Periarticular Aiming Arm Instruments for LCP Condylar Plate 4.5/5.0. Part of the LCP Periarticular Aiming Arm Instrument System (large).

Transcription

1 Periarticular Aiming Arm Instruments for LCP Condylar Plate 4.5/5.0. Part of the LCP Periarticular Aiming Arm Instrument System (large). Surgical Technique This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation.

2 Image intensifier control This description alone does not provide sufficient background for direct use of DePuy Synthes products. Instruction by a surgeon experienced in handling these products is highly recommended. Processing, Reprocessing, Care and Maintenance For general guidelines, function control and dismantling of multi-part instruments, as well as processing guidelines for implants, please contact your local sales representative or refer to: For general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, as well as processing of Synthes non-sterile implants, please consult the Important Information leaflet (SE_023827) or refer to:

3 Table of Contents Introduction Periarticular Aiming Arm Instruments 2 LCP Condylar Plate 4.5/5.0 3 AO Principles 4 Indications and Contraindications 5 Surgical Technique Preoperative Planning 6 Attach Insertion Handle 7 Make Incision 9 Reduce Articular Surface 10 Insert Plate 11 Determine Plate Position 12 Insert Cannulated Screws B 5.0 and 7.3 mm 12 Secure Aiming Arm to Plate 16 Use of Pull Reduction Device (optional) 21 Insert Cortex Screws B 4.5 mm 23 Insert Locking Screws B 5.0 mm 26 Remove Aiming Arm and Insertion Handle 29 Cleaning Instructions 30 Product Information Plates 31 Screws 32 Instruments 34 Sets 39 MRI Information 42 Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 1

4 Periarticular Aiming Arm Instruments for LCP Condylar Plate 4.5/5.0. Part of the LCP Periarticular Aiming Arm Instrument System (large). Periarticular Aiming Arm Instruments The aiming arms for the LCP Condylar Plates 4.5/5.0 facilitate percutaneous, submuscular insertion of the plate. The Periarticular Aiming Arm Instruments provide common instrumentation throughout the system including: Screwdrivers Drill guides Drill bits Guide sleeves Drill sleeves Wire guides Trocars Additional features include: Aiming for all three positions of the combi-hole: Locking Load (compression) Neutral Instruments snap into aiming arms for quick assembly and removal Multiple options for connecting plates and insertion handles accommodate surgeon preferences Color-coding facilitates system familiarity 2 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

5 LCP Condylar Plate 4.5/5.0 The Synthes LCP Condylar Plate 4.5/5.0 is part of the LCP Periarticular Plating System, which merges locking screw technology with conventional plating techniques. The LCP Periarticular Plating System is capable of addressing complex fractures of the distal femur with the LCP Condylar Plates 4.5/5.0, proximal femur with the LCP Proximal Femoral Plates 4.5/5.0 and the LCP Proximal Femoral Hook Plates 4.5/5.0, proximal tibia with the LCP Proximal Tibia Plates 4.5/5.0 and LCP Medial Proximal Tibia Plates 4.5/5.0. The LCP Condylar Plate 4.5/5.0 System has many similarities to traditional plate fixation methods, with a few important improvements. The technical innovation of locking screws provides the ability to create a fixed-angle construct while using familiar AO plating techniques. Locking capability is important for a fixed-angle construct in osteopenic bone or multifragment fractures where screw purchase is compromised. These screws do not rely on plate-tobone compression to resist patient load, but function similarly to multiple, small angled blade plates. The Locking Compression Plate (LCP) has combi-holes in the plate shaft that combine a dynamic compression unit (DCU) hole with a locking screw hole. The combi-hole provides the flexibility of axial compression and locking capability throughout the length of the plate shaft. Note: More detailed information on conventional and locked plating principles can be found in the Synthes Locking Compression Plate (LCP) surgical technique (Art. No / DSEM/TRM/0115/0278). Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 3

6 AO Principles AO PRINCIPLES In 1958, the AO formulated four basic principles, which have In become 1958, the guidelines AO formulated internal four basic fixation principles, 1,2. which have become the guidelines for internal fixation 1, 2. 4_Priciples_03.pdf :08 Anatomic reduction Fracture reduction and fixation to restore restore anatomical relationships. 1 2 Stable fixation Fracture fixation providing absolute absolute relative or relative stability, stability, as required as by the or patient, required the by injury, the patient, and the the personality injury, of and the the fracture. personality of the fracture. Early, active mobilization Early and safe mobilization and rehabilitation of the injured part and and the patient the patient as a whole. as a whole. 4 3 Preservation of blood supply Preservation of of the blood supply to soft tissues and bone by by gentle reduction gentle reduction techniques techniques and careful and handling. careful handling. 1 Müller ME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal Fixation. 3rd ed. Berlin Heidelberg New York: Springer Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation. 3 rd ed. Berlin, Heidelberg, New York: Springer Rüedi TP, Buckley RE, Moran CG. AO Principles of Fracture Management. 2 nd ed. Stuttgart, New York: Thieme DePuy Synthes Expert Lateral Femoral Nail Surgical Technique 4 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

7 Indications and Contraindications Indications The Synthes LCP Condylar Plates 4.5/5.0 are intended for buttressing of multifragment distal femur fractures including: Supracondylar fractures Intra-articular and extra-articular condylar fractures Malunions and nonunions of the distal femur Periprosthetic fractures Osteotomies of the femur Fractures in normal or osteopenic bone Contraindications No specific contraindication. Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 5

8 Surgical Technique 1 Preoperative planning Sets LCP Condylar Plates 4.5/5.0 (Stainless Steel) in Modular Trays, Vario Case System Periarticular Aiming Arm Instruments for LCP Condylar Plates 4.5/5.0 and LCP Proximal Tibial Plate 4.5/5.0, in Vario Case Periarticular Instruments in Vario Case LCP Large Fragment Instruments and Standard Instruments Large Fragment Screws including Cannulated Locking and Conical Screws Complete a preoperative radiographic assessment and prepare the preoperative plan. Position the patient supine on a radiolucent table. Viewing the distal femur under image intensifier control in both the lateral and AP views is necessary. Use the AO preoperative planner template for the LCP Condylar Plate 4.5/5.0. Precaution: Plate bending is not recommended as this may weaken the plate and the plate-screw interface and can compro mise the targeting function of an aiming arm, if in use. However, there may be cases in which plate bending is clinically necessary. In such cases, the plate should only be bent to fit proximal femur anatomy and only bend the plate incrementally and between screw holes using the plate bending press ( ), and never bend back-and-forth. Insert at least one screw distal to the bend. X-ray-template for LCP Condylar Plate 4.5/5.0, curved (Art. No ) 6 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

9 2 Attach insertion handle Instruments Insertion Handle for Aiming Arm for LCP Condylar Plate 4.5/5.0, curved, right or Insertion Handle for Aiming Arm for LCP Condylar Plate 4.5/5.0, curved, left Wire Guide B 2.5, for Cannulated Locking Screws B 7.3 mm and Cannulated Conical Screws B 7.3 mm Wire Guide B 2.5, for Locking Screws B 5.0, for Cannulated Locking Screws B 5.0 mm and for Cannulated Conical Screws B 5.0 mm Nut for No Hexagonal Pin Wrench B 4.0 mm with ball tip Wire Guide 5.0, percutaneous, for Guide Wire B 2.5 mm Thread a nut onto a wire guide for screws B 5.0 mm until the hex stops flush against the head of the wire guide. Choose an appropriate insertion handle (left or right). Insert an assembled wire guide with nut in the insertion handle and thread it into the corresponding locking hole B 5.0 mm in the distal plate head. Finger-tighten the wire guide into the plate. In the same manner, thread at least one additional wire guide with nut into the plate. Place as many assemblies into the plate as necessary for wire guides. Notes: Two wire guides with nuts must remain threaded into the plate head to maintain the insertion handle/aiming arm connection for subsequent aiming of screws in the shaft. In certain cases (e.g. distal fracture treated with a short plate) it may be advantageous to do the surgery without using an aiming arm. Cortex and locking screws can be inserted by applying the technique described in the LCP Locking Compression Plate surgical technique (DSEM/ TRM/0115/0278). Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 7

10 Surgical Technique Notes It is not necessary to thread the wire guide assemblies into the plate in any particular order. However, it is recommended that one of the wire guide assemblies is placed through the most proximal hole of the insertion handle corresponding with the first combi-hole in the plate shaft. A hexagonal pin wrench may be used to facilitate insertion and removal of the wire guide from the most proximal position. The hole immediately distal to the insertion handle will not accept a wire guide for screws B 5.0 mm and nut due to its proximity to the handle. A percutaneous wire guide is used in this hole. Turn each of the nuts down their wire guide and fingertighten to firmly clamp the insertion handle to the plate. Thread the wire guide for screws B 7.3 mm through the central head hole of the insertion handle and into the central locking head hole B 7.3 mm on the plate. Optional instruments Screwdriver, hexagonal, for Cannulated Screws B 6.5 and 7.3 mm, for Screw Removal Screwdriver, hexagonal, cannulated, for Cannulated Screws B 6.5 and 7.3 mm A hexagonal screwdriver can be used to facilitate insertion and removal of wire guides. 8 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

11 3 Make incision Lateral incision A lateral incision is recommended when a simple articular (AO classification 33-C1) or extra-articular fracture (AO classification 32- or 33-A) is present. The skin incision starts at Gurdy s tubercle and extends about 80 mm in a proximal d i r e c t i o n. Precaution: The incision can be extended if necessary to im prove visualization of the articular surface or lateral metaphy sis and diaphysis. It may not always be appropriate to use limited incisions and closed reduction techniques. Lateral parapatellar incision In the presence of a complex intra-articular fracture (AO classifications 33-C2 or C3), perform a lateral parapatellar approach. Perform an arthrotomy to expose the joint for reduction. Evert the patella and extend the incision for adequate exposure of the joint for reduction and anatomic fixation. Lateral Lateral parapatellar Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 9

12 Surgical Technique 4 Reduce articular surface Instruments Countersink, large, length 180 mm, for Cortex Screws B 4.5 mm Guide for LCP Condylar Plate, right Guide for LCP Condylar Plate, left Reduce and temporarily secure the articular fragments with pointed reduction forceps and/ or Kirschner wires. If a posterior Hoffa fragment is present, it must be reduced and provisionally stabilized with Kirschner wires inserted from anterior to posterior. Secure the condyles with appropriately placed bone screws. The guide for LCP Condylar Plate, or the plate itself, may be held laterally on the condyle to select an area where the screw(s) will not interfere with plate placement. For fixation of a posterior articular fragment (Hoffa fracture), place cortex screws or cancellous bone screws from anterior to posterior and countersink the screw heads so they lie below the level of the articular cartilage. It may occasionally be necessary to reposition one of these screws to avoid impingement on screws placed through the plate, considered essential for fixation. Precaution: Kirschner wires are single use items, do not reuse. 11 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

13 5 Insert plate Using the insertion handle assembly, insert the plate submuscularly distal-to-proximal. Slide the plate proximally until the plate head is oriented properly on the lateral condyle. Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 11

14 Surgical Technique 6 Determine plate position Place a Kirschner wire across the femoral condyles at the level of the knee to indicate the joint axis. Place a second Kirschner wire across the patellofemoral joint on the trochlear surface. 7 Insert cannulated screws B 5.0 and 7.3 mm in plate head Instruments Wire Guide B 2.5, for Locking Screws B 5.0, for Cannulated Locking Screws B 5.0 mm and for Cannulated Conical Screws B 5.0 mm Guide Wire B 2.5 mm, with drill tip, length 300 mm, Cobalt-Chrome Alloy (Co Cr W N i ) or Guide Wire B 2.5 mm, with drill tip, length 300 mm, Cobalt-Chrome Alloy 11 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

15 Screwdriver, hexagonal, cannulated, for Cannulated Screws B 6.5 and 7.3 mm Screwdriver Shaft, hexagonal, cannulated Measuring Device for Cannulated Locking Screws and Cannulated Conical Screws B 5.0 and 7.3 mm Direct Measuring Device, percutaneous Wire Guide 5.0, percutaneous, for Guide Wire B 2.5 mm Notes: Although screws may be inserted in any order, it is usually advantageous to start with the central screw B 7.3 mm. Before proceeding, confirm plate head placement. Use clinical examination and image intensifier control to confirm that the plate is properly oriented on the condyle under the lateral image. Because the shaft of the femur is frequently out of alignment with the distal fragment, proper plate placement can be determined by orienting the distal plate shape to that of the condyle. Placement of the plate on the condyle at this point will determine final flexion/extension reduction. The plate should be oriented so that the shape mimics the condyle anteriorly and posteriorly (1). 1 Secure the plate position on the lateral femoral condyle with at least three guide wires before inserting the first screw. Lag screw external to the plate Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 11

16 Surgical Technique Precaution: Take into consideration that the most posterior distal screw hole B 5.0 may be positioned distal to Blumensaat s line, requiring a unicondylar screw (2, 3). 2 3 Note: If the plate shifts during screw insertion, the guide wires must be removed and reinserted for the screws to lock to the plate properly. Advance a guide wire through a wire guide for screws B 5.0 mm until it reaches the medial wall of the femoral condyle. Measure for screw length using the measuring device for cannulated screws. For proper screw length measurement, the measuring device must contact the end of the wire guide. This will place the tip of the screw at the tip of the guide wire. Notes: If it is desired to place a cannulated locking screw in the hole immediately distal to the insertion handle, a percutaneous wire guide can be used. Measure for screw length using the percutaneous direct measuring device. The self-drilling, self-tapping flutes of the cannulated locking screws B 5.0 mm and 7.3 mm make predrilling and pretapping unnecessary in most cases. In dense bone, the lateral cortex can be predrilled, if necessary. 11 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

17 Optional instruments Drill Bit B 5.0 mm, cannulated, length 200 mm, with Quick Coupling Drill Bit B 4.3 mm, cannulated, length 200 mm, with Quick Coupling Torque Limiter, 4 Nm, for AO/ASIF Quick Coupling for Reamers Using the cannulated hexagonal screwdriver, remove a wire guide assembly and insert the appropriate length screw over the guide wire and into the bone. Locking screws may be inserted using power equipment and the torque limiter. However, final tightening should be done by hand. Precaution: Two wire guides for screws B 5.0 mm with nuts must remain threaded into the plate head to maintain the insertion handle/aiming arm connection for subsequent aiming of screws in the shaft. Warning: If the torque limiter is unavailable, do not tighten the screws to the plate under power. Perform final tightening by hand. Note: If required, lag screw reduction of a fragment must be accomplished before inserting locking screws into the fragment. Lag screw reduction can be accomplished using the partially threaded cannulated conical screws B 5.0 mm or 7.3 mm. Conical screws may be replaced with locking screws after reduction is complete. Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 11

18 Surgical Technique 8 Secure aiming arm to plate Instruments Insertion Handle for Aiming Arm for LCP Condylar Plate 4.5/5.0, curved, right Aiming Arm for LCP Condylar Plate 4.5/5.0, curved, right Insertion Handle for Aiming Arm for LCP Condylar Plate 4.5/5.0, curved, left Aiming Arm for LCP Condylar Plate 4.5/5.0, curved, left Guide Sleeve for Periarticular Aiming Arm Instruments Trocar with Handle for No Attach the appropriate aiming arm onto the insertion handle for aiming arm for LCP Condylar Plate 4.5/5.0. Finger-tighten the connecting bolt to secure the aiming arm to the insertion handle. Locate the hole in the aiming arm that corresponds with the most proximal combi-hole in the plate. The aiming arm is numbered to facilitate locating the most proximal hole in the plate. Make a small skin incision at this location. 11 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

19 Optional instrument Scalpel Handle for Periarticular Aiming Arm Instruments Attach a blade to the scalpel holding end of the handle. The scalpel handle will pass through the aiming arm holes and assist in performing a minimally invasive and accurate incision. (The scalpel handle, with a #10 blade, will only travel through the aiming arm as far as the top edge of the plate.) Remove the scalpel from the aiming arm. Precaution: Always remove the scalpel blade before storage in the case. Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 11

20 Surgical Technique Insert the trocar with handle into a guide sleeve for periarticular aiming arm instruments and align the self-retaining features until the trocar snaps into place within the guide sleeve. Orient the arrow on the guide sleeve in the direction of the LOCKING SCREW arrow on the aiming arm, and then use the assembled trocar and guide sleeve to push down to the plate through the incision. 11 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

21 Push the assembly completely down, aligning the self-retaining features, until it snaps into the aiming arm. Remove the trocar with handle by gently depressing its release mechanism and slowly pulling it away from the guide sleeve. Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 11

22 Surgical Technique Instruments Handle for Nos and Guide Wire B 2.5 mm, with drill tip, length 300 mm, Cobalt-Chrome Alloy (Co Cr W N i ) or Guide Wire B 2.5 mm, with drill tip, length 300 mm, Cobalt-Chrome Alloy Wire Guide 5.0, percutaneous, for Guide Wire B 2.5 mm Thread the handle for percutaneous drill guide into the percutaneous wire guide 5.0. Insert the handle and wire guide assembly through the guide sleeve, and securely thread it into the plate. Turn the handle counterclockwise to disengage and remove it from the wire guide. Precaution: Be sure to securely tighten the wire guide to the plate to achieve a stable construct between the aiming arm and the plate. Insert a guide wire B 2.5 mm into the bone through the percutaneous wire guide. Alternative instruments Drill Guide B 4.3 mm, percutaneous, with thread Drill Bit B 4.3 mm, percutaneous, calibrated, length 300/200 mm, for Quick Coupling Using the appropriate diameter drill bit, drill through the drill guide to the far cortex, leaving the drill bit in place to stabilize the proximal portion of the plate on the bone. 22 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

23 9 Use of pull reduction device (optional) Instruments Guide Sleeve for Periarticular Aiming Arm Instruments Pull Reduction Device for Percutaneous Drill Guide B 4.3 mm, with Nut Combination Wrench B 11.0 mm Drill Guide B 4.3 mm, percutaneous, with thread Additional correction can be completed prior to placement of screws in both main fracture fragments. The pull reduction device with quick coupling is placed through the guide and plate holes to pull or push bone fragments in relation to the plate. This instrument can be used for: Minor varus-valgus adjustment (approximately 2 4 ) Translational adjustments Stabilization of plate-bone orientation during insertion of the first screws Alignment of segmental fragments Predrilling dense or thick cortical bone before placing a locking screw B 5.0 mm Note: The pull reduction device must be used with a percutaneous drill guide B 4.3 mm and a guide sleeve. Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 22

24 Surgical Technique Thread the nut for pull reduction device over the drill tip of the pull reduction device. When the pull reduction device has been attached to a power tool (quick coupling), insert it through a percutaneous drill guide B 4.3 mm that has already been threaded into the plate. With the nut in its highest position possible, begin power insertion of the pull reduction device. Stop insertion before the end of the threaded portion meets the plate surface. Precaution: Attempting to advance beyond this point may cause threads to strip in bone. Remove the power tool and begin tightening the nut toward the drill guide, while monitoring progress under image intensifier control. The combination wrench can facilitate tightening. Stop when the desired reduction is achieved. The pull reduction device is 4.3 mm in diameter and calibrated for screw length measurement to allow later placement of a locking screw B 5.0 mm in the same hole. Optional instrument Stopper for Periarticular Aiming Arm Instruments Mark each screw location in the aiming arm using a stopper for reference as screw insertion proceeds. 22 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

25 10 Insert cortex screws B 4.5 mm Instruments Screwdriver Shaft 3.5, hexagonal, Stardrive T25 and Handle for Screwdriver Shaft 3.5, hexagonal, Stardrive T Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling or Screwdriver Shaft, hexagonal, large, B 3.5 mm, length 165 mm, for Quick Coupling Guide Sleeve for Periarticular Aiming Arm Instruments Trocar with Handle for No Drill Sleeve B 3.2 mm, for neutral position, for Periarticular Aiming Arm Instruments Drill Sleeve B 3.2 mm, for load position, for Periarticular Aiming Arm Instruments Drill Bit B 3.2 mm, percutaneous, calibrated, length 300/200 mm, for Quick Coupling Choose an aiming arm hole through which to make an appropriate incision. Create an incision. As described on page 18, assemble a trocar with handle and guide sleeve. Orient the arrow on the guide sleeve in the direction of the CORTEX SCREW arrow on the aiming arm, and then use the assembled trocar and guide sleeve to stab down to the plate through the chosen aiming arm hole and corresponding incision. Note: If a combination of cortex (1) and locking screws (2) is used, a cortex screw should be inserted first to pull the plate to the bone. If locking screws (1) have been used to fix the plate to a fragment, subsequent insertion of a standard screw (2) in the same fragment without loosening and retightening the locking screws is not recommended. Neutral Compression Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 22

26 Surgical Technique Push the assembly completely down until it snaps into the self-retaining feature of the aiming arm. Remove the trocar with handle by depressing its release mechanism and pulling it away from the guide sleeve. Choose an appropriate drill sleeve, neutral or load, and insert it into the guide sleeve while aligning the self-retaining features until it snaps into place. When using the drill sleeve B 3.2 mm for load position, orient the sleeve s directional arrow in the direction of the CORTEX SCREW arrow on the aiming arm. Use the percutaneous drill bit B 3.2 mm to drill and determine screw length from the drill bit calibration aligned with the top of the drill sleeve. Remove the drill bit. 22 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

27 Alternative instrument Direct Measuring Device, percutaneous Place the percutaneous direct measuring device over the drill bit and against the end of the drill sleeve. Determine screw length from the end of the drill bit. Remove the drill sleeve and insert screw using the screwdriver shaft with handle. Repeat this process to insert as many cortex screws B 4.5 mm as necessary into the plate shaft. Option Mark each screw location in the aiming arm using a stopper for reference as screw insertion proceeds. Precaution: All of the cortex screws B 4.5 mm must be inserted before insertion of locking screws. Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 22

28 Surgical Technique 11 Insert locking screws B 5.0 mm Instruments Screwdriver Shaft 3.5, hexagonal, Stardrive T25 and Handle for Screwdriver Shaft 3.5, hexagonal, Stardrive T Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling or Screwdriver Shaft, hexagonal, large, B 3.5 mm, length 165 mm, for Quick Coupling Guide Sleeve for Periarticular Aiming Arm Instruments Trocar with Handle for No Handle for Nos and Hexagonal Pin Wrench B 4.0 mm with ball tip Drill Guide B 4.3 mm, percutaneous, with thread Drill Bit B 4.3 mm, percutaneous, calibrated, length 300/200 mm, for Quick Coupling Torque Limiter, 4 Nm, for AO/ASIF Quick Coupling for Reamers Choose an aiming arm hole through which to make an appropriate incision. Create an incision. As described on page 18, assemble a trocar with handle and guide sleeve. 22 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

29 Orient the arrow on the guide sleeve in the direction of the «LOCKING» arrow on the aiming arm, and then use the assembled trocar and guide sleeve to stab down to the plate through the chosen aiming arm hole and corresponding incision. Push the assembly completely down until it snaps into the self-retaining feature of the aiming arm. Remove the trocar by depressing its release mechanism and pulling it away from the guide sleeve. Thread the handle for percutaneous drill guide into an appropriate percutaneous drill guide. For locking screws B 5.0 mm, use the percutaneous drill guide B 4.3 mm. Insert the handle and percutaneous drill guide assembly through the guide sleeve, and thread it into the plate. Turn the handle counterclockwise to disengage and remove it from the drill guide. Drill using the appropriate percutaneous drill bit. Determine screw length from the drill bit calibration aligned with the top of the drill guide. Alternative instrument Direct Measuring Device, percutaneous Place the percutaneous direct measuring device over the drill bit and against the end of the drill guide. Determine screw length from the end of the drill bit. Remove the drill bit. Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 22

30 Surgical Technique Remove the drill guide. Notes: Use the tip of the handle for percutaneous drill guide as a pin wrench to loosen the drill guides from the plate. The hexagonal pin wrench B 4.0 mm can also be used. Insert a screw using the screwdriver shaft with handle or screwdriver shaft. Option Mark each screw location in the guide, using a stopper for reference as screw insertion proceeds. 22 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

31 Repeat this process to insert as many locking screws B 5.0 mm into the plate shaft as necessary. 12 Remove aiming arm and insertion handle Remove all guide sleeves. Turn the connecting bolt on the aiming arm counterclockwise to loosen and remove the aiming arm from the insertion handle. As desired, insert guide wires B 2.5 mm and measure for remaining screws in the plate head where wire guides for screws B 5.0 mm were maintained. Remove the wire guide assemblies from the plate head and insert the remaining screws. Remove the insertion handle and any remaining guide wires. Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 22

32 Surgical Technique Cleaning Instructions Instrument Cleaning Stylet B 2.5 mm, for Cannulated Instruments Cleaning the cannulation in each instrument is imperative for proper function. Instruments should be cleared intraoperatively using the cleaning stylet to prevent accumulation of debris in the cannulation and potential binding of the instruments about the guide wire. 33 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

33 Plates LCP Condylar Plates 4.5/5.0 Stainless steel Holes Length (mm) right right right right right right right left left left left left left left Additionally available (only sterile packed) Stainless steel Holes Length (mm) S right S right S left S left All plates are available sterile packed. For sterile implants add suffix S to article number. Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 33

34 Screws Used with the LCP Condylar Plate 4.5/5.0 Cannulated Locking Screw B 7.3 mm Creates a locked, fixed-angle screw/plate construct Threaded conical head Fully threaded shaft Self-drilling, self-tapping tip Cannulated Conical Screw B 7.3 mm Compresses the plate to the lateral femoral condyle Smooth conical head Fully threaded shaft Self-drilling, self-tapping tip Cannulated Conical Screw B 7.3 mm, partially threaded Compresses the plate to the lateral femoral condyle and provides interfragmentary compression Smooth conical head Partially threaded shaft Self-drilling, self-tapping tip Locking Screw B 5.0 mm Creates a locked, fixed-angle screw/plate construct Threaded conical head Fully threaded shaft Self-tapping tip Cannulated Locking Screw B 5.0 mm Creates a locked, fixed-angle screw/plate construct Threaded conical head Fully threaded shaft Self-drilling, self-tapping tip 33 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

35 Cannulated Conical Screw B 5.0 mm Compresses the plate to the lateral femoral condyle and provides interfragmentary compression Smooth conical head Partially threaded shaft Self-drilling, self-tapping tip Screw Nut B 5.0 mm Offers additional fixation and compression options for complex fractures Self-cutting, serrated tip Inserted from the medial aspect of the distal femur Internal threads mate with the cannulated conical screw B 5.0 mm Cortex Screw B 4.5 mm Compresses the plate to the bone or creates axial compression May be used in the DCU portion of the combi-holes in the plate shaft Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 33

36 Periarticular Aiming Arm Instruments Insertion Handle for Aiming Arm for LCP Condylar Plate 4.5/5.0, curved, right Aiming Arm, for LCP Condylar Plate 4.5/5.0, curved, right Insertion Handle for Aiming Arm for LCP Condylar Plate 4.5/5.0, curved, left Aiming Arm, for LCP Condylar Plate 4.5/5.0, curved, left Aiming Arm, for LCP Proximal Tibial Plate 4.5/5.0, right Insertion Handle for Aiming Arm for LCP Proximal Tibial Plate 4.5/5.0, right 33 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

37 Angled Aiming Guide for No , right Aiming Arm, for LCP Proximal Tibial Plate 4.5/5.0, left Insertion Handle for Aiming Arm for LCP Proximal Tibial Plate 4.5/5.0, left Angled Aiming Guide for No , left Connecting Bolt for Nos and Guide Sleeve for Periarticular Aiming Arm Instruments Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 33

38 Periarticular Aiming Arm Instruments Trocar with Handle for No Scalpel Handle for Periarticular Aiming Arm Instruments Drill Sleeve B 3.2 mm, for neutral position, for Periarticular Aiming Arm Instruments Drill Sleeve B 3.2 mm, for load position, for Periarticular Aiming Arm Instruments Wire Guide B 2.5, for Cannulated Locking Screws B 7.3 mm and Cann. Conical Screws B 7.3 mm Wire Guide B 2.5, for Lock. Screws B 5.0, for Cannulated Locking Screws B 5.0 mm and for Cann. Conical Screws B 5.0 mm Nut for No DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

39 Handle for Nos and Pull Reduction Device for Percutaneous Drill Guide B 4.3 mm, with Nut Nut for No Stopper for Periarticular Aiming Arm Instruments Guide Wire B 2.5 mm, with drill tip, length 300 mm, Cobalt-chrome alloy (CoCrWNi) Locking Bolt, for Nos and length 151 mm Hexagonal Pin Wrench B 4.0 mm with ball tip Connecting Bolt for Aiming Arm for Periarticular Aiming Arm Instruments Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 33

40 Periarticular Aiming Arm Instruments Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling Screwdriver Shaft, hexagonal, large, B 3.5 mm, length 165 mm, for Quick Coupling Combination Wrench B 11.0 mm Drill Guide B 4.3 mm, percutaneous, with thread Direct Measuring Device, percutaneous Drill Bit B 3.2 mm, percutaneous, calibrated, length 300/200 mm, for Quick Coupling Drill Bit B 4.3 mm, percutaneous, calibrated, length 300/200 mm, for Quick Coupling Wire Guide 5.0, percutaneous, for Guide Wire B 2.5 mm Guide Wire B 2.5 mm, with drill tip, length 300 mm, Cobalt-Chrome Alloy 33 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

41 Sets Periarticular Aiming Arm Instruments for LCP Condylar Plate 4.5/5.0 and LCP Proximal Tibial Plate 4.5/5.0, in Vario Case Vario Case for Periarticular Aiming Arm Instruments, size 1/1, without Contents Modular Tray 1, for Periarticular Aiming Arm Instruments, size 1/1, without Contents, Vario Case System Modular Tray 2, for Periarticular Aiming Arm Instruments, size 1/1, without Contents, Vario Case System Periarticular Instruments in Vario Case Modular Tray for Periarticular Instruments, size 1/1, without Contents, Vario Case System Vario Case for Periarticular Instruments, size 1/1, without Contents Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 33

42 Sets LCP Condylar Plates 4.5/5.0 (Stainless Steel) in Modular Trays, Vario Case System Modular Tray for LCP Condylar Plates 4.5/5.0, short plates, size 1/1, without Contents, Vario Case System Modular Tray for LCP Condylar Plates 4.5/5.0, long Plates, size 1/1, without Contents, Vario Case System Modular Large Fragment Screw Rack Modular Insert, for Modular Screw Rack, for Screws B 5.0 mm, size 1/3, without Contents, Vario Case System Modular Insert, for Modular Screw Rack, for Screws B 4.5 mm, size 1/3, without Contents, Vario Case System Modular Insert, for Modular Screw Rack, for Screws B 6.5 mm, size 1/3, without Contents, Vario Case System 44 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

43 Modular Insert, for Modular Screw Rack, for Screws B 7.3 mm, size 1/3, without Contents, Vario Case System Modular Screw Rack, with Drawer, Measuring Block and Lid, length 200 mm, height 115 mm, size 1/2, without Contents, Vario Case System Auxiliary Modular Insert, for Modular Screw Rack, size 1/3, without Contents, Vario Case System Auxiliary Module, size 1/3, height 14 mm, for Screw Rack, size 1/ Auxiliary Module, size 1/3, height 28 mm, for Screw Rack, size 1/2 Additionally required LCP Large Fragment Instrument Set Recommended LCP Large Fragment Instruments and Standard Instruments in Vario Case LCP Large Fragment Instruments and Standard Instruments, in Vario Case constisting of Modular Tray for LCP Large Fragment Instruments, size 1/1, without Contents, Vario Case System and Modular Tray for Large Fragment Standard Instruments, size 1/1, without Contents, Vario Case System Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique DePuy Synthes 44

44 MRI Information Torque, Displacement and Image Artifacts according to ASTM F , ASTM F e1 and ASTM F Non-clinical testing of worst case scenario in a 3 T MRI system did not reveal any relevant torque or displacement of the construct for an experimentally measured local spatial gradient of the magnetic field of 3.69 T/m. The largest image artifact extended approximately 169 mm from the construct when scanned using the Gradient Echo (GE). Testing was conducted on a 3 T MRI system. Radio-Frequency-(RF-)induced heating according to ASTM F a Non-clinical electromagnetic and thermal testing of worst case scenario lead to peak temperature rise of 9.5 C with an average temperature rise of 6.6 C (1.5 T) and a peak temperature rise of 5.9 C (3 T) under MRI Conditions using RF Coils (whole body averaged specific absorption rate [SAR] of 2 W/kg for 6 minutes [1.5 T] and for 15 minutes [3 T]). Precautions: The above mentioned test relies on non-clini - cal testing. The actual temperature rise in the patient will depend on a variety of factors beyond the SAR and time of RF application. Thus, it is recommended to pay particular attention to the following points: It is recommended to thoroughly monitor patients undergoing MR scanning for perceived temperature and/or pain sensations. Patients with impaired thermoregulation or temperature sensation should be excluded from MR scanning proce - dures. Generally, it is recommended to use a MR system with low field strength in the presence of conductive implants. The employed specific absorption rate (SAR) should be reduced as far as possible. Using the ventilation system may further contribute to reduce temperature increase in the body. 44 DePuy Synthes Periarticular Aiming Arm Instruments for LCP Condylar Plate 4 Surgical Technique

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48 DSEM/TRM/0815/0460(1) 09/16 Synthes GmbH Eimattstrasse Oberdorf Switzerland Tel: Fax: Not all products are currently available in all markets. This publication is not intended for distribution in the USA. All surgical techniques are available as PDF files at DePuy Synthes Trauma, a division of Synthes GmbH All rights reserved