Fitmore®

Hip Stem

Surgical Technique

Draft 5.4, 14 september 2007

A New Concept in Bone Conservation
 Fitmore® Hip Stem – Surgical Technique 3

Surgical Technique Table of Contents

Fitmore Hip Stem Introduction/The Offset Options 4

General Information/Indications/Contraindications 5

Preoperative Planning 6
The Primary Objectives of Preoperative Planning 6

Positioning for X-rays 6

Templating the Acetabulum 6

Templating the Femur 6

Planning Steps 7
Acetabular Component 7

Determination of the Stem Family 8

Equalizing Leg Length 8

Determination of the Size 9

Final Result 9

Surgical Technique 10

Osteotomy of the Femoral Neck 10

Preparation of the Femoral Canal 10

Trial Reduction 12

Insertion of the Fitmore Hip Stem 13

Intraoperative Extraction of the Fitmore Hip Stem 14

Exchangeable Plastic Jaws 14

Postoperative Treatment 14
Fitmore Hip Stem Implants 15
Fitmore Hip Stem Instruments 16
4 Fitmore® Hip Stem – Surgical Technique

Introduction The Offset Options

The Fitmore Hip Stem is a curved The Fitmore Hip Stem offers a wide range
uncemented stem with a trapezoidal cross- of offset options to address a variety
section, which is coated proximally with of anatomic offsets among individuals.
Ti-VPS (Titanium Vacuum Plasma Spray) Biomechanical characteristics such as the
and rough-blasted distally. femoral offset and the leg length can
be restored while achieving soft tissue
The stem system is comprised of 3 stem balance around the hip joint.
families A, B and C (family B with two
offsets), in order to cover different The same surgical technique is used
anatomies. for implantation of the Fitmore Hip Stem
family A, family B, family B-Extended
The anchorage is mainly metaphyseal, and family C.
in the intertrochanteric region. The rasps
and the corresponding implants are not In most cases, the B families will be the
inserted straight into the femoral canal, appropriate choice because they fit in most
but rather along the calcar, so that the area femora and offer the possibility to
of the greater trochanter and, therefore, accommodate a bigger offset (B and B-
the insertion of the gluteal muscles can be Extended options). The A family might be
preserved. more suitable for hips with a small offset,
whereas varus hips with long necks may be
The Fitmore Hip Stem is compatible with better treated with C family stems.
all Zimmer® MIS approaches, with the
exception of the Zimmer MIS 2-Incision™ In order to preserve bone stock of the
approach, and with all traditional greater trochanter and to be MIS
approaches. compatible the Fitmore Hip Stem offers:

1. A curved shape and trapezoidal cross-

section for maximum rotational stability
2. A three-dimensional wedge shape and
proximal Ti-VPS coating for press-fit
fixation
3. Various medial curves to optimize
proximal fit
4. Different offsets independent from
stem size to accurately restore joint
biomechanics
 Fitmore® Hip Stem – Surgical Technique 5

General Information Indications Contraindications

• Indications and contraindications for the • This femoral stem is for total or hemi • Patient’s physical conditions that would
use of these components may be relative hip arthroplasty and is indicated for the eliminate or tend to eliminate adequate
or absolute and must be carefully following conditions: Patient conditions implant support or prevent the use of an
weighed against the patient’s entire of noninflammatory degenerative joint appropriately sized implant, e. g.,
evaluation and the prognosis for possible disease (NIDJD), e.g., avascular necrosis, previous surgery, insufficient quality or
alternative procedures osteoarthritis and inflammatory degenerative quantity of bone resulting from
joint disease (IJD), e.g., rheumatoid arthritis; conditions such as cancer or congenital
• Patient selection should be largely those patients with failed previous surgery dislocation, metabolic bone disease of
dependent on patient’s age, general where pain, deformity, or dysfunction the upper femur or pelvis, femoral
health, conditions of available bone persists; revision of previously failed osteotomy revision, girdlestone
stock, prior surgery and anticipated hip arthroplasty revision, osteoporosis, osteomyelitis,
further surgeries. An implantation is neuromuscular compromise or vascular
generally only indicated for patients • Total hip replacements may be considered for deficiency in the affected limb in
who have reached skeletal maturity younger patients if any unequivocal indiction sufficient degree to render the procedure
outweighs the risks associated with the unjustifiable (e. g., absence of
age of the patient and modified demands musculoligamentous supporting
regarding activity and hip joint loading are structures, joint neuropathy) or other
assured. This includes severely crippled conditions that may lead to inadequate
patients with multiple joint involvement, for skeletal fixation
whom an immediate need of hip mobility
leads to an expectation of significant • Active infection of the hip, old or remote
improvement in the quality of their lives infection. This may be an absolute or
relative contraindication. Every effort
• This stem is for uncemented use should be undertaken to rule out
preoperative infection in a patient with
suspicious symptoms, such as a history
of, or when there are signs of, local
inflammation, abscesses, fever,
increased blood sedimentation rate,
evidence of rapid joint destruction or
bone resorption

• Allergy to the implanted material, above

all to metal (e. g. cobalt, chromium,
nickel, etc.)

• Local bone tumors and/or cysts

• Pregnancy
6 Fitmore® Hip Stem – Surgical Technique

Preoperative Planning The Primary Objectives of Templating the Acetabulum

Preoperative Planning are to The primary objective of templating the
It is important that the preoperative 1. Determine preoperative leg length acetabulum is to estimate the size of
planning is made with the necessary 2. Determine acetabular component size the acetabular component. Preoperative
accuracy and that the individual steps of and position determination of the correct acetabular
the operation are followed exactly. 3. Choose the family of the Fitmore Hip component size requires an X-ray of the
Stem by restoring offset, center of affected hip in both AP and lateral views.
Although X-ray quality may vary, a carefully rotation and by matching the medial The initial templating should start with
planned total hip replacement helps to contour of the stem with the calcar arch the AP X-ray. Furthermore, component
minimize intraoperative complications. 4. Determine femoral component size, position with respect to inclination and
position and fit anteversion of the cup is planned while
achieving sufficient bony cup coverage.
In addition, preoperative planning will Finally, the amount of osteophytes
assist in identifying bone deformities necessary to remove to avoid
and potential problems that might require impingement is estimated.
special instrumentation during surgery.
In the event that adverse bone conditions
are present, it is recommended to have Templating the Femur
a C-arm ready in the operating room in The primary objective of templating the
order to assess the implant position femur is to choose the appropriate
intraoperatively. family and size of the stem. It requires
an X-ray of the entire pelvis, which
includes the proximal third of the femur.
Positioning for X-rays
For the AP X-ray of the pelvis, both femurs Choice of the appropriate family and
should be rotated internally until both size of the stem: Three different families
patellae point straight anteriorly, to be (A, B, C) of the Fitmore Hip Stem are
able to assess the femoral neck length shown on the overview template.
and offset. An axial view may also be With this template the most suitable
helpful in determining implant size and family is determined by restoring
version of the femur. anatomical offset and by confirming that
the medial curve of this stem follows
Considerations closely the inner line of the cortex in the
• In a proper X-ray, it is possible to draw calcar region when the stem is in axis
a continuous line from the femoral neck with the femoral canal. After choosing
to the greater trochanter the correct stem family with the help of
• In external rotation contracture, it may the overview template, the appropriate
be helpful to use the contralateral hip size is selected using the family-specific
for planning templates. The width of the medullary
canal determines the body size.
Templating
There are four basic steps
• Determination of the position and
orientation of the acetabular component
• Choice of the right family of the Fitmore
hip stem
• Restoration of the leg length
• Choice the right size of the Fitmore
Hip Stem
 Fitmore® Hip Stem – Surgical Technique 7

Planning Steps
The preoperative planning determines
the correct position and size of the
acetabular and femoral component. The
correct positioning of the acetabular and
femoral components is mandatory in
order to ensure optimal component
fixation and restore hip biomechanics.

Acetabular Component
The cup templates are placed on the
X-ray with the acetabular component in
approximately 40 to 45 degrees of
inclination. Several sizes are assessed to
determine which acetabular component
will provide the optimal fit with maximum
coverage. The anatomical center of
rotation of the femoral head should be
reproduced by the position of the
acetabular component. The component
that meets these requirements is
selected. The tracing paper is placed on
the X-ray and the template. The contour
of the hemipelvis and the chosen cup are
drawn on the tracing paper. Then the
paper is removed.
8 Fitmore® Hip Stem – Surgical Technique

Determination of the Stem Family

Place the overview template on the pelvis
X-ray. In the overview template, the three
stem families are displayed with their
smallest and biggest sizes. The correct
family is chosen primarily based on the
correct offset.

To choose the correct stem family,

position the overview template of the
family that seems most appropriate into
the medullary canal so that the reference
line of the femoral axis is parallel to the
femur and that the medial contour of
the prosthesis is aligned with the cortex.
Now move the template up- or downward
until the centers of rotation of the cup and
the chosen stem family are in line (with
the reference center line). If these centers
overlap the selected stem family
reproduces the offset correctly and you
will continue your planning with this stem
family. If the centers do not overlap,
repeat the procedure with the other
families until one family fits correctly
representing the family of choice. Trace
the medial outline of the selected stem
family on the tracing paper.

Equalizing Leg Length

Place the tracing paper on the opposite
side with the cup and the medial contour
of the stem aligned to the femur. The tips
of the greater and lesser trochanters are
drawn as reference for leg length.

Place the tracing paper again on the side

to be operated. The drawn trochanters are
placed in line with the trochanters of the
side to be operated which automatically
equalizes leg length in the planning. Be
aware that the positioning of the pelvis on
the tracing paper will reflect changes in
leg lenth and may not be aligned with the
x-ray during the remaining steps. The
inner and outer contours of the femur are
outlined.
 Fitmore® Hip Stem – Surgical Technique 9

Determination of the Size

Take the sizing templates of the selected
stem family, place its medial contour
accurately on the previously drawn
contour and increase the size starting
with size one until the stem fills the
medullary canal, i.e. the lateral side of
the stem touches the lateral cortex. It is
very important that the axis of the stem
shown on the template is parallel to the
femoral axis. The stem that fits best
completes the drawing of the contour of
the optimal stem on the tracing paper.

Final Result
The distance between the proximal end
of the stem taper and the lesser
trochanter is measured and written down.
Other reference marks may be used
depending on the individual technique
and can be measured as well, for
example the distance between the tip of
the greater trochanter and the shoulder
of the prosthesis. Finally, all necessary
information about the patient and the
prosthetic components is written down.
10 Fitmore® Hip Stem – Surgical Technique

Surgical Technique
This surgical technique may be adapted
to the surgeon’s specific approach.
The following description of the surgical
technique starts with the osteotomy of
the femoral neck.

Osteotomy of the Femoral Neck

The Fitmore Hip Stem instrument set
simplifies the surgery and allows
a well-targeted and efficient operating
procedure. The osteotomy typically
starts at the base of the femoral neck and
is inclined by 45°. Depending on the
planning and the individual anatomy
the osteotomy may vary in height.

Preparation of the Femoral Canal

The femoral canal is entered by opening
the medullary canal with a starter
instrument (curved chisel or curved hand
rasp) which enters into the resection
surface on the posterior side, in the
middle third, and should be in line with
the axis of the femur.

It is recommended to direct the entry

point towards the medullary canal
following the axis of the femur. This will
ensure the correct introduction of the
starter instrument (curved hand rasp or
curved chisel) and the subsequent starter
rasp. The starter instrument should only
be inserted and not twisted in the
cancellous bone. Care must be taken to
preserve as much bone as possible. The
use of an awl is not recommended.
 Fitmore® Hip Stem – Surgical Technique 11

Prepare the femoral canal by first using

the starter rasp to enter the medullary
canal.

Start with the smallest rasp size of the

stem family chosen in the preoperative
planning. The insertion of the first rasp
will determine the anteversion of the
subsequent rasps and the final implant.

The femoral canal is prepared, using

rasps of increasing size, until maximum
stability is obtained usually with the
preoperatively determined stem size. If
the medial fit of the rasp is not adequate,
i.e. there is no cortical contact in the
calcar region, one should consider
switching from stem family A to B or from
stem family B to C. In this case it is
recommended to start rasping two sizes
smaller than the last rasp size used.

Example: If the last rasp used was A8,

start again with rasp B6.

It must be taken into consideration that

by changing the stem family the offset is
also changed. Therefore, the new stem
family and the preoperatively planned
stem height (to the references chosen on
the preoperative planning) need to be
reassessed in order to avoid lengthening
the leg. In most cases switching families
means downsizing one to two sizes
within the new stem family.

Tip
If, based on the X-rays, one is not certain
which family is best, then start with
family A. Then the offset could be
increased gradually from stem family A to
B and then from B to C, but not directly
from A to C. It is only allowed to switch
from a smaller offset prosthesis to a
bigger, which means from family A to B,
or B to C. But do not switch from family A
directly to family C. The order A to B and
B to C must always be maintained.

Warning
Never switch from C to B, or C to A,
or B to A.
12 Fitmore® Hip Stem – Surgical Technique

Trial Reduction
Remove the rasp handle and leave the
rasp in the femoral canal. Choose the
appropriate trial neck following the stem
family concept, i.e. A, B, B-Ext. or C. The
stem families are indicated on the top of
the trial necks. Each rasp family has a
specific design coding feature to prevent
incorrect rasp body and trial neck mating.
Please be aware that only stem family B
has two different offset options (B and
B-Ext.) on the same rasp body. Once the
trial neck is inserted, check the distance
between lesser trochanter and taper
compared with your preoperative Color Coding and Labeling
planning. If the distance is according to
the preoperative planning the adequate
trial head is used for trial reduction. Rasp A

Joint stability and soft-tissue tension

are assessed. This procedure is repeated
Rasp B
as necessary, using trial heads of
different lengths, until optimal offset, leg
length and stability are achieved. A trial
Rasp B Ext. Offset
reduction should not allow significant
push-pull of the joint in full extension.
The range of motion is checked to avoid
bony and implant impingement as well
Rasp C
as instability.

Design Coding
 Fitmore® Hip Stem – Surgical Technique 13

Insertion of the Fitmore Hip Stem

After removal of the rasp, the selected
stem is inserted and driven in until
cortical contact stabilizes the stem.

It is important to adjust the force of the

mallet blows to the quality of the bone
and to stop immediately when the dull
sound (cancellous bone) changes to the
sharp sound (cortical bone).

After driving in the stem, the taper

protector is removed from the taper and a
trial head may be mounted for a final trial
head reduction. Once the final range of
motion and “shuck” tests are completed,
the taper is carefully cleaned and dried.
The selected femoral head is mounted
with a rotational movement and rotated
further with axial force until it is firmly
seated. The femoral head is seated with
one light mallet blow on the head
impactor in an axial direction. After
reduction of the joint, the range of motion
and the stability of the joint are
reassessed throughout the whole range
of motion.

Wound closure is carried out according to

the specific technique and approach
used.
14 Fitmore® Hip Stem – Surgical Technique

Intraoperative Extraction of the

Fitmore Hip Stem
If the stem needs to be removed
intraoperatively, only the specific
extraction instrument, which protects the
taper of the stem, may be used. Slide the
extraction instrument over the stem
taper. Tighten the exchangeable plastic
jaws by closing the lever. Make sure that
the instrument is firmly fixed. Remove the
stem by hammering back on the
extraction instrument.

Important
The extraction instrument must be used
exclusively for intraoperative stem
extraction. It is not suitable for revision
cases. The plastic jaws can be
exchanged, if necessary. In case of
intraoperative repositioning of the stem
the surgeon must verify the integrity of
the stem.
Exchange hole

Exchangeable Plastic Jaws

Insertion of the Plastic Jaw Exchange of
Each plastic jaw is aligned with the slot the plastic jaw
and snapped in place inside the housing.

Exchange of the Plastic Jaws

A pin is used through the hole to release
the plastic jaws.

Postoperative Treatment Insertion of

the plastic jaw

The postoperative treatment depends on

the patient and the bone quality.
Immediate weight bearing can be allowed
in agreement with the orthopedic surgeon
and mobilization may be started on the
first postoperative day depending on the
individual rehabilitation protocol.
Crutches should be used until the patient
is able to walk safely without limping.
 Fitmore® Hip Stem – Surgical Technique 15

Fitmore Hip Stem Implants

Fitmore Hip Stem A, 140o Details Dimensions Offset REF

Size 9 35.50 01.00551.109
Protasul®-64 Alloy Size 2 31.50 01.00551.102
Taper 12/14 Size 3 32.00 01.00551.103 Size 10 36.25 01.00551.110
uncemented Size 4 32.50 01.00551.104 Size 11 37.00 01.00551.111
Size 5 33.00 01.00551.105 Size 12 37.75 01.00551.112
Size 6 33.62 01.00551.106 Size 13 38.50 01.00551.113**
Size 7 34.25 01.00551.107 Size 14 39.25 01.00551.114**
Size 8 34.88 01.00551.108

Fitmore Hip Stem B, 137o Details

Protasul -64 Alloy
Dimensions Offset REF
Size 1 37.00 01.00551.201 Size 8 40.88 01.00551.208
Taper 12/14 Size 2 37.50 01.00551.202 Size 9 41.50 01.00551.209
uncemented Size 3 38.00 01.00551.203 Size 10 42.25 01.00551.210
Size 4 38.50 01.00551.204 Size 11 43.00 01.00551.211
Size 5 39.00 01.00551.205 Size 12 43.75 01.00551.212
Size 6 39.62 01.00551.206 Size 13 44.50 01.00551.213**
Size 7 40.25 01.00551.207 Size 14 45.25 01.00551.214**

Fitmore B Ext. Offset, 129o Details Dimensions Offset REF

Size 8 47.88 01.00551.308
Protasul -64 Alloy Size 1 44.00 01.00551.301
Taper 12/14 Size 2 44.50 01.00551.302 Size 9 48.50 01.00551.309
uncemented Size 3 45.00 01.00551.303 Size 10 49.25 01.00551.310
Size 4 45.50 01.00551.304 Size 11 50.00 01.00551.311
Size 5 46.00 01.00551.305 Size 12 50.75 01.00551.312
Size 6 46.62 01.00551.306 Size 13 51.50 01.00551.313**
Size 7 47.25 01.00551.307 Size 14 52.25 01.00551.314**

Fitmore Hip Stem C, 127o Details

Protasul -64 Alloy
Dimensions
Size 1
Offset
51.00
REF
01.00551.401 Size 8 54.88 01.00551.408
Taper 12/14 Size 2 51.50 01.00551.402 Size 9 55.50 01.00551.409
uncemented Size 3 52.00 01.00551.403 Size 10 56.25 01.00551.410
Size 4 52.50 01.00551.404 Size 11 57.00 01.00551.411
Size 5 53.00 01.00551.405 Size 12 57.75 01.00551.412
Size 6 53.62 01.00551.406 Size 13 58.50 01.00551.413**
Size 7 54.25 01.00551.407 Size 14 59.25 01.00551.414**

** Available upon request

16 Fitmore® Hip Stem – Surgical Technique

Fitmore Hip Stem Instruments

Fitmore Rasp Set A

Fitmore Rasp Set A
(complete set with all instruments)
REF
KT-0055-910-01
Fitmore Trial Neck A, 140°
Fitmore Rasp Tray A Fitmore Rasp A Quantity REF
REF Description Quantity REF 1 01.00559.150
00-7895-061-00 Size 1 1 01.00559.101
Size 2 1 01.00559.102
Lid Size 3 1 01.00559.103
REF Size 4 1 01.00559.104
00-5900-099-00 Size 5 1 01.00559.105
Size 6 1 01.00559.106
Size 7 1 01.00559.107
Size 8 1 01.00559.108
Size 9 1 01.00559.109
Size 10 1 01.00559.110
Size 11 1 01.00559.111
Size 12 1 01.00559.112
Size 13 1 01.00559.113**
Size 14 1 01.00559.114**

Fitmore Rasp Set B

Fitmore Rasp Set B
(complete set with all instruments)
REF
KT-0055-910-02
Fitmore Trial Neck B, 137°
Fitmore Rasp B Quantity REF
Fitmore Rasp Tray B
Description Quantity REF 1 01.00559.250
REF
Size 1 1 01.00559.201
00-7895-063-00
Size 2 1 01.00559.202
Size 3 1 01.00559.203
Lid
Size 4 1 01.00559.204
REF
Size 5 1 01.00559.205
00-5900-099-00
Size 6 1 01.00559.206
Size 7 1 01.00559.207 Fitmore Trial Neck B Ext. Offset, 129°
Size 8 1 01.00559.208 Quantity REF
Size 9 1 01.00559.209 1 01.00559.251
Size 10 1 01.00559.210
Size 11 1 01.00559.211
Size 12 1 01.00559.212
Size 13 1 01.00559.213**
Size 14 1 01.00559.214**
** Available upon request
 Fitmore® Hip Stem – Surgical Technique 17

Fitmore Rasp Set C

Fitmore Rasp Set C
(complete set with all instruments)
REF
KT-0055-910-03
Fitmore Trial Neck C, 127°
Quantity REF
Fitmore Rasp Tray C Fitmore Rasp C
1 01.00559.350
REF Description Quantity REF
00-7895-065-00 Size 1 1 01.00559.301
Size 2 1 01.00559.302
Lid Size 3 1 01.00559.303
REF Size 4 1 01.00559.304
00-5900-099-00 Size 5 1 01.00559.305
Size 6 1 01.00559.306
Size 7 1 01.00559.307
Size 8 1 01.00559.308
Size 9 1 01.00559.309
Size 10 1 01.00559.310
Size 11 1 01.00559.311
Size 12 1 01.00559.312
Size 13 1 01.00559.313**
Size 14 1 01.00559.314**

** Available upon request

18 Fitmore® Hip Stem – Surgical Technique

Fitmore General Instrument Set

Fitmore General Set (complete set with all
instruments)

REF

KT-0055-910-00
Fitmore Intra-Operative Extraction
Fitmore Curved Hand Rasp
Instrument
Fitmore Base Tray General Quantity REF
Quantity REF
Instruments REF 1 00-7942-020-00
1 01.00559.620

00-7895-067-00

Fitmore Tray Insert General

Instruments REF

00-7895-068-00 Fitmore Curved Chisel

MIS Double Offset Rasp Handle 45°
Quantity REF
Quantity REF
Lid 1 01.00559.630
1 Left 00-7712-035-01
REF
1 Right 00-7712-035-02

00-5900-099-00

Fitmore Starter Rasp

Quantity REF
1 01.00559.610
 Fitmore® Hip Stem – Surgical Technique 19

Straight Rasp Handle 45° Femoral head provisionals

Quantity REF Size Quantity REF
1 00-7712-050-60 28 mm (–3.5) 1 00-7895-028-01
28 mm (+0) 1 00-7895-028-02
28 mm (+3.5) 1 00-7895-028-03
28 mm (+7.0) 1 00-7803-028-14
28 mm (+10.5) 1 00-7895-028-05
32 mm (–3.5) 1 00-7895-032-01
32 mm (+0) 1 00-7895-032-02
Modular Repositioning Handle, short 32 mm (+3.5) 1 00-7895-032-03
Quantity REF 32 mm (+7.0) 1 00-7803-032-14
1 75.11.00-02 32 mm (+10.5) 1 00-7895-032-05
36 mm (–3.5) 1 00-7895-036-01
36 mm (+0) 1 00-7895-036-02
36 mm (+3.5) 1 00-7895-036-03
36 mm (+7.0) 1 00-7895-036-04
36 mm (+10.5) 1 00-7895-036-05

Repositioning Top
Size Quantity REF
28 mm 1 78.00.38-28
32 mm 1 78.00.38-32
36 mm 1 78.00.38-36
Stem Driver (offset with teardrop-tip)
Quantity REF
1 00-7712-057-10

Ball-Head Impactor Attachment

Quantity REF
1 78.00.38

MIS Osteotomy Guide 45°

Quantity REF
1 00-7806-009-45
20 Fitmore® Hip Stem – Surgical Technique

Upon Request

Stem Driver (with locking mechanism) Calcar Planer Stem Driver (straight with teardrop tip)
Quantity REF Quantity Size REF Quantity REF
1 00-7712-056-00 1 small 00-7942-023-00 1 00-7712-057-00
1 large 00-7942-025-00

MIS Anterior Offset Rasp Handle 45° Plastic Jaws for REF 01.00559.620 TM Primary Rasp Handle 23.5°
Quantity REF Quantity REF Quantity REF
1 00-7806-050-00 1 01.00559.621* ** 1 00-7865-035-20

Stem Driver (straight with round tip)

Quantity REF
1 00-7712-064-00

* Reusable
** Available upon request
Please refer to package insert for complete product
information, including contraindications, warnings,
precautions, and adverse effects.

Contact your Zimmer representative or visit us at www.zimmer.com

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