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T2 Ankle Arthrodesis Nail Operative Technique 1 Ankle Arthrodesis Nailing System Contributing Surgeons Joseph D. DiCicco D.O. Chief Orthopedic Trauma Good Samaritan Hospital Chairman, Dept of Orthopaedic Surgery Grandview Hospital, Dayton, Ohio Clinical Professor Orthopaedic Surgery Ohio University & Wright State University Dayton, Ohio Thomas Mückley, M.D. Department of Trauma, Hand and Reconstructive Surgery University Hospital Jena Germany Anthony T. Sorkin, M.D. Rockford Orthopaedic Associates, LLP Clinical Instructor, Department of Surgery University of Illinois, College of Medicine Director, Orthopaedic Traumatology Rockford Memorial Hospital Rockford, Illinois, USA This publication sets forth detailed recommended procedures for using Stryker Osteosynthesis devices and instruments. It offers guidance that you should heed, but, as with any such technical guide, each surgeon must consider the particular needs of each patient and make appropriate adjustments when and as required. A workshop training is required prior to first surgery. See package insert (L22000007) for a complete list of potential adverse effects, contraindications, warnings and precautions. The surgeon must discuss all relevant risks, including the finite lifetime of the device, with the patient, when necessary. Warning: All bone screws referenced in this document here are not approved for screw attachment or fixation to the posterior elements (pedicles) of the cervical, thoracic or lumbar spine. 2 Contents Page 1. Introduction 4 Implant Features 4 Design Rational 4 Technical Details 5 Instrument Features 6 2. Relative Indications & Contraindications 7 3. Pre-operative Planning 7 4. Locking Options 7 5. Operative Technique 8 Patient Positioning and Joint Surface Preparation 8 Incision and Entry Point 9 Reaming 11 Target Device Assembly 12 Nail Insertion 13 Guided Locking via Targeting Device 14 Approsition/Compression Locking Mode 14 Static Locking Mode 20 Freehand Proximal Locking of Long Nails 23 End Cap Insertion 24 Nail Removal 25 Case Resport 26 References 27 Ordering Information – Implants 28 Ordering Information – Instruments 29 3 Introduction Introduction Implant Features Design Rationale The T2 Nailing System represents The T2 Ankle Arthrodesis Nail offers The design of the T2 Ankle Stryker´s latest and most strong biomechanical* intramedullary Arthrodesis Nail features a 5° comprehensive development of the stabilization using cannulated lateral (valgus) bend providing an original intramedullary principles implants for the tibiotalocalcaneal anatomical fit with better purchase presented by Prof. Gerhard Küntscher fusion. through the calacaneal bone. in 1940. With a new generation of T2 Nails (e.g. T2 Proximal Humeral All implants of the T2 Ankle Proximal locking is performed Nail, T2 Supracondylar Nail, T2 Arthrodesis Nailing System are from medial to lateral in order to: Recon Nail), the indications have made of Type II anodized titanium extended from shaft fractures to alloy (Ti6Al4V) for enhanced • Avoid damage of muscular and fractures of the metaphyseal regions. biomechanical and biomedical neuro-vascular stuctures located performance*. on the lateral side of the tibia In addition to the T2 Nailing systems for Femoral, Tibial, and Humeral Standard 5mm cortical screws • Avoid interference with the fibula. fractures, Stryker Osteosynthesis has simplify the surgical procedure and developed the T2 Knee Arthrodesis offer the advantages of both reduced The low profile design of T2 Nail and, more recently, the T2 Ankle insertion torque and low profile Locking Screws helps reduce Arthrodesis Nail to provide the heads*. Fully Threaded Locking prominence under the soft tissue option for tibiotalocalcaneal fusion Screws are available for standard on the medial cortex of the tibia. with a retrograde intramedullary nail. locking procedures. Partially The main advantages of the technique Threaded Locking Screws (Shaft Two 5mm Fully Threaded Locking are limited soft tissue damage in the Screws) are designed for use if Screws can be placed in the ankle area, high primary stability apposition/compression is applied. calcaneus: the proximal one in a allowing early weight bearing, L/M direction through a threaded (3) as well as compression of the The proximal locking configuration locking hole, and the distal one in subtalar and tibiotalar joints (5). features a round and an oblong hole to P/A direction with a 10° angle from allow for static or dynamic locking. postero-medial to antero-lateral Severe arthrosis and deformity Controlled apposition/compression (Fig. 1). This design dictates the of the ankle and subtalar joints up to 5mm can be applied at the need for left and right nails. are debilitating problems that tibio-talar joint by introducing a Internal compression techniques are can be difficult to treat. The Compression Screw from the driving preferred because of higher union tibiotalocalcaneal fusion with a end of the nail against the 5mm rates, shorter fusion times, and fewer retrograde intramedullary nail can Shaft Screw placed in the talus. The complications (2). be considered a salvage procedure Compression Screw is cannulated for severe arthrosis and deformity therefore allowing nail insertion over End Caps in different sizes are of the ankle and subtalar joints (1). the guide-wire with the compression available to provide the improved Ankle arthrodesis is a challenging screw pre-loaded. fit for every indication and lock procedure due to poor host conditions down on the PA calcaneal screw. (e.g. bad skin, deformity, avascular T2 Ankle Arthrodesis Nails come in This feature creates a fixed angle necrosis), inability to get adequate 10, 11 and 12mm diameters and 150, between the nail and Locking fixation for this slow healing process, 200 and 300mm lengths. The driving Screw. and the inability to get adequate end diameter is 12mm for all nails. compression across the fusion. Like other nails in the T2 family, the T2 Ankle Arthrodesis Nail enables the surgeon to create an inherently stable construct by providing internal compression to the fusion mass and distal crosslock holes within the nail to generate an intramedullary fixed-angle device. Performing an ankle arthrodesis can be technically demanding because of the shape and small size of the talus. Therefore, preoperative planning is * Data on file at Stryker: See the detailed chart on the next an absolute necessity to determine - Test Report No 130505CG1 Strength calculation page for the design specifications placement and number of screws (2). (FEA) of 10mm T2 Ankle Arthrodesis Nail and size offerings of the implants. The T2 Ankle Arthrodesis Nailing - White Paper: Ti6Al4V with Anodization Type II Biological Behavior and Biomechanical Effects System is based on the established Axel Baumann, Dipl.-Ing. DOT GmbH, Rostock, T2 instrument platform and locking Germany, Nils Zander, Dipl.-Ing. Stryker screws. It offers the advantages of a Trauma GmbH, Schönkirchen / Kiel, Germany unique locking configuration allowing - Test Report 080103HK1 T2 / S2: Modified screw for tibiotalocalcaneal fixation. head design of cross screws Ø4 / 5mm 4 Features Technical Details - T2 Ankle Arthrodesis Nail Diameter 10, 11 and 12mm (Left and Right) Sizes 150, 200 and 300mm 15mm 5mm Note: 40mm Driving end diameter is 12mm for all nails. 5.0mm Partially Threaded Locking Screws (Shaft Screws) L=25mm – 120mm lateral medial Note: Screw length is measured Compression Screw from top of head to tip. 5mm 5.0mm Fully Threaded 47mm Locking Screws 7.5mm L=25mm – 120mm 19.5mm Endcap anterior 10° Compression Screw (cannulated) lateral medial End Caps Fig 1 Standard +5mm +10mm +15mm View from distal 5 Features Instrument Features The major advantage of the instrument system is the integration of a core instrument platform Targeting Device which can be used not only for the complete T2 Nailing System, but also represent the platform for all future Stryker Osteosynthesis nailing and further reduces complexity and inventory. The T2 instrument Apposition Sleeve platform offers advanced precision and usability, as well as ergonomically styled targeting devices. Except for the addition of a small number of dedicated instruments, the T2 Femoral Instrument platform is used Apposition Ring for the T2 Ankle Arthrodesis Nail. Dedicated instruments for the T2 Ankle Arthrodesis Nail include the Ankle Arthrodesis Targeting Device and a special Apposition Handle Compression Screwdriver. A pre-assembled Apposition Handle and Ring/Sleeve allow for applying additional external compression. As with all T2 Nailing Systems, the T2 Ankle Arthrodesis Targeting Device is made of carbon fiber and features a friction locking mechanism to lock the Tissue Protection Sleeves in place. Both proximal and distal holes of the 150mm and 200mm nails can be locked with the Targeting Device. For proximal locking of the 300mm nails, free hand technique must be applied. An additional Aiming Adapter can be attached to the Targeting Device to help achieve the appropriate rotation based on the position of the PA calcaneal screw aligned with the anatomic calcaneal body axis. Aiming Adapter 6 Relative Indications & Contraindications Relative Pre-operative Locking Options Indications and Planning Contraindications The T2 Ankle Arthrodesis Nail Preoperative clinical and radiological Based on the clinical and radiological may be used for: assessments are very important for the assessment, different locking surgical outcome. options can be used to obtain • Posttraumatic and
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