T2 R1.5 Femoral Nailing System

Operative Technique Femoral Nailing System

Contributing Surgeons

Prof. Dr. med. Volker Bühren Chief of Surgical Services Medical Director of Murnau Trauma Center Murnau Germany

Joseph D. DiCicco III, D. O. Director Orthopaedic Trauma Service Good Samaritan Hospital Dayton, Ohio Associate Clinical Professor of Orthopeadic Surgery Ohio University and Wright State University USA

Thomas G. DiPasquale, D. O. Medical Director, Orthopedic Trauma Services Director, Orthopedic Trauma Fellowship and This publication sets forth detailed Orthopedic Residency Programs recommended procedures for using York Hospital Stryker Osteosynthesis devices and York instruments. USA 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.

All non-sterile devices must be cleaned and sterilized before use. Follow the instructions provided in our reprocessing guide (L24002000). Multi-component instruments must be disassembled for cleaning. Please refer to the corresponding assembly/ disassembly instructions.

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: Fixation Screws: Stryker Ostreosynthesis bone screws are not approved or intended 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 Instrument Features 6 References 6 2. Indications, Precautions and Contraindications 7 Indications 7 Precautions 7 Relative Contraindications 7 3. Additional Information 8 Locking Options 8 4. Pre-operative Planning 10 5. Operative Technique – Retrograde Technique 11 Patient Positioning 11 Incision 11 Entry Point 12 Unreamed Technique 13 Reamed Technique 13 Nail Selection 15 Nail Insertion 16 Guided Locking Mode (via Target Device) 18 Static Locking Mode 19 Freehand Proximal Locking 23 End Cap Insertion 25 Dynamic Locking Mode 26 Apposition /Compression Locking Mode 26 Advanced Locking Mode 28 External Compression Device 30 Nail Removal 32 6. Operative Technique – Antegrade Technique 33 Patient Positioning and Fracture Reduction 33 Incision 33 Entry Point 34 Unreamed Technique 35 Reamed Technique 35 Nail Selection 37 Nail Insertion 38 Guided Locking Mode (via Target Device) 40 Static Locking Mode 41 Freehand Distal Locking 43 End Cap Insertion 44 Dynamic Locking Mode 45 Apposition /Compression Locking Mode 46 Advanced Locking Mode 48 External Compression Device 48 Nail Removal 50

Ordering Information – Implants 51 Ordering Information – Instruments 54

3 Introduction

Implant Features Over the past several decades ante­ The T2 Femoral Nailing System is Besides the T2 Femoral nail with a grade femoral nailing has become the realization of excellent biome­ 3m radius of curvature, Stryker offers the treatment of choice for most chanical intramedullary stabilization also a 1.5m radius T2 Femoral Nail femoral shaft fractures. Retrograde using small caliber, strong, cannu­ to complete the product offering for femoral nailing has expanded the lated implants for internal fixation those patients with a higher anterior use of intramedullary nails (1, 2). of long bones. According to the femoral curvature. Complicated multiple trauma injuries, frac­­ture type, the system offers the associated pelvic and acetabular option of different locking modes. In Common 5mm cortical screws* frac­­­­tures, ipsilateral femoral shaft addition to static locking, a control­ sim­­plify the surgical procedure fractures, supracondylar and inter­ led dynamization with rotational and promote a minimally invasive condylar fractures, may be better stability is an option. approach. Fully Threaded Locking managed by utilizing retrograde Screws are available for regular femoral nailing techniques In some indications, a controlled locking procedures. Partially (3, 4, 5, 6, 7). apposition/compression of bone Threaded Locking Screws (Shaft fragments can be applied by intro­ Screws) are designed if appo- The T2 Femoral Nailing System ducing a Compression Screw from sition/compression is applied. Special is one of the first femoral nailing the top of the nail. To further help Condyle Screws with adjustable systems to offer an option for either in­crease rotational stability, the nail washers for improved fit are designed an antegrade or a retrograde ap­­proach can be locked statically after using to fix fragments in the condyle area. to repair fractures of the femur. the controlled dynamization and They also allow controlled “lag effect” apposition/compression option. with intercondylar split type fractures. One Implant, Two Approaches The Compression Screw is pushed Compression Screws to close the against the Partially Threaded fracture site and End Caps are Stryker has created a next generation Locking Screw (Shaft Screw) that available in various sizes to allow an locking nail system, bringing together has been placed in the oblong improved fit. all the capabilities and benefits of hole, drawing either the distal or separate antegrade and retrograde the proximal segment towards the All implants of the T2 Femoral nailing systems to create a single, fracture site. In stable fractures, this Nailing System are made of Type II integrated surgical resource for offers the biomechanical advantage anodized titanium alloy (Ti6AL4V) fixation of long-bone fractures. of creating active circumferential for enhanced biomechanical and compression to the fracture site, biomedical performance**. Furthermore, the development of transferring axial load to the bone, the T2 Femoral Nailing System offers and reducing the function of the nail See the detailed chart on the next page the competitive advantages of: as a load bearing device (8). for the design specifications and size offerings. • Not limiting the approach to This ability to transfer load back to a certain nailing technique the bone may reduce the incidence • Accommodating reamed or of implant failure secondary to unreamed procedures fatigue. Typical statically locked nails •  Providing locking options for function as load bearing devices, and * Special order 8mm T2 Femoral Nails can only be locked with 4mm Fully Threaded screws at the non- all types of fractures, plus the failure rates in excess of 20 % have driving end. As with all diameters of T2 Femoral Advanced Locking Mode for been re­ported (9). Nails, the screws for driving end locking are 5mm. increased rotational stability The beneficial effect of apposition/ ** Axel Baumann, Nils Zander Ti6Ai4V with Anodization Type II: Biological and Through the development of a com­ compression in treating long-bone Biomechanical Effects, White Paper, March 2005 mon, streamlined and intuitive fractures in cases involving transverse surgical approach, both in principle and short oblique fractures that are and in detail, the T2 Femoral Nailing axially stable is well documented System offers the potential for (10, 11). increased speed and functionality for the treatment of fractures as well as Anthropological (13) and forensic simplifying the training requirements (14) literature reveals that differences for all personnel involved. in the anterior femoral curvature between racial and ethnic groups have long been recognized.

4 Introduction

Antegrade 0mm

15 Nails Diameter 9−15mm (special order 8mm)* 25 Sizes 240−480mm 35 32.5 40 42.5 50 Note: Screw length is measured from top 45mm of head to tip.

5.0mm Partially Threaded Locking Screws (Shaft Screws) L = 25−120mm

5.0mm Fully Threaded Locking Screws L = 25−120mm

5.0mm Condyle Screws L = 40−120mm

Condyle Nut

Compression Screws

Femur Advanced 60 Compression Compression 45 47.5 Screw Range* 35 50 Advanced 32.5 Compression Screw 15

25 0mm

0mm Retrograde Standard +5mm +10mm +15mm

End Caps * 8mm nails (special order) require 4mm Fully Threaded Screws for Distal Locking

* Compression Range

Total Length of Slot 15mm Less Screw Diameter (-) 5mm Maximum Movement of Screw 10mm Standard +5mm +10mm +15mm +20mm +25mm +30mm +35mm 5 Introduction

Instrument Features

A major advantage of the instru- Symbol Drills ment system is a breakthrough in the integration of the instrument plat­form Square = Long instruments Drills feature color coded rings : which can be used for the complete T2 4.2mm = Green Nailing System, thereby to help reduce complexity and inventory. Triangular = Short instruments For 5.0mm Fully Threaded Locking Screws and for the second cortex The instrument platform offers when using 5.0mm Partially Threaded ad­vanced precision and usability, and Locking Screws (Shaft Screws). features ergonomically styled targeting devices. 5.0mm = Black Symbol coding on the instruments For the first cortex when using 5.0mm indicates the type of procedure, and Partially Threaded Locking Screws must not be mixed. (Shaft Screws) and for both corticies when using Condyle Screws.

References 1. Janzing HMJ et al.: The Retrograde 6. Ostrum F. D., Joseph DiCicco, 10. M.E. Müller, et al., Manual of Intramedullary Nail: Prospective Retrograde In­tramedullary Nailing Internal Fixation, Springer-Verlag, Experience in Patients Older than of Femoral Diaphyseal Fractures, Berlin, 1991 Sixty-five Years. Journal of Ortho- Journal of orthopaedic Trauma, paedic Trauma 12 (5) 330-333, 1998 Vol. 12, N° 7, pp. 464-468, 1998 11. O. Gonschorek, G. O. Hofmann, V. Bühren, Interlocking 2. Koval KJ et al.: Distal Femoral 7. Lucas SE et al.: Intramedullary Compression Nailing: a Non-union: Treatment with Supracondylar Nailing of Femoral Report on 402 Applications. a Retrograde Inserted Locked Fractures. A Preliminary Report Arch. Orthop. Trauma Surg (1998), Intramedullary Nail, Journal of of the GSH Supracondylar Nail. 117: 430-437 Orthopaedic Trauma, Vol. 9 N°4, pp. Clinical Orthopaedics and Related 285-291, 1995 Research 296 200-206, 1993 12. Mehdi Mousavi, et al., Pressure Changes During Reaming with 3. Herscovici D Jr. and Whiteman 8. T. E. Richardson, M. Voor, Different Parameters and Reamer KW: Retrograde Nailing of the D. Seligson, Fracture Site Designs, Clinical Orthopaedics Femur Using an Intercondylar Compression and Motion with and Related Research, Number Approach. Clinical Orthopaedics Three Types of Intramedullary 373, pp. 295-303, 2000 and related Research, 332, 98-104, Fixation of the Femur, 1996 Osteosynthese International (1998), 13. Gilbert BM. Anterior femoral 6: 261-264 curvature: its propabable basis 4. Roy Sanders, Kenneth J. Koval et and utility as a criterion of a racial al.: Retrograde Reamed Femoral 9. Hutson et al., Mechanical assessment. Am J Phys Anthropol. Nailing. Journal of Orthopaedic Failures of Intramedullary Tibial 1976;45:601-604.5 Trauma 1993; Vol. 7, No. 4: 293-302 Nails Applied without Reaming, Clin. Orthop. (1995), 315: 129-137 14. Ballard ME, Trudell MB. Anterior 5. Ostrum F. D., et al., A Prospective femoral curvature revisited: race Comparison of Antegrade and assessment from the femur. J Retrograde Intramedullary Nailing, Forensic Sci. 1999;44:700-707. Friday, October 9, 1998 Session V, 11:31 a. m. OTA Vancouver

6 Indications, Precautions and Contraindications

Indications Precautions • Open and closed femoral Stryker Osteosynthesis systems have fractures not been evaluated for safety and use • Pseudarthrosis and Correction in MR environment and have not been Osteotomy tested for heating or migration in the • Pathologic fractures, impending MR environment, unless specified pathologic fractures and tumor otherwise in the product labeling or resections respective operative technique. • Supracondylar fractures, including those with intraarticular extension • Ipsilateral femur fractures

• Fractures proximal to a total knee Antegrade arthroplasty • Fractures distal to a hip joint • Nonunions and malunions. Retrograde

Relative Contraindications The physician’s education, training and professional judgement must be relied upon to choose the most appropriate device and treatment. Conditions presenting an increased risk of failure include: • Any active or suspected latent • Implant utilization that would infection or marked local interfere with anatomical inflammation in or about the structures or physiological affected area. performance. • Compromised vascularity that • Any mental or neuromuscular would inhibit adequate blood disorder which would create supply to the fracture or the an unacceptable risk of fixation operative site. failure or complications in • Bone stock compromised by postoperative care. disease, infection or prior • Other medical or surgical implantation that can not provide conditions which would preclude adequate support and/or fixation the potential benefit of surgery. of the devices. • Material sensitivity, documented or suspected. • Obesity. An overweight or obese patient can produce loads on the implant that can lead to failure of the fixation of the device or to failure of the device itself. • Patients having inadequate tissue coverage over the operative site.

7 Additional Information

Locking Options

Antegrade Static Mode Retrograde

8 Additional Information

Dynamic Mode Apposition / Compression Mode Advanced Locking Mode

9 Pre-operative Planning

An X-Ray Template 1806-0006 is available for pre-operative planning.

Thorough evaluation of pre-operative radiographs of the affected extrem­ity is critical. Careful radiographic ex­­­am­ination of the trochanteric region and intercondylar regions may prevent certain intra-operative complications.

The proper nail length when inserted antegrade should extend from the Tip of the Greater Trochanter to the Epiphyseal Scar.

The retrograde nail length is deter­ mined by measuring the distance between a point 5mm–15mm proxi­ mal to the Intercondylar Notch to a point at/or proximal to the Lesser Trochanter.

In either approach this allows the surgeon to consider the apposition/ compression feature of the T2 Femo­ ral Nail, knowing that up to 10mm of active apposition/compression is possible, prior to determining the final length of the implant. If apposition/ compression is planned, the nail should be 10mm to 15mm shorter.

Note: Check with local representative regarding availability of nail sizes.

10 Operative Technique – Retrograde Technique

Incision

A 3cm midline skin incision is made extending from the inferior pole of the Patella to the Tibial Tubercle, followed by a medial parapatellar capsular in­ci­sion. This should be sufficient to 5mm expose the Intercondylar Notch for retrograde nail insertion. Occasionally, a larger incision may be needed, espe­ cially if the fracture has intra-articular extension and fixation of the condyles Patient Positioning is necessary.

Retrograde nail insertion is per­ Distal femoral fractures are often formed with the patient supine on a complicated by intra-articular fracture radiolucent table. The affected lower line extension. These fractures should extremity and hip region are freely be anatomically reduced and secured draped, and the knee is placed over with the aid of titanium Asnis III a sterile bolster. This will allow for 6.5mm/8.0mm Large Cannulated 30-45 degrees of knee flexion. Manual Screws in the anterior and posterior traction through a flexed knee or a aspect of the femoral condyles. This distraction device may be used to will allow for adequate space when facilitate reduction for most acute inserting the nail retrograde. Cannu­ femoral shaft fractures. lated Screws are advantageous, al­low­ing the surgeon to use intra- operative radiographs to check Guide Wire place­­ment prior to screw insertion. An alternative is to reduce and maintain reduction of the femoral condyles with a pointed reduction forceps during the insertion of the retrograde nail and place cannulated screws after the nail is inserted.

11 Operative Technique – Retrograde Technique

Entry Point

The 3 × 285mm K-Wire (1806- 0050S)* can easily be fixed to the Guide Wire Handle (1806-1095 and 1806-1096) (Fig. 1). With the condyles secured, the entry point for retrograde nail in­ser­tion is made by centering the 3 × 285mm K-Wire through the Retrograde Protection Sleeve (703165) and positioning within the Intercondylar Notch anterior to Blumensaat´s line on the M/L radiograph using the Slotted Hammer (1806-0170) (Fig. 2). Note: This point is found by palpating a Fig. 1 During opening the entry portal distinct ridge just anterior to the with the Awl, dense cortex may Posterior Cruciate Ligament (Fig. 2). block the tip of the Awl. An Awl Plug (1806-0032) can be The K-Wire is advanced manually or inserted through the Awl to avoid with the Slotted Hammer ap­prox­i­ penetration of bone debris into mately 10cm confirming its place­­ment the cannulation of the Awl shaft. within the center of the distal femur on an A/P and Lateral radiograph. The Retrograde Protection Sleeve is contoured to fit the profile of the Intercondylar Notch. It is designed to help reduce the Fig. 2 potential for damage during reaming, and also provide an avenue for the reamer debris to exit the knee joint (Fig. 3).

When the inner Retrograde K-Wire Guide is removed, the Ø12mm Rigid Reamer (1806-2014) is inserted over the 3 × 285mm K-Wire and through the Retrograde Protection Sleeve. The distal most 8cm of the femur is reamed (Fig. 4).

The Ø12mm Rigid Reamer is used for nails 9mm−11mm in diameter. Larger Fig. 3 nail diameters may be reamed with a flexible reamer 1mm larger than the nail.

Caution: Prior to advancing the K-Wire within the distal femur, check the correct guidance through the Ø12mm Rigid Reamer. Do not use bent K-Wires.

* Outside of the U. S., product with an “S” may be Fig. 4 ordered Non-Sterile without the “S” at the end of the corresponding REF Number.

12 Operative Technique – Retrograde Technique

Unreamed Technique

If an unreamed technique is pre­­ferred, The Guide Wire is advanced until the the 3 × 1000mm Ball Tip Guide Wire tip rests at/or just above the Lesser (1806-0085S) is passed through the Trochanter. The Guide Wire should fracture site using the Guide Wire lie in the center of the metaphysis in Handle. the A/P and M/L views to avoid offset positioning of the nail. The Guide The Universal Rod (1806-0110) with Wire Handle is removed, leaving the Fig. 5 Reduction Spoon (1806-0125) may be Guide Wire in place. used as a fracture reduction tool to facilitate Guide Wire insertion (Fig. 5). Internal rotation during insertion will aid in passing the Guide Wire down the femoral shaft.

Reamed Technique

For reamed techniques, the 3 × 1000mm Ball Tip Guide Wire is inserted through the fracture site and does not require a Guide Wire exchange. The Universal Rod with Reduction Spoon may be used as a fracture reduction tool to facilitate Guide Wire insertion through the fracture site (see Fig. 5).

Note: The Ball Tip at the end of the Guide Wire will stop the reamer head.

Reaming (Fig. 6)is commenced in 0.5mm increments until cortical contact is appreciated. Final reaming should be 1mm-1.5mm larger than the Fig. 6 diameter of the nail to be used.

13 Operative Technique – Retrograde Technique

The Guide Wire Pusher can be used to help keep the Guide Wire in position during reamer shaft extraction. The metal cavity at the end of the handle pushed on the end of the power tool facilitates to hold the Guide Wire in place when starting to pull the power tool (Fig. 7). When close to the Guide Wire end place the Guide Wire Pusher with its funnel tip to the end of the power tool cannulation (Fig. 8). While removing the power tool the Guide Wire Pusher will keep the Guide Wire in place.

Caution: The diameter of the driving end of the 9mm–11mm (and special Fig. 7 oder 8mm nails) diameter nails is 11.5mm. Additional metaphyseal reaming may be required to facilitate nail insertion. Nail sizes 12–15mm have a constant diameter. Thoroughly irrigate the knee joint to remove any debris.

Note: • 8mm Femoral Nails cannot be inserted over the 3 × 1000mm Ball Tip Guide Wire (1806- 0085S). The Ball Tip Guide Wire must be exchanged for the 3 × 800mm Smooth Tip Guide Wire (1806-0090S) prior to nail insertion. • Use the Teflon Tube (1806-0073S) for the 8mm Nail Guide Wire exchange only. Fig. 8

14 Operative Technique – Retrograde Technique

Nail Selection Diameter The diameter of the selected nail 3 1 2 1 should be 1mm smaller than that of the last reamer used. Alternatively, the nail diameter may be determined Length Scale Diameter Scale using the Femur X-Ray Ruler (1806- Fig. 9.1 0015) (Fig. 9.1 and 9.2).

Fig. 9.1 Hole Positions (nondriving end) Antegrade or Retrograde* Length Hole Positions 1. Static Locking – both M/L holes (driving end) 2. Oblong hole – depending on 1 2 1 Antegrade or Retrograde; static or dynamic modes – A/P 3. Static Locking – A/P 330 mm Fig. 9.2 Hole Positions (driving end) Antegrade or Retrograde* 1. Static Locking – both M/L holes 2. Oblong hole – depending on Length Static and Dynamic Calibration Slot Locking Options Fig. 9.2 Antegrade or Retrograde; static, dynamic, apposition/compres­­sion, advanced locking modes – M/L

Length Nail length may be determined by measuring the remaining length of the Guide Wire. The Guide Wire Ruler (1806-0022) may be used by placing it on the Guide Wire reading the correct nail length at the end of the Guide Wire on the Guide Wire Ruler (Fig. 10 and Fig. 11). End of Guide Wire Ruler is the measurement reference. Alternatively, the X-Ray Ruler (1806- 0015) may be used to determine nail Fig. 10 diameter and length (Fig. 9.1, 9.2). Additionally, the X-Ray Ruler can be used as a guide for locking screw positions.

Note: X-Ray Ruler and Guide Wire Ruler can be used for nail length determination beginning from 240mm. Shorter nail length can be determined via the template. Fig. 11 Caution: If the fracture is suitable for ap­po­ sition/compression, the implant selected should be 10–15mm shorter than measured, to help avoid migration of the nail beyond the insertion site. The Guide Wire Ruler can be easily * see pages 8-9 for detailed illustrations of Antegrade folded and unfolded. and Retrograde Locking Options.

15 Operative Technique – Retrograde Technique

Nail Holding Screw Nail Insertion

Strike Plate The selected nail is assembled onto the Femoral Target Device (1806-1005) with the Femoral Nail Holding Screw (1806-0165) (Fig. 12). Tighten the Nail Fixation Screw Holding Screw with the Universal Clamp Joint Socket Wrench (1806-0400) securely so that it does not loosen during nail insertion.

Fixation Screw Alternatively, the Fixation Screw Clamp (1806-0273) can be used to fix the Targeting Arm to the Nail Handle. After clamping it on the Targeting Arm the knob will tighten the sleeve Nail Handle to the Targeting Arm. Targeting Arm Caution: Prior to nail insertion please check correct alignment by inserting a drill bit through the K-Wire Hole assembled Tissue Protection- and Drill Sleeve placed in the required holes of the targeting device (Fig. 12.1).

Upon completion of reaming, the appropriate size nail is ready for in­ser­tion. Unique to the T2 Femoral Nail, the 3 × 1000mm Ball Tip Guide Fig. 12 Wire does not need to be exchanged. The Strike Plate (1806-0150) may be threaded into the hole next to the Nail Holding Screw and the nail is advanced through the entry point past the fracture site to the appropriate Fig. 12.2 level.

Additionally, the 3 × 285mm K-Wire may be inserted through the Targeting Device which identifies the junction of the nail and insertion post which helps determine nail depth through a mini incision using X-Ray (see Fig. 12.2).

Insertion of the 3 × 285mm K-Wire into the lateral cortex may also help to lock the targeting device to the distal femur and prevent rotation of the nail in cases where the Apposition/ Compression Locking Mode is utilized.

Caution: Curvature of the nail must match the curvature of the femur. Fig. 12.1

16 Operative Technique – Retrograde Technique

Note: DO NOT hit the Target Device. Only hit on the Strike Plate.

The Slotted Hammer can be used on the Insertion Wrench that is placed onto the Nail Holding Screw to insert the nail over a Guide Wire (Fig. 13).

A chamfer is located on the driving end of the nail to denote the end under X-Ray. Three circumferential grooves are located on the insertion post at 2mm, 10mm, and 15mm from the driving end of the nail. Depth of insertion may be visualized with the aid of fluoroscopy.

If the nail has been inserted to far, it Fig. 13 has to be repositioned. Repositioning should be carried out either by hand or by using the Strike Plate attached to the Target Device. The Universal Rod and Slotted Hammer may then be attached to the Strike Plate to carefully and smoothly extract the assembly (Fig. 14).

When locking the retrograde nail in the Static Mode, the nail is countersunk a minimum of 5mm to the chondral surface. When the implant is inserted in the Dynamic Mode, without active apposition/ compression, the recommended insertion depth is 10mm. When the implant is inserted with active apposition/compression or in the Advanced Locking Mode, the recommended depth of insertion is 15mm (Fig. 15). Fig. 14

Note: Remove the Guide Wire prior to drilling and inserting the Locking Screws.

5mm 2mm Static 10mm Dynamic 15mm Apposition/Compression

Fig. 15

17 Operative Technique – Retrograde Technique

Guided Locking Mode (via Target Device)

Before locking the nail distally, the Nail Holding Screw must be firmly tightened using the Universal Joint Socket Wrench to ensure that the nail is correctly aligned with the Target Device.

The Target Device is designed to provide four options for distal locking (Fig. 16.1–16.3). 3 2 In Static Locking Mode, all three 1 indicated holes may be used (Fig. 16.1).

Fig. 16.1 1. Static 2. Static 3. Static

In controlled Dynamic Mode, and/or controlled Apposition/Compression Mode, the dynamic hole is required. This hole is also used for compression (Fig. 16.2). 4 4. Dynamic

In Advanced Locking Mode, the dynamic hole is required. After Fig. 16.2 utilizing compression with the Advanced Compression Screw, either or both static holes are used (Fig. 16.3).

4. Dynamic 1. Static 3. Static 3 4 1 The Long Tissue Protection Sleeve (1806-0185) together with the Long Drill Sleeve (1806-0215) and the Long Trocar (1806-0315) is inserted into the Fig. 16.3 Target Device by pressing the safety clip (Fig. 17). The mechanism will help keep the sleeve in place and help prevent it from falling out. It will also help prevent the sleeve from sliding during screw measurement. To release the Tissue Protection Sleeve, released locked the safety clip must be pressed again.

Fig. 17

18 Operative Technique – Retrograde Technique

Static Locking Mode

When treating supracondylar frac­tures, three screws should be used whenever possible. The screw placed within the oblong hole should be in the static position. Always start with the most proximal screw.

If secondary dynamization is planned, it is recommended to dynamize at the proximal portion of the nail. This is achieved by putting a Fully Threaded Locking Screw at the proxi­ mal location of the A/P oblong hole at the top of the nail. This allows dynamization of the fracture in case of delayed union after removal of the most proximal screw. Fig. 18 The Long Tissue Protection Sleeve together with the Long Drill Sleeve and Long Trocar, are positioned through the static locking hole on the Target Device. A small skin incision is made, and the assembly is pushed through until it is in contact with the lateral cortex of the femur (Fig. 18).

The Trocar is removed, with the Tissue Protection Sleeve and the Drill Sleeve remaining in position.

Alternatively, the Trocar (1806-0311) can be advanced together with the Tissue Protection Sleeve. Push the assembly down to the bone. The paddle tip design may help to pass the soft tissue and prepare the way for Fig. 19 drilling. Remove the Trocar to insert the Drill Sleeve (Fig. 19).

19 Operative Technique – Retrograde Technique

To ensure accurate drilling and easy determination of screw length, use the center tipped, Ø4.2 × 340 calibrated Drill (1806-4260S). The centered Drill is forwarded through the Drill Sleeve 50mm and pushed onto the cortex.

After drilling both cortices, the screw length may be read directly off of the calibrated Drill at the end of the Drill Sleeve. If measurement with the Screw Gauge, Long is preferred, first remove the Drill Sleeve, Long and read the screw length directly at the end of the Tissue Protection Sleeve, Long (Fig. 20 and Fig. 21).

Fig. 20 Caution: Make sure the Tissue Protection Sleeve/Drill Sleeve Assembly is seated on bone prior to selecting final screw length. 50mm Note: The position of the end of the Drill as it relates to the far cortex is equal to where the end of the screw will be. Therefore, if the end of the Drill is 3mm beyond the far cortex, the end of the Fig. 21 screw will also be 3mm beyond.

Alternatively, the Screw Gauge can be Alternatively, the 3.5mm Hex Self- used to measure the screw length. Holding Screwdriver Long (1806-0233) can be used for the screw insertion. The Screw Gauge, Long is calibrated so that with the bend at the end pulled Caution: back flush with the far cortex, the The coupling of Elastosil handles screw tip will end 3mm beyond the far contains a mechanism with Fig. 22 cortex (Fig. 21). one or multiple ball bearings. In case of applied axial stress When the Drill Sleeve is removed, the on the Elastosil handle, those correct Locking Screw is inserted components are pressed into the through the Tissue Protection Sleeve surrounding cylinder resulting in using the Long Screwdriver Shaft a complete blockage of the device (1806-0227) with Teardrop Handle and possible bending. (702429). The screw is advanced through both cortices. To help avoid intra-operative The screw is near its’ proper seating complications and promote long- position when the groove around the term functionality, we mandate shaft of the screwdriver is approach­ing that Elastosil handles be used only the end of the Tissue Protection Sleeve for their intended use. (Fig. 22). DO NOT HIT on any Elastosil Repeat the locking procedure for handles. the other statically positioned Cross Locking Screws.

20 Operative Technique – Retrograde Technique

Condyle Screw Locking If a Condyle Screw is to be inserted, both cortices are drilled with the Ø5 × 340mm Drill (1806-5020S) (Fig. 23). After drilling both cortices, the screw length may be read directly off of the calibrated Drill at the end of the Drill Sleeve. The Condyle Screw K-Wire (0152-0218S) is inserted from the lateral side through the Tissue Protection Sleeve to the medial side. At the medial point of the perforation a skin incision is made for the Condyle Screw.

From the medial side, the Condyle Screw is now brought forward over the Condyle Screw K-Wire and inserted using the Condyle Screw Screwdriver (1806-0255). Fig. 23

If necessary, contour the bone geometry with the Countersink for Condyle Screw prior to inserting the Condyle Screw and Nut to optimize the seating of the washer (Fig. 24). The lateral cortex can be contoured through the Tissue Protection Sleeve, the medial cortex in a freehand technique, guided by the 1.8mm K-Wire.

Fig. 24

21 Operative Technique – Retrograde Technique

To insert the Condyle Nut, the Tissue Protection Sleeve and the Drill Sleeve are removed, and the K-Wire is withdrawn to the medial side. This allows for the nut to be positioned between the Target Device and the level of the skin and onto the Condyle Screw K-Wire (Fig. 25). Alternatively, if the patient anatomy allows, the Condyle Screw may be introduced from Lateral to Medial in a similar manner as described above (Fig. 25a).

Condyle Screw- Using both Condyle Screw Screw­ introduced M-L drivers, the Condyle Nut and the Condyle Screw are tightened. Once tightened, the K-Wire is removed. Fig. 25 The adjustable screw washer of the Condyle Screw and the Condyle Nut adapt to the surface of the bone eliminating the need to countersink both.

The geometry of the implant allows three Condyle Screws to be used. At least two of the three distal holes should be engaged with either Locking Screws and/or Condyle Screws (Fig. 26). Always lock the most proximal hole.

Condyle Screw- introduced L-M

Fig. 25a

Fig. 26

22 Operative Technique – Retrograde Technique

Freehand Proximal Locking

The freehand technique is used to insert Locking Screws into both the A/P oblong hole and A/P round hole in the nail. In Static, Apposition/ Compression and Advanced Locking Mode, the Locking Screw placed in the oblong hole should be positioned in the distal position. Rotational alignment must be checked prior to locking the nail statically.

Caution: Only one Locking Screw is inserted in the Dynamic Locking Mode. The Locking Screw is placed in the proximal position of the A/P oblong hole in order Fig. 27 to optimize dynamization at the proximal end of the nail.

The M/L holes may also be used alternatively or in addition to A/P Locking Screws by adjusting the C-Arm and leg position to locate the holes.

Multiple locking techniques and radiolucent drill devices are available for freehand locking. The critical step with any freehand locking technique, proximal or distal, is to visualize a perfectly round locking hole, or perfectly oblong locking hole with the C-Arm. Fig. 28

The center-tipped Ø4.2 × 230mm Drill (1806-4290S) is held at an oblique angle to the center of the locking hole (Fig. 27 and 28). Upon X-Ray verification, the Drill is placed perpendicular to the nail and drilled Green Ring through the anterior and posterior cortex. Confirm that the Drill passes through the hole in the nail in both the A/P and M/L planes by X-Ray.

After drilling both cortices the screw length may be read directly off of the calibrated Screw Scale, Long (1806- 0365) at the green ring on the center- tipped Drill (Fig. 29). As with proximal locking (Fig. 20, p. 20), the position of the end of the Fig. 29 drill is equal to the end of the screw as they relate to the far cortex.

23 Operative Technique – Retrograde Technique

Routine Locking Screw insertion is employed with the assembled Long Screwdriver Shaft and the Teardrop Handle (Fig. 30).

40mm Alternatively, the Screw Gauge can be used to determine the screw length.

Alternatively, the 3.5mm Hex Self- Holding Screwdriver Extra-short (1806-0203) can be used for the screw insertion.

Caution: Special order 8mm T2 Femoral Nails can only be locked with 4mm Fully Threaded screws at the non-driving end. Use the Ø3.5 × 180mm Drill (1806-3570S) for freehand locking.

Fig. 30

24 Operative Technique – Retrograde Technique

End Cap Insertion

After removal of the Target Device, an End Cap is used. Eight different sizes of End Caps* are available to adjust nail length and to reduce the potential for bony ingrowth into the proximal thread of the nail (Fig. 31). Standard +5mm +10mm +15mm +20mm +25mm +30mm +35mm Note: Fig. 31 All End Caps are designed to tighten down onto the locking screw at the working end of the nail. This will help prevent the nail from M/L sliding.

The End Cap is inserted with the Long Screwdriver Shaft and Teardrop Handle after intra-operative radio­ graphs show satisfactory reduction and hardware implantation (Fig. 32). Fully seat the End Cap to minimize the potential for loosening.

Caution: Final verification of implants should be confirmed by X-Ray at Fig. 32 this time.

Thoroughly irrigate the wound to prevent debris from remaining within the knee joint. Close the wound using standard technique.

Fig. 32a

Alternatively, the 3.5mm Hex Self- Holding Screwdriver Long (1806-0233) can be used for the End Cap insertion.

* Optional 8mm diameter End Caps are available in +5, +10 and +15mm length to facilitate insertion through the Nail Adapter (Fig. 32a & 32b). Fig. 32b 25 Operative Technique – Retrograde Technique

Dynamic Locking Mode

When the fracture profile permits, controlled dynamic locking may be utilized for transverse or axially stable fractures. While dynamic locking can be performed at either end of the nail, routine retrograde dynamic locking should utilize the oblong hole at the proximal end of the nail. The potential for nail migration into the joint is thereby reduced.

Retrograde dynamization is performed by statically locking the nail distally via the Target Device.

The freehand Locking Screw is then placed in the dynamic position of the oblong hole. This allows the nail to move and the fracture to settle while torsional stability is maintained (Fig. 33). Fig. 33

Apposition/Compression Locking Mode

In transverse or axially stable This will allow for a maximum of Wire (if used) is withdrawn. fracture patterns, active apposition/ 10mm of active, controlled apposition/ With the driving end of the nail compression may increase fracture compression. In order to insert the still not fully seated and extending stability, may enhance fracture Shaft Screw, drill both cortices with out of the bone, the Nail Holding healing, and allow for early weight the Ø4.2 × 340 Drill (1806-4260S). Screw is removed and the Advanced bearing. The T2 Femoral Nail Next, drill the near cortex, ONLY, Compression Screw is inserted. provides the option to treat a femur with the Ø5 × 230mm Drill (1806- fracture with active mechanical 5000S). Caution: apposition/compression prior to Care should be taken that leaving the operating room. After the opposite cortex is drilled the shaft of the Advanced with the Ø4.2 × 340mm Drill, the Compression Screw does not Caution: correct screw length can be read extend into the area of the oblong Proximal freehand static directly off of the calibrated Drill at hole. locking with at least two Fully the end of the Drill Sleeve. ONLY the Advanced Compression Threaded Locking Screws must Screw allows reattachment of be performed prior to applying The 3.5mm Hex Self-Holding the Targeting Device without active, controlled apposition/ Screwdriver Long (1806-0233) can be extending in the area of the compression to the fracture site. use for screw insertion. oblong hole.

If active apposition/compression is It may be easier to insert the Advanced required, a Partially Threaded Locking Compression Screw prior to fully Screw (Shaft Screw) is inserted via the seating the nail. Once the nail tip has Target Device in the dynamic position cleared the fracture site, the Guide of the oblong hole.

26 Operative Technique – Retrograde Technique

Caution: In order to prevent damage during drilling and insertion of the most proximal locking screw, the Advanced Compression Screw has to be placed between the oblong hole and the most proximal locking hole.

After the Shaft Screw is inserted, the Nail Holding Screw securing the nail to the insertion post is removed, leaving the insertion post intact with the nail (Fig. 34). This will act as a guide for the Compression Screw. The Compres­sion Screw is inserted with the Compression Screwdriver Fig. 34 Shaft (1806-0268) assembled on the Teardrop Handle through the insertion post. When the ring marked with an “F” on the Com­pression Screwdriver Shaft is close to the Target Device, it indicates the engagement of the apposition/compression feature of the nail. This applies only when the Advanced Compression Screw is used.

Note: The ring marked with a “T” is for the Tibial Compression Screw.

The Long Tissue Protection Sleeve is removed and the Compression Screw is gently tightened utilizing the two- finger technique. As the Compression Screw is advanced against the 5.0mm Partially Threaded Locking Fig. 35 Screw (Shaft Screw), it draws the proximal fracture segment towards the fracture site, employing active apposition/compression (Fig. 35). Image intensification will enable the surgeon to visualize active apposition/ compression (Fig. 36). Some bending of the transverse Shaft Screw may be seen.

Caution: • Apposition/compression must be carried out under X-Ray control. Over compression may cause the nail or the Fig. 36 Shaft Screw to fail.

27 Operative Technique – Retrograde Technique

• When compressing the nail, Compression Screws are available in the implant must be inserted different lengths. A short Advanced a safe distance from the entry Compression Screw to enable the point to accommodate for the Advanced Locking Mode and longer 10mm of active compression. Compression Screws from Standard to The three grooves on the +15mm offer an improved fit. An End insertion post help attain Cap can only be inserted when using accurate insertion depth of the Advanced Compression Screw or the implant. when not using compression.

Advanced Locking Mode

In order to achieve additional fixation and to reduce the load on the Partially Threaded Locking Screw (Shaft Screw), the design of the T2 Femoral Nail provides the opportunity to insert an additional Fully Threaded Lock­ing Screw into the hole nearest the driving end of the nail after apposition/com­ pression is utilized. An additional Fully Threaded Locking Screw should be inserted in either the more proxi­ mal or more distal of the static holes depending on the fracture stability.

Affix the Compression Screw on the self-retaining Compression Screwdriver Shaft. Remove the Nail Fig. 37 Holding Screw leaving the Target Device in place (Fig. 37). Advance the Compression Screw through the Target Device until the ring marked with an “F” on the Compression Screwdriver Shaft is close to the Target Device (Fig. 38). This applies only when the Advanced Compression Screw is used.

Fig. 38

28 Operative Technique – Retrograde Technique

To insert the most distal Screw, follow the locking procedure for static locking (Fig. 39−41). To insert the Advanced Compression Screw, follow the OP-Tech­nique under Apposition/Compression Locking Mode section (p. 26) on the previous page.

It may be easier to insert the Compression Screw prior to fully seating the nail.

To reattach the Target Device to the nail, detach the Teardrop Handle from the Compression Screwdriver Shaft and screw the Nail Holding Screw over the Compression Screwdriver Shaft Fig. 39 into its required position.

Prior to guided locking via the Target Device, the Nail Holding Screw must be tightened using the Universal Joint Socket Wrench.

Fig. 40

Fig. 41

29 Operative Technique – Retrograde Technique

External Compression Device Alternatively, the External Com- pression Device (1806-0272) can be used. After the Shaft Screw is inserted, the External Compression Device is threaded into the Nail Holding Screw (Fig. 42 & 42a). The 8mm Hex “click” Screwdriver bit, ball tip (1806-0065) is attached to the Handle and placed on top of the External Compression Device to carefully apply compression (Fig.43, 43a, 44 & 44a).

Fig. 42a

Fig. 42

Fig. 43a

Fig. 43

30 Operative Technique – Retrograde Technique

After successful compression a second Locking Screw is inserted in the round hole below the oblong hole (Fig. 45). This will keep the com- pression. After screw insertion, the External Compression Device can be detached. Fig. 44a Note: The round hole above the oblong hole is engaged by the External Compression Device and can not be used, while being attached.

For cleaning the External Com- pression Device parts have to be disas- sembled. Fig. 44

Fig. 45

31 Operative Technique – Retrograde Technique

Nail Removal Nail removal is an elective procedure. If needed, the End Cap and Compres­ sion Screw (if Advanced Locking Mode was utilized after the most distal screw is extracted) are removed with the Long Screwdriver Shaft and Teardrop Handle (Fig. 46).

The Self-holding Screwdriver Long (1806-0233) or Extra-short (1806- 0203) can be used for Screw removal.

As an alternative to removing the Advanced Compression Screw (if Fig. 46 used), it can be just disengaged from the Partially Threaded Locking Screw (Shaft Screw) by turning the Compression Screwdriver one full turn in a counter-clockwise direction. There is no need to remove it from the nail.

The Universal Rod is inserted into the driving end of the nail. All Locking Screws are removed with the Long Screwdriver Shaft and Teardrop Handle (Fig. 47).

The Slotted Hammer is used to extract the nail in a controlled Fig. 47 manner (Fig. 48). A captured Sliding Hammer (1806-0175) is available as an “optional” instrument.

Note: • Stryker offers also a Universal Extraction Set for the removal of internal fixation systems and associated screws. For more information, please refer to the Literature Number B1000057. • Check with local representative regarding the availability of the Universal Extraction Set.

Fig. 48

32 Operative Technique – Antegrade Technique

Patient Positioning and Fracture Reduction

Patient positioning for antegrade femoral nail insertion is surgeon dependent. The patient may be positioned supine or lateral on a fracture table, or simply supine on a radiolucent table.

Incision

The design of the implant allows for insertion either through the Piriformis Fossa or the Tip of the Greater Trochanter.

Piriformis Fossa A skin incision is made beginning at the level of the Greater Tro­chanter extending proximal and slightly posterior, in line with the Gluteus Muscle, exposing the Piriformis Fossa for antegrade femoral nail insertion.

Tip of the Greater Trochanter With experience, the Tip of the Greater Trochanter can be located by palpation, and a horizontal skin incision is made from the Greater Trochanter to the Iliac Crest.

33 Operative Technique – Antegrade Technique

Entry Point

The Tip (Medial Edge) of the Greater Trochanter (A) The medullary canal is opened with the Curved Awl (1806-0040) at the junction of the anterior third and pos­terior two-thirds of the Greater Trochanter, on the medial edge of the tip itself (Fig. 49). Image intensifica­ tion (A/P and Lateral) is used for confirmation.

Piriformis Fossa (B) Alternatively, the implant may be introduced in the Piriformis Fossa, with a starting point just medial to the Greater Trochanter and slightly posterior to the central axis of the Fig. 49 femoral neck.

Once the Tip of the Greater Trochanter or the Piriformis Fossa (Fig. 50) has been penetrated, the 3 × 1000mm Ball Tip Guide Wire (1806-0085S) may be advanced through the cannulation of the Curved Awl with the Guide Wire Handle (1806-1095 and 1806-1096) (Fig. 51).

Note: During opening the entry portal Fig. 50 with the Awl, dense cortex may block the tip of the Awl. An Awl Plug (1806-0032) can be in- serted through the Awl to avoid penetration of bone debris into the cannulation of the Awl shaft.

Fig. 51

34 Operative Technique – Antegrade Technique

Unreamed Technique

If an unreamed technique is pre­­ferred, the 3 × 1000mm Ball Tip Guide Wire (1806-0085S) is passed through the fracture site using the Guide Wire Handle.

The Universal Rod (1806-0110) with Reduction Spoon (1806-0125) may be used as a fracture reduction tool to facilitate Guide Wire insertion (Fig. 52). Internal rotation during insertion will aid in passing the Guide Wire down the femoral shaft. The Guide Wire is advanced until Fig. 52 the tip rests at/or to the level of the Epiphyseal Scar or the mid-pole of the Patella. The Guide Wire should lie in the center of the metaphysis in the A/P and M/L views to avoid offset positioning of the nail. The Guide Wire Handle is removed, leaving the Guide Wire in place.

Reamed Technique

If the procedure will be performed using a reamed technique, the 3 × 1000mm Ball Tip Guide Wire is inserted with the Guide Wire Handle through the fracture site to the level of the Epiphyseal Scar or the mid-pole of the Patella and does not need a Guide Wire exchange. The Ø9mm Universal Rod (1806-0110) with Reduction Spoon (1806-0125) may be used as a fracture reduction tool to facilitate Guide Wire insertion through the fracture site (Fig. 52), and in an unreamed technique, may be used as a “sound” to help determine the diameter of the medullary canal.

Note: The Ball Tip at the end of the Fig. 53 Guide Wire will stop the reamer head.

Reaming is commenced in 0.5mm increments until cortical contact is appreciated (Fig. 53). Final reaming should be 1mm-1.5mm larger than the diam­eter of the nail to be used.

35 Operative Technique – Antegrade Technique

The Guide Wire Pusher can be used to help keep the Guide Wire in position during reamer shaft extraction. The metal cavity at the end of the handle pushed on the end of the power tool facilitates to hold the Guide Wire in place when starting to pull the power tool (Fig. 54). When close to the Guide Wire end place the Guide Wire Pusher with its funnel tip to the end of the power tool cannulation (Fig. 55). While removing the power tool the Guide Wire Pusher will keep the Guide Wire in place.

Note: • The proximal diameter (driving end) of the 9mm– Fig. 54 11mm diameter nails is 11.5mm. Nail sizes 12–15mm have a constant diameter. Additional metaphyseal reaming may be required to facilitate nail insertion. • 8mm Femoral Nails cannot be inserted over the 3 × 1000mm Ball Tip Guide Wire (1806-0085S). The Ball Tip Guide Wire must be exchanged for the 3 × 800mm Smooth Tip Guide Wire (1806-0090S) prior to nail insertion. • Use the Teflon Tube (1806- 0073S) for the 8mm Nail Guide Wire exchange only.

Fig. 55

36 Operative Technique – Antegrade Technique

Nail Selection

Diameter The diameter of the selected nail should be 1mm smaller than that of the last reamer used. Alternatively, the diameter may be determined using the Femur X-Ray Ruler (1806-0015) with the different diameters matching with the radiographs (see Fig. 9.1 on page 15).

Length Nail length may be determined with the X-Ray Ruler or may be deter- mined by measuring the remaining End of Guide Wire Ruler length of the Guide Wire. The Guide is the measurement reference Wire Ruler (1806-0022) may be used Fig. 56 by placing it on the Guide Wire reading the correct nail length at the end of the Guide Wire on the Guide Wire Ruler (Fig. 56 and 57).

Note: X-Ray Ruler and Guide Wire Ruler can be used for nail length determination beginning from 240mm. Shorter nail length can be determined via the template.

Caution: If the fracture is suitable for Fig. 57 apposi­tion/compression, the implant se­lect­ed should be 10–15mm shorter than measured, to help avoid migration of the nail beyond the insertion site.

The Guide Wire Ruler can be easily folded and unfolded.

37 Operative Technique – Antegrade Technique

Nail Insertion The selected nail is assembled onto the Target Device with the Nail Holding Screw (Fig. 58). Tighten the Nail Holding Screw with the Universal Joint Socket Wrench (1806-0400) K-Wire securely so that it does not loosen Fig. 58.1 during nail insertion.

Alternatively, the Fixation Screw Clamp (1806-0273) can be used to fix the Targeting Arm to the Nail Handle. After clamping it on the Targeting Arm the knob will tighten the sleeve to the Targeting Arm.

Caution: Prior to nail insertion please check correct alignment by inserting a drill bit through the assembled Tissue Protection and Drill Sleeve placed in the required holes of the targeting device Fig. 58 (Fig. 58.2).

Upon completion of reaming, the appropriate size nail is ready for insertion. Unique to the T2 Femoral Nail the 3 × 1000mm Ball Tip Guide Fig. 58.2 Wire does not need to be exchanged. The Strike Plate (1806-0150) is threaded into the Target Device and the nail is advanced through the entry point past the fracture site to the appropriate level.

Additionally, the 3 × 285mm K-Wire may be inserted through the Target Device which indicates the junc­tion of the nail and insertion post (see Fig. 58.2).

Insertion of the 3 × 285mm K-Wire into the lateral cortex may also help to lock the Target Device to the proximal Fig. 59.1 femur and prevent rotation of the nail in cases where the Apposition/Com- pression Locking Mode is utilized.

Caution: Curvature of the nail must match the curvature of the femur.

The Slotted Hammer can be used on the Strike Plate (Fig. 59.1), or if dense bone is encountered, the Universal Rod may be attached to the Nail Holding Screw and used in conjunc­ tion with the Slotted Hammer to insert the nail (Fig. 59.2). Fig. 59.2 38 Operative Technique – Antegrade Technique

Note: DO NOT hit the Target Device. Only hit on the Strike Plate.

A chamfer is located on the working 5mm Static end of the nail to denote the end 2mm under X-Ray. Three circumferential 10mm Dynamic grooves are located on the insertion 15mm Apposition/Compression post at 2mm, 10mm, and 15mm from the driving end of the nail (Fig. 60). Fig. 60 Depth of insertion may be visualized with the aid of fluoroscopy.

If the nail has been inserted to far, it has to be respositioned. Repositioning should be carried out either by hand or by using the Strike Plate on the top of the Target Device. The Universal Rod and Slotted Hammer may then be Fig. 61 attached to the Strike Plate to carefully and smoothly extract the assembly.

When locking the antegrade nail in the static mode, the nail is counter­ sunk a minimum of 5mm (Fig. 61).

When the implant is inserted in the dynamic mode, without active apposition/compression, or when Fig. 62 the implant is inserted with active apposition/compression, the recom- mended depth of insertion is 15mm (Fig. 62).

Note: Remove the Guide Wire prior to drilling and inserting the Locking Screws.

39 Operative Technique – Antegrade Technique

Guided Locking Mode (via Target Device)

Prior to guided locking via the Target Device, the Nail Holding Screw must be firmly tightened using the Universal Joint Socket Wrench, to help ensure that the nail is in correct alignment with the Target Device (Fig. 63).

The Target Device is designed with four locking holes. According to the selected locking mode, the appropri­­ate holes are used (see Fig. 16.1.–16.3 on p. 18).

The Long Tissue Protection Sleeve (1806-0185) together with the Long Drill Sleeve (1806-0215) and the Long Trocar (1806-0315) is inserted into the Target Device by pressing the safety clip (see Fig. 17 on p. 18). The mechanism will help keep the sleeve in place and help prevent it from falling out. It will also help prevent the sleeve from sliding during screw measurement. To release the Tissue Protection Sleeve, the safety clip must be pressed again.

Fig. 63

40 Operative Technique – Antegrade Technique

Static Locking Mode

The Long Tissue Protection Sleeve to­- gether with the Long Drill Sleeve and the Long Trocar are positioned through the static locking hole on the Target Device. A small skin incision is made, and the assembly is pushed through until it is in contact with the lateral cortex of the femur (Fig. 64). The Trocar is removed while the Tissue Protection Sleeve and the Drill Sleeve remain in position.

Alternatively, the Trocar (1806-0311) can be advanced together with the Tissue Protection Sleeve. Push the assembly down to the bone (Fig. 65). The paddle tip design may help to pass the soft tissue and prepare the way for drilling. Remove the the Trocar to Fig. 64 insert the Drill Sleeve.

To help ensure accurate drilling, and easy determination of screw length, use the center tipped, calibrated Ø4.2 × 340 Drill (1806-4260S). The centered Drill is forwarded through the Drill Sleeve and pushed onto the cortex.

After drilling both cortices, the screw length may be read directly off of the calibrated Drill at the end of the Drill Sleeve (Fig. 66 and see Fig. 20 and 21 on p. 20).

Fig. 65

Fig. 66

41 Operative Technique – Antegrade Technique

When the Drill Sleeve is removed, the correct Locking Screw is inserted through the Tissue Protection Sleeve using the Long Screwdriver Shaft (1806-0227) with Teardrop Handle (702429) (Fig. 67).

Alternatively, the 3.5mm Hex Self- Holding Screwdriver Long (1806- 0233) can be used for screw insertion. The screw is ad­­vanced through both cortices. The screw is near its proper seating position when the groove around the shaft of the screwdriver is ap­-proaching the end of the Tissue Pro­tection Sleeve (see Fig. 22 on p. 20). Repeat the locking procedure for the other statically positioned Locking Screws (Fig. 68). The most proximal Fig. 67 M/L hole (nearest the driving end of the nail) is not generally utilized in the antegrade mode.

Caution: In unstable fracture patterns, static locking should always be per­­­formed with at least two distal Locking Screws and two proximal Locking Screws.

Fig. 68

42 Operative Technique – Antegrade Technique

Freehand Distal Locking

The freehand technique is used to insert Fully Threaded Locking Screws into both distal M/L holes in the nail. Rotational alignment must be checked prior to locking the nail statically.

Multiple locking techniques and radiolucent drill devices are available for freehand locking. The critical step with any freehand locking tech­­nique, proximal or distal, is to visualize a perfectly round locking hole or perfectly oblong locking hole with the C-Arm. Fig. 69

The center-tipped Ø4.2 × 180mm Drill (1806-4270S) is held at an oblique angle to the center of the locking hole (Fig. 69 and 70). Upon X-Ray verification, the Drill is placed per­ pendicular to the nail and drilled through the lateral and medial cortex. Confirm in both the A/P and M/L planes by X-Ray that the Drill passes through the hole in the nail.

Caution: Special order 8mm T2 Femoral Nails can only be locked with Fig.70 4mm Fully Threaded screws at the non-driving end. Use the Ø3.5 × 180mm Drill (1806-3570S) for freehand locking.

After drilling both cortices, the screw length may be read directly off of the Long Screw Scale (1806-0365) at the green ring on the center tipped Drill (see Fig. 29 on p. 23). Alternatively, the optional Depth Gauge, Standard Style for Freehand Locking (1806- 0390), may be used after drilling to determine the length of screw needed.

Routine Locking Screw insertion Fig. 71 is employed with the assembled Long Screwdriver Shaft and Teardrop Handle (Fig. 71).

Alternatively, the 3.5mm Hex Self- Holding Screwdriver Long (1806-0233) or Extra-short (1806-0203) can be used for screw insertion.

43 Operative Technique – Antegrade Technique

End Cap Insertion

After removal of the Target Device, an End Cap is used. Eight different sizes of End Caps* are available to adjust nail length and to reduce the potential for bony ingrowth into the proximal thread of the nail. (see Fig. 31 on p. 25)

Note: All End Caps are designed to tighten down onto the Locking or Fig. 72 Condyle Screw at the driving end of the nail. This will help prevent the nail from M/L sliding.

The End Cap is inserted with the Long Screwdriver Shaft and Teardrop Han­dle after intra-operative radio- graphs show satisfactory reduction and hard­ware implantation (Fig. 72). Fully seat the End Cap to minimize the potential for loosening.

The 3.5mm Hex Self-Holding Screwdriver Long (1806-0233) or Extra-short (1806-0203)can be used for end cap insertion. Fig. 72a Caution: Final verification of implants should be confirmed by X-Ray at this time.

Thoroughly irrigate the wound to prevent debris from remaining. Close the wound using the standard technique.

Fig. 73b

* Optional 8mm diameter End Caps are available in +5, +10 and +15mm length to facilitate insertion through the Nail Adapter (Fig. 61a & 61b).

44 Operative Technique – Antegrade Technique

Dynamic Locking Mode

When the fracture profile permits, dynamic locking may be utilized for transverse, axially stable fractures. While dynamic locking can be per­ formed at either end of the nail, routine antegrade dynamic locking should utilize the M/L oblong hole at the Target Device.

The Partially Threaded Locking Screw is placed in the dynamic posi­­ tion of the oblong hole via the Target Device. This allows the nail to move and the fracture to settle while provid­ing torsional stability (Fig. 74).

Antegrade dynamization is performed by statically locking the nail distally with two M/L Fully Threaded Locking Screws in a freehand technique.

Fig. 74

45 Operative Technique – Antegrade Technique

Apposition / Compression Locking Mode

In transverse, axially stable fracture Caution: This will act as a guide for the Com- patterns, active apposition/compres­ • Care should be taken that pression Screw. The Compression sion increases fracture stability, may the shaft of the Advanced Screw is inserted with the Com- enhance fracture healing, and allow Compression Screw does not pression Screwdriver Shaft (1806- for early weight bearing. The T2 extend into the area of the oblong 0268) and Teardrop Handle through Femoral Nail gives the option to treat hole. the insertion post (Fig. 76). When a femur fracture with active mechani­ ONLY the Advanced Compression the ring marked with an “F” on the cal apposition/compression prior to Screw allows reattachment of Compression Screwdriver Shaft is leaving the operating room. the Targeting Device without close to the Target Device, it indicates extending in the area of the the engagement of the apposition/ Caution: oblong hole. compression feature of the nail. Distal freehand static locking • In order to prevent damage This applies only when the Advanced with at least two Fully Threaded during drilling and insertion Compression Screw is used. Locking Screws must be per­ of the most proximal locking formed prior to applying screw, the Advanced Compression Note: active, control­led apposition/ Screw has to be placed between The ring marked with a “T” is for compression to the fracture site. the oblong hole and the most the Tibial Compression Screw. proximal locking hole. If active apposition/compression is required, a Partially Threaded Locking After the Shaft Screw is inserted, the Screw (Shaft Screw) is in­­serted via the Nail Holding Screw securing the Target Device in the dynamic position nail to the insertion post is removed, of the oblong hole. leaving the insertion post intact with This will allow for a maxi­mum of the nail (Fig. 75). 10mm of active, controlled ap­­po­sition/ compression. In order to insert the Shaft Screw, drill both cortices with the Ø4.2 × 340mm Drill (1806-4260S). Next, drill the near cortex, ONLY, with the Ø5 × 230mm Drill (1806- 5000S).

After the opposite cortex is drilled with the Ø4.2 × 340mm Drill, the correct screw length can be read directly off of the calibrated Drill at the end of the Drill Sleeve.

The 3.5mm Hex Self-Holding Screwdriver Long (1806-0233) can be use for screw insertion.

It may be easier to insert the Advanced Compression Screw prior to fully seating the nail. Once the nail tip has Fig. 75 cleared the fracture site, the Guide Wire (if used) is withdrawn. With the driving end of the nail still not fully seated and extending out of the bone, the Nail Holding Screw is removed and the Advanced Compression Screw is inserted.

46 Operative Technique – Antegrade Technique

The Long Tissue Protection Screw is removed and the Compression Screw is gently tightened utilizing the two-finger technique. As the Compression Screw is advanced against the 5.0mm Partially Thread­ed Locking Screw (Shaft Screw), it draws the distal fracture segment towards the fracture site, employing active ap­po­­­­si­tion/compression (Fig. 77). Image intensification will enable the surgeon to visualize active apposition/ compression. Some bending of the transverse Shaft Screw may be seen.

Caution: • Apposition/compression must be carried out under X-Ray control. Over compression may cause the Fig. 76 nail or the Shaft Screw to fail. • When compressing the nail, the im­plant must be inserted a safe distance from the entry point to accommodate for the 10mm of active com­pression. The three grooves on the insertion post help attain accurate insertion depth of the implant.

Compression Screws are available in different lengths. A short Advanced Compression Screw to enable the Advanced Locking Mode and longer Compression Screws from Standard to +15mm provide an improved for every indication. An End Cap can only be inserted when using the Advanced Compression Screw or when not using compression.

Fig. 77

47 Operative Technique – Antegrade Technique

Advanced Locking Mode

In order to achieve additional Warning: fixation and to reduce the load on the Using the most proximal locking Partially Threaded Locking Screw hole to reduce the load on the (Shaft Screw), an additional Locking Partially Threaded Locking Screw Screw should also be inserted in the requires appropriate positioning more distal or more proximal of the of the nail. Ensure secure screw proximal locking holes depending on placement below the calcar region. the fracture stability. End Caps in eight different lengths allow for intra-operative length adjustment.

External Compression Device

Alternatively, the External Com- pression Device (1806-0272) can be used. After the Shaft Screw is inserted, the External Compression Device is threaded into the Nail Holding Screw “click” (Fig. 78). The 8mm Hex Screwdriver bit, ball tip (1806-0065) is attached to the Handle and placed on top of the External Compression Device to carefully apply compression (Fig. 79 & 80). The Ball Tip design may help to reduce collusion with the ilium and/or soft tissue.

Fig. 78

Fig. 79 48 Operative Technique – Antegrade Technique

After successful compression a second Locking Screw is inserted in the round hole below the oblong hole (Fig. 81). This will keep the compression. After screw insertion, the External Compression Device can be detached.

Note: The round hole above the oblong hole is engaged by the External Compression Device and can not be used, while it is being attached.

For cleaning the External Com- pression Device parts have to be disas- sembled.

Fig. 80

Fig. 81

49 Operative Technique – Antegrade Technique

Nail Removal

Nail removal is an elective procedure. If needed, the End Cap and Compres­ sion Screw (if Advanced Locking Mode was utilized after the most distal screw is extracted) are removed with the Long Screwdriver Shaft and Teardrop Handle (Fig. 82).

The Self-holding Screwdriver Long (1806-0233) or Extra-short (1806- 0203) can be used for Screw removal.

As an alternative to removing the Advanced Compression Screw (if used), it can be just disengaged from the Partially Threaded Locking Screw (Shaft Screw) by turning the Compression Screwdriver one full turn in a counter-clockwise direction. Fig. 82 There is no need to remove it from the nail.

The Universal Rod is inserted into the driving end of the nail. All Locking Screws are removed with the Long Screwdriver Shaft and Teardrop Handle.

The Slotted Hammer is used to extract the nail in a controlled manner (Fig. 83). A captured Sliding Hammer (1806-0175) is available as an “optional” instrument.

Note: • Stryker offers also a Universal Extraction Set for the removal of internal fixation systems and associated screws. For more information, please refer to the Literature Number B1000057. • Check with local representative regarding the availability of the Universal Extraction Set.

Fig. 83

50 Ordering Information – Implants

T2 Femoral Locking Nail R1.5

REF Diameter Length REF Diameter Length mm mm mm mm

1828-0824S 8.0 240 1828-1224S 12.0 240 1828-0826S 8.0 260 1828-1226S 12.0 260 1828-0828S 8.0 280 1828-1228S 12.0 280 1828-0830S 8.0 300 1828-1230S 12.0 300 1828-0832S 8.0 320 1828-1232S 12.0 320 1828-0834S 8.0 340 1828-1234S 12.0 340 1828-0836S 8.0 360 1828-1236S 12.0 360 1828-0838S 8.0 380 1828-1238S 12.0 380 1828-0840S 8.0 400 1828-1240S 12.0 400 1828-0842S 8.0 420 1828-1242S 12.0 420 1828-0844S 8.0 440 1828-1244S 12.0 440 1828-0846S 8.0 460 1828-1246S 12.0 460 1828-0848S 8.0 480 1828-1248S 12.0 480

1828-0924S 9.0 240 1828-1324S 13.0 240 1828-0926S 9.0 260 1828-1326S 13.0 260 1828-0928S 9.0 280 1828-1328S 13.0 280 1828-0930S 9.0 300 1828-1330S 13.0 300 1828-0932S 9.0 320 1828-1332S 13.0 320 1828-0934S 9.0 340 1828-1334S 13.0 340 1828-0936S 9.0 360 1828-1336S 13.0 360 1828-0938S 9.0 380 1828-1338S 13.0 380 1828-0940S 9.0 400 1828-1340S 13.0 400 1828-0942S 9.0 420 1828-1342S 13.0 420 1828-0944S 9.0 440 1828-1344S 13.0 440 1828-0946S 9.0 460 1828-1346S 13.0 460 1828-0948S 9.0 480 1828-1348S 13.0 480

1828-1024S 10.0 240 1828-1424S 14.0 240 1828-1026S 10.0 260 1828-1426S 14.0 260 1828-1028S 10.0 280 1828-1428S 14.0 280 1828-1030S 10.0 300 1828-1430S 14.0 300 1828-1032S 10.0 320 1828-1432S 14.0 320 1828-1034S 10.0 340 1828-1434S 14.0 340 1828-1036S 10.0 360 1828-1436S 14.0 360 1828-1038S 10.0 380 1828-1438S 14.0 380 1828-1040S 10.0 400 1828-1440S 14.0 400 1828-1042S 10.0 420 1828-1442S 14.0 420 1828-1044S 10.0 440 1828-1444S 14.0 440 1828-1046S 10.0 460 1828-1446S 14.0 460 1828-1048S 10.0 480 1828-1448S 14.0 480

1828-1124S 11.0 240 1828-1524S 15.0 240 1828-1126S 11.0 260 1828-1526S 15.0 260 1828-1128S 11.0 280 1828-1528S 15.0 280 1828-1130S 11.0 300 1828-1530S 15.0 300 1828-1132S 11.0 320 1828-1532S 15.0 320 1828-1134S 11.0 340 1828-1534S 15.0 340 1828-1136S 11.0 360 1828-1536S 15.0 360 1828-1138S 11.0 380 1828-1538S 15.0 380 1828-1140S 11.0 400 1828-1540S 15.0 400 1828-1142S 11.0 420 1828-1542S 15.0 420 1828-1144S 11.0 440 1828-1544S 15.0 440 1828-1146S 11.0 460 1828-1546S 15.0 460 1828-1148S 11.0 480 1828-1548S 15.0 480

Special Order Implants in sterile packaging.

Note : Check with local representative regarding availability of nail sizes. 51 Ordering Information – Implants

5mm Fully Threaded Locking Screws 5mm Partially Threaded Locking Screws

REF Diameter Length REF Diameter Length mm mm mm mm

1896-5025S 5.0 25.0 1891-5025S 5.0 25 1896-5027S 5.0 27.5 1891-5030S 5.0 30 1896-5030S 5.0 30.0 1891-5035S 5.0 35 1896-5032S 5.0 32.5 1891-5040S 5.0 40 1896-5035S 5.0 35.0 1891-5045S 5.0 45 1896-5037S 5.0 37.5 1891-5050S 5.0 50 1896-5040S 5.0 40.0 1891-5055S 5.0 55 1896-5042S 5.0 42.5 1891-5060S 5.0 60 1896-5045S 5.0 45.0 1891-5065S 5.0 65 1896-5047S 5.0 47.5 1891-5070S 5.0 70 1896-5050S 5.0 50.0 1891-5075S 5.0 75 1896-5052S 5.0 52.5 1891-5080S 5.0 80 1896-5055S 5.0 55.0 1891-5085S 5.0 85 1896-5057S 5.0 57.5 1891-5090S 5.0 90 1896-5060S 5.0 60.0 1891-5095S 5.0 95 1896-5065S 5.0 65.0 (Shaft Screws) 1891-5100S 5.0 100 1896-5070S 5.0 70.0 1891-5105S 5.0 105 1896-5075S 5.0 75.0 1891-5110S 5.0 110 1896-5080S 5.0 80.0 1891-5115S 5.0 115 1896-5085S 5.0 85.0 1891-5120S 5.0 120 1896-5090S 5.0 90.0 1896-5095S 5.0 95.0 1896-5100S 5.0 100.0 1896-5105S 5.0 105.0 1896-5110S 5.0 110.0 1896-5115S 5.0 115.0 1896-5120S 5.0 120.0

4mm Fully Threaded Locking Screws Condyle Screws

REF Diameter Length REF Diameter Length mm mm mm mm

1896-4020S 4.0 20 1895-5040S 5.0 40 1896-4025S 4.0 25 1895-5045S 5.0 45 1896-4030S 4.0 30 1895-5050S 5.0 50 1896-4035S 4.0 35 1895-5055S 5.0 55 1896-4040S 4.0 40 1895-5060S 5.0 60 1896-4045S 4.0 45 1895-5065S 5.0 65 1896-4050S 4.0 50 1895-5070S 5.0 70 1896-4055S 4.0 55 1895-5075S 5.0 75 1896-4060S 4.0 60 1895-5080S 5.0 80 1895-5085S 5.0 85 1895-5090S 5.0 90 1895-5095S 5.0 95 1895-5100S 5.0 100 1895-5105S 5.0 105 1895-5110S 5.0 110 1895-5115S 5.0 115 1895-5120S 5.0 120

Nut for Condyle Screws

REF Diameter Length mm mm

1895-5001S 5.0

52 Ordering Information – Implants

End Caps Advanced Compression Screw, Femur

REF Diameter Length REF Diameter mm mm mm

Standard +5mm +10mm 1822-0003S 8.0 Standard 1825-0001S 8.0 1822-0005S 11.5 + 5mm 1822-0010S 11.5 +10mm 1822-0015S 11.5 +15mm 1822-0020S 11.5 +20mm 1822-0025S 11.5 +25mm +15mm +20mm +25mm 1822-0030S 11.5 +30mm 1822-0035S 11.5 +35mm

Compression Screws

REF Diameter Length mm mm +30mm +35mm 1825-0000S 8.0 1825-0005S 8.0 5 1825-0010S 8.0 10 1825-0015S 8.0 15

Note: Outside of the U. S., Locking Screws and other specific products may be ordered Non-Sterile without the “S” at the end of the corresponding REF Number. 53 Ordering Information – Instruments

REF Description REF Description Quantity

T2 Basic Long T2 Femur

702429 Teardrop Handle, AO 702427 T-Handle, AO Coupling Coupling 0152-0218* K-Wire 1,8x310mm 2 703165 Protection Sleeve, Retrograde 1806-0015 X-Ray Ruler, Femur

1806-0022 Guide Wire Ruler 1806-0050 K-Wire 3x285mm 2

1806-0065 8mm Hex Screwdriver bit, ball tip

1806-0032 Awl Plug 1806-0165 Nail Holding Screw, 2 Femur 1806-0041 Awl, Curved, 9mm 1806-0255 Screwdriver, Condyle 2 1806-0110 Universal Rod, 9mm Screw

1806-0125 Reduction Spoon, 9mm 1806-0257 Revision Screwdriver Bit, 6.3mm 1806-0130 Wrench 8mm/10mm 1806-0272 External Compression 1806-0135 Insertion Wrench, 10mm Device

1806-0273 Fixation Screw Clamp 1806-0150 Strike Plate 1806-0311 Trocar, Paddle 1806-0170 Slotted Hammer 1806-0400 Socket Wrench, 1806-0185 Tissue Protection Sleeve, Universal Joint 10mm Long, 9mm 1806-1005 Target Device, Femur 1806-0203 Screwdriver, Self-Holding, (2 components) Extra Short (3.5mm)

1806-0215 Drill Sleeve, Long, 5mm 1806-2016 Countersink for Condyle 1806-0227 Screwdriver Shaft AO, Screws Long, 3.5mm 1806-4260* Drill Ø4.2 × 340mm, AO 1806-0233 Screwdriver, Self-Holding, Long (3.5) 1806-4270* Drill Ø4.2 × 180mm, AO

1806-0268 Screwdriver Shaft, 1806-4290* Drill Ø4.2 × 230mm, AO Compression (hex3.5) 1806-5000* Drill Ø5.0 × 230mm, AO 1806-0271 Guide Wire Pusher

1806-0315 Trocar, Long 1806-5020* Drill Ø5.0 × 340mm, AO

1806-0325 Screw Gauge, Long 1806-9920 T2 Femur Instrument Tray

1806-0331 Screw Gauge (20-120mm)

1806-0350 Extraction Rod, Conical (Ø8mm) T2 8mm Femur Nail Instruments 1806-0365 Screw Scale, Long 1806-0073S Teflon Tube (for 8mm Nail 1806-1095 Guide Wire Handle Guide Wire exchange ONLY)

1806-1096 Guide Wire Handle 1806-0090 Guide Wire, Smooth Tip 3×800 mm Chuck, 2-3.5mm (outside of U. S.)*

1806-2014 Rigid Reamer Ø12mm 1806-0090S Guide Wire, Smooth Tip 3×800 mm, sterile (U. S.) 1806-9900 T2 Basic Long Instrument Tray 1 8 0 6 - 3 5 7 0 S Drill Ø3.5×180mm AO, sterile (U. S.)

Caution: 8mm Nails require 4mm Fully Threaded Screws for locking at the non-driving end. * Instruments designated “Outside of the U. S.” may not be ordered for the U. S. market. 54 Ordering Information – Instruments

REF Description REF Description

Optional Optional

1806-0006 X-Ray Template, Femur 702427 T-Handle, AO Coupling

0140-0002 Reaming Protector , 161mm

1806-0045 Awl, Straight, Ø10mm 1806-0047 Awl, Straight Ø11.5mm

1806-0085 Guide Wire, Ball Tip, 3 × 1000mm 1806-0202 Screwdriver, Extra Short, 3.5mm (outside of U. S.)* 1806-0450 Long Freehand Tissue 1806-0085S Guide Wire, Ball Tip, 3 × 1000mm, Protection Sleeve sterile (U. S.) 1806-0460 Long Drill Sleeve Ø 4.2mm 1806-0175 Sliding Hammer 1806-1007 Target Device Locking Nut, Spare 1806-0232 Screwdriver, Long, 3.5mm

1806-0237 Screwdriver, Short, 3.5mm Spare Parts 1806-0240 Screw Capture Sleeve, Long, 1806-1097 Handle 1806-0270 Ratchet T-Handle AO 1806-0098 Cage 1806-0300 Screw Driver Shaft, Ball Tip, 3.5mm 1806-0099 Clamping Sleeve 1806-0480 Long Screw Gauge (20mm–80mm)

1806-4260S Drill Ø4.2 × 340mm, AO, sterile (U. S.)

1806-4270S Drill Ø4.2 × 180mm, AO, sterile (U. S.)

1806-4290S Drill Ø4.2 × 230mm, AO, sterile (U. S.)

1806-5000S Drill Ø5.0 × 230mm, AO, sterile (U. S.)

1806-5020S Drill Ø5.0 × 340mm, AO, sterile (U. S.)

1806-9010 Screw Tray

1806-9971 T2 Femur Drill Rack

1806-9982 T2 Silicon Mat

* Instruments designated “Outside of the U. S.” may not be ordered for the U. S. market. 55 Ordering Information – Instruments

Complete range of modular and Bixcut fixed-head reamers to match surgeon preference and optimize O. R. efficiency, presented in fully sterilizable cases.

Large clearance rate resulting from reduced number of reamer blades coupled with reduced length of reamer head to allow for effective relief of pressure and efficient removal of material3.

Cutting flute geometry optimized to lower pressure generation3.

Forward- and side-cutting face combination produces efficient material removal and rapid clearance3.

Double-wound shaft transmits torque effectively and with high reliability. Low-friction surface finish aids rapid debris clearance3.

Smaller, 6 and 8mm shaft diameters are designed to reduce IM pressure. Typical Standard Bixcut Reamer Ø14mm Reamer Ø14mm

Studies1 have demonstrated that the pressures developed within the medullary cavity through the introduction of unreamed IMnails can be far greater than those devel­oped Clearance area : Clearance area : 32% of cross section 59% of cross section during reaming − but this depends very much upon the design of the reamer.

After a three year development study2 involving several universities, the factors that determine the pressures and temperatures developed during reaming were clearly established. These factors were applied to the de­- velopment of advanced reamers that demonstrate significantly better per­- form­ance than the best of previous designs3.

1 Jan Paul M. Frolke, et al. ; Bixcut Intramedullary Pressure in Reamed Femoral Nailing with Two Different Reamer Designs., Eur. J. of Trauma, 2001 #5

2 Medhi Moussavi, et al.; Pressure Changes During Reaming with Different Parameters and Reamer Designs, Clinical Orthopaedics and Related Research Number 373, pp. 295-303, 2000

3 Andreas Speitling; Intramedullary Reamers, commented slides of internal test report, Sep 1999

56 Ordering Information – Instruments

Bixcut Modular Head Bixcut Fixed Head − AO Fitting**

REF Description Diameter REF Diameter Length mm mm mm

0226-3090 Bixcut Head 9.0 0225-5060 6.0* 400 0226-3095 Bixcut Head 9.5 0225-5065 6.5* 400 0226-3100 Bixcut Head 10.0 0225-5070 7.0* 400 0226-3105 Bixcut Head 10.5 0225-6075 7.5 480 0226-3110 Bixcut Head 11.0 0225-6080 8.0 480 0226-3115 Bixcut Head 11.5 0225-6085 8.5 480 0226-3120 Bixcut Head 12.0 0225-6090 9.0 480 0226-3125 Bixcut Head 12.5 0225-6095 9.5 480 0226-3130 Bixcut Head 13.0 0225-6100 10.0 480 0226-3135 Bixcut Head 13.5 0225-6105 10.5 480 0226-3140 Bixcut Head 14.0 0225-6110 11.0 480 0226-3145 Bixcut Head 14.5 0225-8115 11.5 480 0226-3150 Bixcut Head 15.0 0225-8120 12.0 480 0226-3155 Bixcut Head 15.5 0225-8125 12.5 480 0226-3160 Bixcut Head 16.0 0225-8130 13.0 480 0226-3165 Bixcut Head 16.5 0225-8135 13.5 480 0226-3170 Bixcut Head 17.0 0225-8140 14.0 480 0226-3175 Bixcut Head 17.5 0225-8145 14.5 480 0226-3180 Bixcut Head 18.0 0225-8150 15.0 480 0226-4185 Bixcut Head 18.5 0225-8155 15.5 480 0226-4190 Bixcut Head 19.0 0225-8160 16.0 480 0226-4195 Bixcut Head 19.5 0225-8165 16.5 480 0226-4200 Bixcut Head 20.0 0225-8170 17.0 480 0226-4205 Bixcut Head 20.5 0225-8175 17.5 480 0226-4210 Bixcut Head 21.0 0225-8180 18.0 480 0226-4215 Bixcut Head 21.5 0226-4220 Bixcut Head 22.0 0226-4225 Bixcut Head 22.5 Optional Instruments 0226-4230 Bixcut Head 23.0 0226-4235 Bixcut Head 23.5 REF Description 0226-4240 Bixcut Head 24.0 0226-4245 Bixcut Head 24.5 0227-0060 Hand Reamer 6 mm 0226-4250 Bixcut Head 25.0 w/Mod Trinkle connection 0226-4255 Bixcut Head 25.5 0227-0070 Hand Reamer 7 mm 0226-4260 Bixcut Head 26.0 w/Mod Trinkle connection 0226-4265 Bixcut Head 26.5 0227-0080 Hand Reamer 8 mm 0226-4270 Bixcut Head 27.0 w/Mod Trinkle connection 0226-4275 Bixcut Head 27.5 0227-0090 Hand Reamer 9 mm 0226-4280 Bixcut Head 28.0 w/Mod Trinkle connection 1806-6520 Curved Reduction Rod 8.5 mm

1,2,3, 4 w/Mod Trinkle connection Bixcut Shafts (Sterile) 1806-6500 T-Handle w/Mod Trinkle connection

REF Description Length mm

0227-8240S Mod. Trinkle 284 0227-3000S Mod. Trinkle 448 0227-8510S Mod. Trinkle 510 Bixcut Trays empty 0227-8885S Mod. Trinkle 885 REF Description 0226-8240S AO 284 0226-3000S AO 448 0225-6000 Tray, Modular Head (up to size 22.0mm) Shaft Accessories 0225-6001 Tray, Modular Head (up to size 28.0mm) 0225-8000 Tray, Fixed Head REF Description (up to size 18.0mm) 3212-0-210 Grommet (pack of 25) 0225-6040 Mini Trauma Tray 3212-0-220 Grommet inserter/extractor (for modular heads 9-18) 0225-6010 Grommet Case 0225-6050 Mini Revision Tray (for modular heads 9-28)

Note: Bixcut Fixed Head − Modified Trinkle fitting available in same diameters and length as the AO Fitting (REF No: 0227-xxxx) * Use with 2.2mm × 800mm Smooth Tip and 2.5mm × 800mm Ball Tip Guide Wires only. ** Use with Stryker Power Equipment. 1. Non-Sterile shafts supplied without grommet. Use new grommet for each surgery. See Shaft Accessories. 2. Sterile shafts supplied with grommet pre-assembled. 3. For Non-Sterile leave “S” off the REF Number when ordering (510 and 885mm available only sterile Modified Trinkle Fitting). 4. Non-Sterile, AO Fitting Shafts in 510 and 885mm are available as build to order items: • CM810921 AO Fitting Shaft, length 510mm • CM810923 AO Fitting Shaft, length 885mm.

57 Notes

58 Notes

59 Stryker Trauma GmbH Prof.-Küntscher-Straße 1–5 D - 24232 Schönkirchen Germany

www.osteosynthesis.stryker.com

This document is intended solely for the use of healthcare professionals. A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery. The information presented in this brochure is intended to demonstrate a Stryker product. Always refer to the package insert, product label and/or user instructions including the instructions for Cleaning and Sterilization (if applicable) before using any Stryker products. Products may not be available in all markets. Product availability is subject to the regulatory or medical practices that govern individual markets. Please contact your Stryker representative if you have questions about the availability of Stryker products in your area.

Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trade- marks or service marks: Stryker, T2 and BixCut.

All other trademarks are trademarks of their respective owners or holders. The products listed above are CE marked.

Literature Number : B1000062 LOT B0610

Copyright © 2010 Stryker