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 in crease 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 re ported (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 plat form 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 ad vanced 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 In tramedullary 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