TRAUMATOLOGY. Trochanter

Transcription

1 TRAUMATOLOGY Trochanter 1

2 References Prof. Dr. András Sárváry Head of Department Fővárosi Önkormányzat Péterfy Sándor úti Kórház Rendelőintézet és Baleseti Központ Budapest The following surgical description contains general outlines for intramedullary nailings performed on the femur with SpectruM Trochanter system. However, the operating surgeon shall adapt the content to the patient, fracture type and all other relevant factors that may have influence on the outcome of the surgery. Therefore, Sanatmetal Ltd. strongly recommends participation on workshops and trainings prior to the initial operation.

3 Contents 1. Introduction 4 4. Implant list The implant SpectruM Trochanter nail, short The instrumentarium SpectruM Trochanter nail, long Indications Trochanter spiral Implant sizes Support screw Closing cap Surgical description Locking screw Patient positioning Incision Preparation of the intramedullary Reaming Instrument list Filled up tray Instruments Assembly of the targeting arm and the 7 implant, determinig nail length (long nail) 3.6 Introduction of the nail Guide wire insertion I Guide wire insertion II Measuring the length of the trochanter 9 screw 3.10 Proximal locking I Proximal locking II Proximal locking III Supporting screw insertion Distal locking I. (short nail) Distal locking II. (short nail) Distal locking I. (long nail) Distal locking II. (long nail) Distal locking III. (long nail) Removal of the targeting arm End cap insertion Implant removal 14

4 1 Introduction The SpectruM Trochanter implant and instrument system combines the advantages of the previously distributed and successfully applied systems furthermore the advantages of the radiolucent targeting arm. The system based on a well-considered development process, where the main aims were the simplicity and the striving for the minimal time duration of the operation. 1.1 The implant 1.2 The instrument set Cannulated nail Short nail trochanter fractrures Long, anatomic nail combined fractures 125, 130, 135 angled nails Dynamic locking possibility Usable with Trochanter Spiral as well The supporting screw is protected against loosening Sliding assured by support screw Asymmetric slots on the screw shaft limited blacksliding Special thread profile for easier screw insertion Raw materials:, Titanium alloy Special distal hole for the distal targeting device Different length end caps Radiolucent targeting arm Universal targeting arm (125, 130, 135 ) Canullated technique reposition keeping during operation Optimal targeting arm shape for more comfortable insertion point Colour coded instrument set for obvious surgical steps Instrument are protected against fall out 1.3 Indications Intertrochanteric fractures Pertrochanteric fractures Pseudarthrosis Subtrochanteric fractures (long nail) Pertrochanteric and diaphysis fractures (long nail) Pathological fracture trochanter and diaphysis (long nail) 4

5 Implant range SpectruM Trochaner nail Short Long (left, right) CCD (angle) Proximal diameter (mm) Distal diameter (mm) Tochanter screw Ø10.5 mm Raw material Anodised Titanium 2.3 Locking screw Ø4.8 mm Raw material Anodised Titanium Raw material Anodised Titanium 2.5 Closing cap 2.4 Support screw 0-25 Raw material Anodised Titanium Raw material Anodised Titanium The support screw and the nail are in the same package. 5

6 3 Surgical description 3.1 Patient positioning In supine position on extension surgical table. 3.2 Incision Between the greater trochanter and the wing of the iliac bone. The proper place depends on the quantity of the soft tissues. 3.3 Preparation of the intramedullary Drill in the Kirschner wire (Ø3.2 mm, NOT threaded) through the tip of the greater trochanter under image intensifier control. Drive the awl to the wire and open the intramedullary canal. Remove the Kirschner wire. 3.4 Reaming Introduce the 4/3x900 mm olive tip guide rod through the awl to the intramedullary canal with the T-handle. Remove the awl. Place the soft tissue protector to the trochanter tip through the guide rod and ream the proximal place of the nail with the cannulated conical reamer. While using the soft tissue protector and the conical reamer the position of the awl made gap can be slightly modified. Remove the conical reamer and the soft tissue protector. Ream the intramedullary canal if needed, then remove the reamer. In case of problems remove the reamer head with the olive tip guide rod. 6

7 3.5 Assembly of the targeting arm the implant, determining nail length (long nail) In case of long nails measure the length of the guide wire part outside of the femur with a measuring rod. Subtract this value from the 900 mm length of the olive tip guide wire. The result is the required nail length. To make measurement easier the 500 mm is marked on the guide wire. Assemble the chosen Spectrum Trochanter nail onto the targeting arm with the fixing screw. Tighten the screw with the 8 mm screwdriver. Attention Always check the assembly before insertion. Place the soft tissue protector into the red slot. Push the stepped drill through the tissue protector. In case of optimal assembly the sleeve drives the drill to the proper hole. 3.6 Introduction of the nail Insert the nail into the intramedullary canal with rotating movements. The proximal end of the nail is indicated by the Kirschner wire led through the targeting arm as per the image. There are 3 slots on the metal part of the targeting arm connecting to the nail. This can help the identification of the nail tip under image intensifier. The nail tip is located 5 mms away from the most distal slot. Determine the rotational position of the nail with a Kirschner wire under image intensifier as seen on the image. Check the optimal sinking of the nail with the indicator. Place the indicator into the targeting arm to the corresponding angulation slots in such a way that its sleeves for Kirschner wires shall facet he anterior. Place a Kirschner wire into the distal of the two sleeves and under image intensifier check the depth of the nail. In optimal case the Kirschner wire s centerline is about 8 mm from the Adam arch. 7

8 3 Surgical description If the nail insertion is blocked, and the surgeon decide that the guide wire is removable, after removal of the guide wire, connect the 8 mm screwdriver to the connecting screw and guide the nail to its final position with light mallet blows. In case the guide wire is irremovable, remove the nail, ream again the intramedullary canal, and introduce the nail again into the canal. Remove the olive tip guide rod. Important Do not hit the targeting arm. 3.7 Guide wire insertion I. Push the red marked soft tissue protector (assembled with the drill sleeve) to the appropriate angulation hole (125, 130, 135 ) on the targeting arm and hit the bone surface. 3.8 Guide wire insertion II. Through the red sleeve open the cortical with a 3.2 mm spiral drill (1). Drill the 3.2 mm Kirschner wire to 5 mm far from the subchondralis surface through the distal hole of the red sleeve under image intensifier control (2). Repeat the process in the proximal holes (3,4)

9 3.9 Measuring the length of the trochanter screw Remove the 3.2 mm sleeve and push the length gauge to the Kirschner wire. Read the necessary screw length at the end of the Kirschner wire. Inbetween values should be rounded up Proximal locking I. Set the bumper of the stepped drill to the value of the previous step (the value is shown in the window) then drill through the Kirschner wire. Remove the stepped drill Proximal locking II. Assemble the chosen trochanter screw with the threaded retaining stem to the screw insertion device and fix with a hand (in case it can be secured by a 3.5 mm screwdriver). The compression nut on the insertion device is set into upper position. 9

10 3 Surgical description 3.12 Proximal locking III. The trochanter screw is driven in through the soft tissue protector that the end of the screw should be 5-8mm far from the subchondralis surface. Check the position under an image intensifier. After performing this operation the T-wrench of the screw insertion device should be perpendicular or parallel with the targeting arm. This way the supporting screw will slide to the slot on the trochanter screw shaft. Turn the compression nut on the retaining stem to the direction of the arrow to achieve necessary compression. (On occasion wrench can be used.) Remove the reposition maintaining Kirschner wire in the proximal hole Supporting screw insertion Put the supporting screw to the 3.5 mm flexible screwdriver and drive it into the nail. Loosen up the support screw with a quarter turn so that the sliding effect may prevail. Move the T-handle with slight rotating movements to check the stability against rotation of the supporting screw. Dismount the screw insertion device and remove the Kirschner wire and the red sleeve. In case of long nail continue with 3.16 step. 10

11 3.14 Distal locking I. (short nail) Place the assembled green soft tissue protector (for dynamic hole - sign ) and the sleeve into the green marked distal targeting arm. Then drill with a 4.2 mm spiral drill. In case of only static locking use the soft tissue protector and drill sleeve (only for static holes - sign) into the chosen S marked hole of the targeting arm. D S S 3.15 Distal locking II. (short nail) Remove the drill sleeve, the length of the screw should be measured through the green soft tissue protector, push the measurer up to the bone surface. The value shown at the soft tissue protector directly determines the necessary length of the interlocking screw. Important Continue with 3.18 step. Alternative length gauging method: put the drill stop on the drillbit, just above the spiral part. Perform drilling. Read the necessary screw length at bottom side of the stop. The selected screw should be driven in with a 3.5 mm screwdriver through the soft tissue protector. 11

12 3 Surgical description 3.16 Distal locking I. (long nail) Check the position of the hole under an image intensifier and make skin incision on the given place. Put the free-hand target device onto the bone and find the accurate place of the locking hole with the help of the image intensifier. Drill the closer corticalis with a 6 mm spiral drill through the soft tissue protector. Make drilling carefully. As soon as the drill passes through the corticalis and reaches the nail stop the movement. Remove the free-hand target device Distal locking II. (long nail) Put the distal targeting device into the hole on the bone (the double hole should face to distal direction) then click it into the special slot on the nail (1). After skin incision put the tissue protector and the drill sleeve into the chosen hole of the distal targeting device, push them to the bone surface and perform drilling (2). Hold the distal targeting device continuously on the bone surface during drilling. Remove the drill sleeve. 1 Measure the required screw length through the soft tissue protector, push the measurer up to the bone surface (3). Alternative length gauging method: put the drill stop on the drillbit, just above the spiral part. Perform drilling. Read the necessary screw length at bottom side of the stop. 2 Drive the screw in (4). 3 D Special S 4 12

13 3.18 Distal locking III. (long nail) Remove the manual aiming device and put back the free hand targeting device and the drill sleeve on the special hole. Drill through the ventral wall of the cortical with the 4.2 mm drillbit through the soft tissue protector and drill sleeve. After length measurement introduce the screw. Mind that the screw will hold only in the farther cortical. Do not tighten with excessive force to prevent sinking the screw head. Warning Do not use the scaled drillbit for length gauging! 3.19 Removal of the targeting arm Loosen the connecting screw with the 8 mm screwdriver and dismantle the targeting arm from the nail End cap insertion Drive in the proper size end cap with the 3.5 mm screwdriver or the 3.5 mm adapter assembled to the flexible shaft or the 3.5 mm flexible screwdriver. 13

14 3 Surgical description 3.21 Implant removal Remove the distal 4.8 mm locking screws with the 3.5 mm screwdriver. After opening up the nail end take the end cap out with the 3.5 mm screwdriver. Loosen the supporting screw with the 3.5 mm screwdriver or the 3.5 mm adapter assembled to the flexible shaft. Connect the nail impactor dowel to the end of the Spectrum trochanter nail. Open the soft tissues and assemble the impactor with T-handle with the threaded stem to the end of the trochanter screw. Take the trochanter screw out. Hit the nail out of the bone with the forked hammer. 14

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16 4 Implant list 4.1 SpectruM Trochanter nail, short CCD=125 Distal diameter Anodised Titanium CCD=130 Distal diameter Anodised Titanium CCD=135 Distal diameter Anodised Titanium

17 4.2 SpectruM Trochanter nail, long CCD=125 Distal diameter Left Right Left Right Left Right CCD=130 Distal diameter Left Right Left Right Left Right CCD=135 Distal diameter Left Right Left Right Left Right

18 4 Implant list CCD=125 Anodised Titanium Distal diameter Left Right Left Right Left Right CCD=130 Anodised Titanium Distal diameter Left Right Left Right Left Right Anodised Titanium CCD=135 Distal diameter Left Right Left Right Left Right

19 4.3 Trochanter screw Ø10.5 mm 4.6 Locking screw Ø4.8 mm 4.4 Support screw 4.5 Closing cap Anodised Titanium Anodised Titanium Anodised Titanium Anodised Titanium

20 5 Instrument list 5.1 Filled-up tray Surgical description Description Size Quantity Cat. no. Linear gauge for locking screws T-wrench with compression nut Threaded Retaining Stem Depth gauge for locking screws 4.8 mm Stepped drill 10.5/6.7 can. 3.2 mm Target device SpectruM Trochanter Awl Free-hand target device SpectruM Trochanter Nail Extractor Dowel Flexible shaft T-handle Distal targeting device SpectruM Trochanter Spiral drill 4.2x250 mm Spiral drill 4.2x280 mm Conical reamer 16 mm Soft tissue protector 16 mm Measuring rod 500 mm Spiral drill with quick-conn. end 3.2x310 mm Kirschner wire 3.2x375 mm Threaded kirschner wire 3.2x375x10 mm Fork Hammer Screwdriver 3.5 mm Spiral drill 6 mm Guide Rod with olive Tip 4/3x900 mm Screwdriver 8 mm Wrench Drill stop 4.2 mm Indicator (optional Double wire (optional) Tray (empty) SpectruM Trochanter Filled-up tray (SpectruM Trochanter)

21 5.2 Instruments Linear gauge for locking screws T-wrench with compression nut Threaded Retaining Stem Linear gauge for locking screws (4.8 mm) Stepped drill (10.5/6.7 can. 3.2 mm) Target device SpectruM Trochanter Awl Free-hand target device SpectruM Trochanter Nail Extractor Dowel

22 5 Instrument list Flexible shaft T-handle Distal targeting device-sm Trochanter Spiral drill (4.2x250 mm) Spiral drill (4.2x280 mm) Conical reamer (16 mm) Soft tissue protector (16 mm) Measuring rod (500 mm) Spiral drill with quick-connecting end (3.2x310 mm)

23 Kirschner wire (3.2x375 mm) Threaded kirschner wire (3.2x375x10 mm) Fork Hammer Screwdriver (3.5 mm) Spiral drill (6 mm) Guide Rod with Olive Tip (4/3x900 mm) Screwdriver (8 mm) Wrench Drill stop (4.2 mm) Indicator (optional) Double wire (optional)

24 Product family TRAUMATOLOGY 1.1. Intramedullary nails Humerus nails Ulna-radius nails Trochanter nails Femur nails Tibia nails Fibula nails Sanat PIN 1.2. Plates 1.3. Screws 1.4. Fixateur externe 1.5. Other ORTHOPEADICS DENTAL SPINE Contact address: 5, Faiskola st Eger, Hungary phone: fax: TRAUMA REV_C 16/09/2014