement having interfacial contact with the stem portion of said new hip prosthesis.

6. The method according to claim 5, wherein said stem portion of said new hip prosthesis extends from a proximal end of maximum cross-sectional size to a distal end of minimum cross-sectional size and said distal end has positioned thereover a support element having sidewalls engaged by said stem adjacent said distal end and a closed end, said stem distal end being spaced from said closed end.

7. A method of preparing a medullary canal of a femur for implantation of a hip prosthesis having a stem portion of predetermined configuration comprising the steps of:
(a) forming a cavity larger than said predetermined configuration, said cavity having a bottom and an open top;
(b) placing a restricter at the bottom of said cavity, said restricter having a guidewire engaged thereto, said guidewire extending from said restricter to a point beyond said open top;
(c) placing bone graft material in said cavity;
(d) providing a tamp having a stem extending from a proximal end to a distal end and having a configuration similar to said predetermined configuration and having a passageway extending through said stem from said distal end to said proximal end;
(e) placing said tamp over said guidewire with the guidewire extending through said passageway;
(f) impacting said tamp while guided by said guidewire to compact said bone graft material and to form a prosthesis receiving cavity larger than and similar in shape to said predetermined configuration.

8. The method according to claim 7 further including the steps of:
(h) placing bone cement in said prosthesis receiving cavity;
and (i) positioning a hip prosthesis in said prosthesis receiving cavity with said bone cement having interfacial contact with the stem portion of said hip prosthesis.

9. The method according to claim 8, wherein said stem portion of said hip prosthesis extends from a proximal end of maximum cross-sectional size to a distal end of minimum cross-sectional size and said distal end has positioned thereover a support element having sidewalls engaged by said stem adjacent said distal end and a closed end, said stem distal end being spaced from said closed end.

10. Apparatus for use in preparing a femoral cavity to receive bone graft material and a femoral hip prosthesis comprising:
(a) a guidewire;
(b) means for supporting said guidewire longitudinally in said cavity; and (c) cannulated tamp means having a stem extending from a proximal end having a relatively large cross-sectional size and tapering to a distal end having a relatively small cross-sectional size, said stem having a passageway sized to slideably receive said guidewire, said passageway extending from said proximal end to said distal end.

11. Apparatus according to claim 10, wherein said means for supporting said guidewire comprises a restricter sized to be received in said femoral cavity.

12. Apparatus for performing revision surgery to replace a previously implanted hip prosthesis having a stem portion previously implanted in a medullary canal of a femur with a new hip prosthesis having a stem portion of predetermined configuration comprising:
(a) a tamp having a stem extending from a proximal end to a distal end and having a configuration similar to said predetermined configuration and having a passageway extending through said stem from said distal end to said proximal end;
(b) a guidewire extending through said passageway; and (c) means for supporting said guidewire in said medullary canal;
said tamp being movable over said guidewire into and out of said medullary canal to compact bone graft material placed therein.

13. Apparatus according to claim 12 further including a restricter at the bottom of said cavity, said restricter having said guidewire engaged thereto, said guidewire extending from said restricter to a point beyond said medullary canal.

14. Apparatus for use in preparing a femoral cavity to receive bone graft material and a femoral hip prosthesis of predetermined size and configuration comprising:
(a) a guidewire;
(b) means for supporting said guidewire longitudinally in said cavity;
(c) a cannulated tamp having a stem extending from a proximal end having a relatively large cross-sectional size and tapering to a distal end having a relatively small cross-sectional size, said stem having a size larger than and a configuration similar to said femoral hip prosthesis and a passageway sized to slideably receive said guidewire, said passageway extending from said proximal end to said distal end; and (d) means extending from said proximal end for engagement by a handle.

15. Apparatus according to claim 14, wherein said means for supporting said guidewire comprises a restricter sized to be received in said femoral cavity.

16. Apparatus according to claim 14, wherein said stem is polished to a smooth finish.

17. Apparatus according to claim 14, wherein said proximal end and means for engagement are positioned to receive impacts directed to said handle.

18. Apparatus for performing revision surgery to replace a previously implanted hip prosthesis having a stem portion previously implanted in a medullary canal of a femur with a new hip prosthesis having a stem portion of predetermined size and configuration comprising:
(a) a tamp having a stem extending from a proximal end to a distal end and having a size larger than and a configuration similar to said predetermined configuration and having a passageway extending through said stem from said distal end to said proximal end;
(b) a guidewire extending through said passageway;

(c) means for supporting said guidewire in said medullary canal; and (d) engagement means offset from said passageway extending from said proximal end for moving said tamp over said guidewire into and out of said medullary canal to compact bone graft material placed therein.

19. Apparatus according to claim 18 further including a restricter at the bottom of said medullary canal, said restricter having said guidewire engaged thereto, said guidewire extending from said restricter to a point beyond said medullary canal.

20. Apparatus according to claim 18, wherein said stem is polished to a smooth finish.

21. Apparatus according to claim 18, wherein said proximal end and engagement means are positioned to receive impacts directed to a handle attached to said engagement means.

22. Apparatus for use in preparing a femoral cavity to receive bone graft material and a femoral hip prosthesis of predetermined size and configuration comprising in combination:
(a) a handle;
(b) a gidewire;

(c) means for supporting said guidewire longitudinally in said cavity;
(d) a cannulated tamp having a stem extending from a proximal end having a relatively large cross-sectional size and tapering to a distal end having a relatively small cross-sectional size, said stem having a size larger than and a configuration similar to said femoral hip prosthesis and a passageway sized to slideably receive said guidewire, said passageway extending from said proximal end to said distal end; and (e) means offset from said passageway extending from said proximal end for engagement by said handle.

23. Apparatus according to claim 22, wherein said stem is polished to a smooth finish.

24. Apparatus according to claim 22, wherein said proximal end and means for engagement are positioned to receive impacts directed to said handle.

25. A system for preparing an implantation cavity in a medullary canal of a femur to receive a hip prosthesis having a stem portion of predetermined size and configuration comprising:
(a) means for forming in said medullary canal a first cavity larger in size than the desired size of said implantation cavity;
(b) bone graft material;
(c) a tamp having a stem extending from a proximal end having a relatively large cross-sectional size and tapering to a smaller distal end and having a size larger than and a configuration similar to said predetermined size and configuration and having a passageway extending through said stem from said distal end to said proximal end;

(d) a guidewire extending through said passageway;
(e) means for supporting said guidewire in said medullary canal;
(f) a handle; and (g) engagement means on said proximal end in offset relation to said guidewire for retaining said handle;
said tamp being movable over said guidewire into and out of said medullary canal to compact said bone graft material placed therein.

26. Apparatus according to claim 25, wherein said stem is polished to a smooth finish.