Expert Nailing System With Radiolucent Instrumentation Suprapatellar Instrumentation for Titanium Cannulated Tibial Nails Surgical Technique TABLE OF CONTENTS INTRODUCTION Suprapatellar Instrumentation for Titanium 2 Cannulated Tibial Nails Titanium Cannulated Tibial Nails Expert Nailing System 4 AO Principles 6 Indications 7 SURGICAL TECHNIQUE Preoperative Planning 8 Opening the Tibia 9 Reaming (optional) 17 Inserting the Nail 19 Locking Options 24 Distal Locking 25 Proximal Locking—Diaphyseal and Distal Segment 31 Fractures Proximal Locking—Compression Locking Mode 35 (Optional) Proximal Locking—Proximal Segment Fractures 38 End Cap Insertion 45 Implant Removal (optional) 47 PRODUCT INFORMATION Implants 52 Instruments 62 MR Information The Titanium Cannulated Tibial Nail System has not been evaluated for safety and Set Lists 70 compatibility in the MR environment. It has not been tested for heating, migration or image artifact in the MR environment. The safety of the Titanium Cannulated Tibial Nail System in the MR environment is unknown. Scanning a patient who has this device may result in patient injury. Image intensifier control Suprapatellar Instrumentation for Titanium Cannulated Tibial Nails Surgical Technique DePuy Synthes 1 SUPRAPATELLAR INSTRUMENTATION FOR TITANIUM CANNULATED TIBIAL NAILS EXPERT NAILING SYSTEM ADVANCED INSTRUMENTATION Two-hole wire guides • Offset hole to “dial-in” placement of the guide wire • Blunt tip • Gentle transitions Reusable PEEK opening trocars • Reusable solid design • Smooth, rounded tip • Gentle transitions Steel inner protection sleeves • Suction holes • Retention feature • Finger grips for easy removal • Protects soft outer sleeve during drilling and reaming Handle • Retention knob • Lever locks • Through slot and holes to anchor handle • Suction port Soft outer protection sleeves • Soft, flexible material to cushion soft tissue • Locks into handle with a ¼ turn • Conforms to nail shape during insertion 2 DePuy Synthes Suprapatellar Instrumentation for Titanium Cannulated Tibial Nails Surgical Technique Suprapatellar Instrumentation for Titanium Cannulated Tibial Nails Expert Nailing System Insertion handle • Longer length for suprapatellar insertion • Smaller diameter tip • Smooth contoured reverse bevel for smooth transition Aiming arm • Radiolucent material • Protection sleeve retention • Precise targeting • Standard attachment mechanism Inter-lock screwdrivers • Locks into the recess of the screw • Firm, mechanical locking mechanism • Engages and disengages with the turn of a nut Extraction screw • Drill point tip • Cutting flutes to remove debris • Longer tip Suprapatellar Instrumentation for Titanium Cannulated Tibial Nails Surgical Technique DePuy Synthes 3 TITANIUM CANNULATED TIBIAL NAILS EXPERT NAILING SYSTEM ADVANCED SOLUTIONS Advanced proximal locking options • Three innovative locking options, in combination with dual core locking screws, to increase the stability of the proximal fragment for proximal third fractures • Two state-of-the-art mediolateral (ML) locking options enable primary compression or secondary controlled dynamization IMPROVED STABILITY End caps • Gold end caps securely lock the most proximal oblique locking screw to create a fixed-angle construct • Gray end caps feature a lead-in design for easier end cap insertion • End caps prevent ingrowth of tissue 15 mm 10 mm 5 mm 0 mm and facilitate Nail-EXtraction • Self-retaining T40 StarDrive Recess for easy pick up and insertion of end cap • Cannulated • 0 mm end caps sit flush with nail • 5, 10, and 15 mm end caps extend nail height if nail is overinserted 15 mm 10 mm 5 mm 0 mm 4 DePuy Synthes Suprapatellar Instrumentation for Titanium Cannulated Tibial Nails Surgical Technique Titanium Cannulated Tibial Nails Expert Nailing System Advanced nail design Advanced distal locking options • Titanium alloy* for improved • Distal oblique locking options to mechanical and fatigue properties help prevent soft tissue damage • Cannulated nails (from 8 mm to and increase stability of the 13 mm) for reamed or distal fragment unreamed techniques, enabling • Two ML and one anteroposterior nail insertion over guide wire (AP) locking options for stability • All 2.5 mm or 3.0 mm ball-tipped of the distal fragment guide wires may be removed through the nail and insertion handle assembly (no exchange tube required) Titanium Cannulated Tibial Nail–EX with Proximal Bend Titanium Cannulated Tibial Nail–EX MULTIDIRECTIONAL LOCKING OPTIONS FOR IMPROVED STABILITY All locking screws • Double-lead thread for more contact points enhance stability and ease Dual-core locking screws of insertion • Indicated for the three proximal • Thread closer to screwhead provides locking options of all tibial nails better bone purchase in the near • Dual-core design for optimized Standard locking screws cortex and improved stability purchase in cancellous bone • Larger cross section for • Titanium alloy* for improved • Unicortical improved mechanical mechanical and fatigue properties • Lengths: 30 mm–90 mm resistance • Self-tapping blunt tip • 4.0 mm diameter for 8 mm • Self-retaining T25 StarDrive Recess and 9 mm tibial nails, lengths: allows improved torque transmission 18 mm–80 mm and increased resistance to stripping • 5.0 mm diameter for 10 mm to relative to a hex recess and secure 13 mm tibial nails, lengths: locking screw pick-up 26 mm–100 mm * Titanium-6% aluminum-7% niobium alloy Suprapatellar Instrumentation for Titanium Cannulated Tibial Nails Surgical Technique DePuy Synthes 5 AO PRINCIPLES AO PRINCIPLES In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation.1,2 In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation1, 2. 4_Priciples_03.pdf 1 05.07.12 12:08 AnatomicAnatomic reduction StableStable fixation fixation Fracture reduction and fixation to Fracture fixation providing absolute Fracture reduction and fixation to Fracture fixation providing abso- restore anatomical relationships. or relative stability, as required by restore anatomical relationships. lute or relative stability, as the patient, the injury, and the personalityrequired by of the the patient,fracture. the injury, 1 2 and the personality of the fracture. Early, active mobilization Preservation of blood supply Early, active mobilization Preservation of blood supply Early and safe mobilization and Preservation of the blood supply Early and safe mobilization and Preservation of the blood supply rehabilitation of the injured part 4 3 to soft tissues and bone by gentle rehabilitation of the injured part to soft tissues and bone by and the patient as a whole. reduction techniques and and the patient as a whole. carefulgentle handling.reduction techniques and careful handling. 1. Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation. 3rd ed. Berlin, Heidelberg, New York: Springer-Verlag; 1991. 2. Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 1 Müller ME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal 2nd ed. Stuttgart New York: Thieme; 2007. Fixation. 3rd ed. Berlin Heidelberg New York: Springer. 1991. 2 Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme. 2007. 6 DePuy Synthes Suprapatellar Instrumentation for Titanium Cannulated Tibial Nails Surgical Technique 4 DePuy Synthes Expert Lateral Femoral Nail Surgical Technique INDICATIONS The Suprapatellar Insertion Instruments are part of the Tibial Nail System–EX. The Tibial Nail System–EX is intended to stabilize fractures of the proximal and distal tibia and the tibial shaft; open and closed tibial shaft fractures; certain pre- and post-isthmic fractures; and tibial mal-unions and non-unions. Note: The use of a cannulated Expert Tibial Nail with a large diameter offering more stability associated with the reamed technique is generally recommended for pseudarthroses, tumours, mal-unions and non-unions. Suprapatellar Instrumentation for Titanium Cannulated Tibial Nails Surgical Technique DePuy Synthes 7 PREOPERATIVE PLANNING Use the preoperative planner template to estimate nail diameter and nail length. To estimate nail diameter, place the template on the AP or lateral x-ray of the uninjured tibia and measure the diameter of the medullary canal at the narrowest part that will contain the nail. To estimate nail length, place the template on the AP x-ray of the uninjured tibia and select the appropriate nail length based on patient anatomy. When selecting nail size, consider canal diameter, indication, fracture pattern, patient anatomy, and postoperative protocol. Note: Templates are available in two sizes: actual size and 115% magnification in which the image is enlarged 15% to correspond to typical radiographic magnification. However, variations in magnification levels are common. 8 DePuy Synthes Suprapatellar Instrumentation for Titanium Cannulated Tibial Nails Surgical Technique OPENING THE TIBIA 1 Position patient Position the patient supine on the radiolucent table. Ensure that the knee of the injured leg can be flexed 10°–20°. Position the image intensifier so that visualization of the tibia, including the articular surface proximally and distally, is possible in AP and lateral views. The knee roll can be placed under the lower part of the thigh if it obstructs the view of the tibial plateau in the AP view. 2 Reduce fracture Instrument 394.35* Large Distractor Perform closed reduction manually by axial traction under