Expert ALFN. Adolescent Lateral Femoral Nail

Transcription

1 Expert ALFN. Adolescent Lateral Femoral Nail Surgical Technique EXPERT Nailing System This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation

2 Image intensifier control Warning This description alone does not provide sufficient background for direct use of the instrument set. Instruction by a surgeon experienced in handling these instruments is highly recommended. Reprocessing, Care and Maintenance of Synthes Instruments For general guidelines, function control and dismantling of multi-part instruments, please refer to: Cleaning of instruments: For detailed information please refer to Reprocessing, Care and Maintenance of Synthes Instruments, Article No For more information about alternative Expert Nail Instruments, please consult pages

3 TABLE OF CONTENTS INTRODUCTION Expert ALFN 2 AO Principles 4 Indications 5 Clinical Cases 6 SURGICAL TECHNIQUE Preoperative Planning 10 Opening the Femur 13 Inserting the Nail 21 Locking Options 26 Proximal Locking Standard 28 Recon (Optional) 32 Distal Locking 37 End Cap Insertion 42 Implant Removal 44 PRODUCT INFORMATION Implants 50 Instruments 54 Comparison Table 65 Handling Information 67 Set List 69 Modular Cases 69 Vario Cases 73 Optional: Angular Stable Locking System (ASLS) 77 Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 1

4 EXPERT ALFN ADOLESCENT LATERAL FEMORAL NAIL SYSTEM Nail features Design accommodates a lateral entry site through the greater trochanter Anatomic nail design based on a femoral canal study* Titanium cannulated nail for reamed or unreamed techniques Lengths from 240 mm to 400 mm, in 20 mm increments Designed for use in patients where Titanium Elastic Nails are not large enough and the Expert Lateral Femoral Nail for adults is too large 8.2 mm, 9 mm, and 10 mm diameter nails with 11 mm diameter proximal ends Improved instrumentation Easy-to-use instrumentation facilitates the surgical procedure Ball-tip reaming rod can be removed through the nail and the insertion instruments, eliminating the need for an exchange tube Tailored to the needs of clinic (available as upgrade set for adolescents to Expert Lateral Femoral System for adults or Standard Instrument Set for Expert Adolescent Lateral Femoral Nail) End caps Prevent ingrowth of tissue and facilitate nail extraction Self-retaining, T40 Stardrive recess for easy pickup and insertion of the end cap Cannulated for insertion over a guide wire 0 mm end cap sits flush with the nail 5 mm, 10 mm, and 15 mm end caps extend nail height if the nail is overinserted * Ehmke L, Polzin B, Roth C, Bottlang M (2006) Femoral Nailing Through the Trochanter: The Reamer Pathway Indicates A Helical Shape. Journal of Orthopedic Trauma Vol. 20 (Number 10): DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

5 Standard locking screws Double-lead thread for ease of insertion Thread closer to screw head provides better bone purchase in the near cortex and improved stability Titanium alloy* for improved mechanical and fatigue properties Self-tapping blunt tip Self-retaining T25 Stardrive recess allows improved torque transmission, increased resistance to stripping relative to a hex recess, and secure locking screw pickup 4.0 mm diameter 5.0 mm hip screws Lengths from 50 mm to 125 mm in 5 mm increments Self-retaining T25 Stardrive recess Titanium alloy* * Titanium 6% aluminum 7% niobium alloy Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 3

6 AO PRINCIPLES In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation 1, 2. 4_Priciples_03.pdf :08 Anatomic reduction Fracture reduction and fixation to restore anatomical relationships. 1 2 Stable fixation Fracture fixation providing absolute or relative stability, as required by the patient, the injury, and the personality of the fracture. Early, active mobilization Early and safe mobilization and rehabilitation of the injured part and the patient as a whole. 4 3 Preservation of blood supply Preservation of the blood supply to soft tissues and bone by gentle reduction techniques and 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 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

7 INDICATIONS The Expert Adolescent Lateral Femoral Nail is indicated for use in adolescent and small-stature adult patients to stabilize: Fractures of the femoral shaft Subtrochanteric fractures Ipsilateral neck/shaft fractures Impending pathologic fractures Nonunions and malunions Note: ASLS, the Angular Stable Locking System, is indicated in cases where increased stability is needed in fractures closer to the metaphyseal area or in poor quality bone. For more details regarding the intramedullary fixator principle, please consult the ASLS technique guide ( ) and concept flyer ( ). Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 5

8 CLINICAL CASES Case 1 standard transverse locking 16-year-old female, 45 kg Isolated transverse femoral shaft fracture Preoperative Case 2 antegrade locking 15-year-old male, 55 kg Oblique midshaft femoral shaft fracture Preoperative 1 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

9 Intraoperative Follow-up (6 weeks after surgery) Postoperative Follow-up (4 months after surgery) Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 1

10 Clinical Cases Case 3 recon locking 12-year-old male, 43 kg Pathologic proximal femoral shaft fracture Preoperative Case 4 distal locking 12-year-old male, 30 kg Oblique distal third femoral shaft fracture Preoperative 8 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

11 Postoperative Follow-up (3 weeks after surgery) Postoperative Follow-up (1 month after surgery) Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 9

12 PREOPERATIVE PLANNING Use the AO preoperative planner templates for the Expert Adolescent Lateral Femoral Nail ( /605) to estimate nail length and medullary canal diameter. To estimate medullary canal diameter, place the template on the AP or lateral x-ray of the femur and measure the dia meter 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 femur and select the appropriate nail length based on patient anatomy. When selecting nail size, consider canal diameter, fracture pattern, patient anatomy and postoperative protocol. Expert Adolescent Lateral Entry Femoral Nail for Right Femur 8.2 mm, 9 mm and 10 mm diameter 240 mm to 400 mm lengths A-P View 15 mm 10 mm 5 mm 0 mm 15 mm 10 mm End Caps 5 mm 0 mm 8.2 mm 9 mm 10 mm 240 mm Lateral View Locking Screw Stardrive 4.0 mm, TAN [ ] Hip Screw Stardrive 5.0 mm, TAN [ ] 1.0 Magnification mm Synthes GmbH Eimattstrasse 3 For use only with the Original AO System of CH-4436 Oberdorf Instruments and Implants mm 9 mm 10 mm 240 mm 260 mm 260 mm 280 mm 280 mm 300 mm 300 mm 320 mm 320 mm 340 mm 340 mm 360 mm 360 mm 380 mm 380 mm Expert Adolescent Lateral Entry Femoral Nail 400 mm for Right Femur 400 mm Ö _AAjä AA /2009 Synthes, Inc. or its affiliates All rights reserved Synthes and Expert are trademarks of Synthes, Inc. or its affiliates 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. 1 Position patient Position the patient in the lateral decubitus or supine position on a fracture table or radiolucent operating table. Position the C-arm to allow visualization of the proximal femur in both the AP and lateral planes. To facilitate access to the medullary canal, abduct the upper part of the body approximately to the contralateral side and adduct the affected limb by Affected leg 10º 15º adduction 11 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

13 2 Reduce fracture Instrument Large Distractor* Perform closed reduction manually by axial traction under image intensifier control. The use of the large distractor may be appropriate in certain circumstances. 3 Confirm nail length Instrument Radiographic Ruler for Expert Femoral Nails The required nail length must be determined after reduction of the femoral fracture. Position the C-arm for an AP view of the proximal femur. With long forceps, hold the ruler alongside the lateral thigh, parallel to and at the same level as the femur. Adjust the ruler until the proximal end is at the desired nail insertion * Additional available Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 11

14 Preoperative Planning Move the C-arm to the distal femur. Verify fracture reduction. Align the proximal end of the radiographic ruler to the skin mark, and take an AP image of the distal femur. Read nail length directly from the ruler image, selecting the measurement proximal to the epiphysis, or at the chosen insertion depth. Note: It is recommended to treat the fracture with the longest nail possible without crossing the physis, taking into account patient anatomy or a previous implant. The distal end of the nail should be 15 mm from the physis. Back-hammering or dynamization to close a fracture gap must be taken into account when determining the nail length. A shorter nail should be chosen when back-hammering or dynamization is planned. The dynamic slot allows 7 mm of movement. 4 Confirm canal diameter Instrument Radiographic Ruler for Nail Diameters for Expert Femoral Nails The required nail length must be determined after reduction of the femoral fracture. Position the C-arm for an AP or lateral view of the femur at the level of the isthmus. Hold the radiographic canal width estimator over the femur with the diameter gauge centered over the narrowest part of the medullary canal. Read the estimated diameter measurement on the circular indicator that fills the canal. Note: If the reamed technique is used, the diameter of the largest medullary reamer must be at least 1.0 mm greater than the nail diameter. 11 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

15 OPENING THE FEMUR 1 Approach Palpate the posterior edge of the greater trochanter. Make a 3 cm incision in line with the central axis of the intramedullary canal in the lateral view, and depending on the anatomy of the patient, 2 5 cm proximal to the tip of the greater trochanter. 2 Determine entry point 12 The insertion point is 12 lateral to the greater trochanter, as measured from a point 20 mm distal to the lesser trochanter. The entry point can also be described as lateral to the greater trochanter at the same level as the superior aspect of the base of the femoral neck (just above the piriformis fossa). This point can be found by extending a line horizontally from the base of the femoral neck to the lateral side of the femur. 20 mm Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 11

16 Opening the Femur 3 Insert guide wire Instruments Handle, with Quick Coupling and Protection Sleeve 13.0 for Expert Adolescent Lateral Femoral Nail, with Quick Coupling and Multihole Drill Guide for Protection Sleeve 13.0 or Drill Sleeve 13.0/3.2, for antegrade approach, for No and Protection Sleeve 13.0, for antegrade approach and Protection Sleeve 13.0, for antegrade approach Guide Wire B 3.2 mm, length 400 mm Insert the protection sleeve, wire guide and trocar assembly into the incision site and to the bone. Remove the trocar. Insert the guide wire through the wire guide. The guide wire must be inserted laterally at an angle of 12 to the center of the medullary canal. The tip of the guide wire should be centered in the medullary canal 20 mm distal to the lesser trochanter. Verify that the guide wire position allows adequate clearance on the lateral side of the femur for the opening drill bit. The guide wire is inserted with it centered in the lateral view. 11 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

17 4 Open proximal femur to medullary canal Required set SynReam Intramedullary Reaming System in Vario Case Instruments Protection Sleeve 15.5 mm/13.7 mm, length mm or Multihole Drill Guide for Protection Sleeve 13.0 and Handle, with Quick Coupling Drill Bit B 13.0 mm, cannulated, length 290 mm, 3-flute, for Quick Coupling No S Reaming Rod B 2.5 mm, length 950 mm, with Olive, sterile S Reaming Rod B 2.5 mm, length 950 mm, with Olive and extension, sterile or SynReam Reaming Rod B 2.5 mm. short, length 950 mm SynReam Reaming Rod B 2.5 mm, long, length 1150 mm Drill to open cortex Drill through the protection sleeve. Drill the cortex until the drill bit stops in the sleeve. Remove the guide wire, drill bit and protection sleeve. 75 mm Precaution: Dispose of the guide wire. Do not reuse. If reaming the medullary canal, proceed to page 17. Ream to open proximal femur Insert the 2.5 mm reaming rod. Using the flexible reamers, open the proximal femur to a depth of approximately 75 mm, starting with an 8.5 mm reamer and ending with a 13.0 mm reamer. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 11

18 Opening the Femur Alternative technique (with awl) Alternative instruments Awl B 14.0/3.2 mm, cannulated Guide Wire B 3.2 mm, length 400 mm Place the cannulated awl over the guide wire and open the medullary canal. Use a twisting motion to advance the awl to a depth of approximately 75 mm. Remove the guide wire and awl. Precaution: After opening the proximal femur, dispose of the guide wire. Do not reuse. 11 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

19 5 Ream medullary canal (optional) Required set SynReam Intramedullary Reaming System in Vario Case Instruments Rod Pusher for Reaming Rod with Hexagonal Screwdriver B 8.0 mm S Reaming Rod B 2.5 mm, length 950 mm, with Olive, sterile S Reaming Rod B 2.5 mm, length 950 mm, with Olive and extension, sterile or SynReam Reaming Rod B 2.5 mm. short, length 950 mm SynReam Reaming Rod B 2.5 mm, long, length 1150 mm Holding Forceps for SynReam Reaming Rod B 2.5 mm Reduction Instrument for Medullary Nails or T-Handle, cannulated, with Quick Coupling, Hex 12 mm and Intramedullary Reduction Tool, curved, with Quick Coupling, Hex 12 mm Universal Chuck, small, with T-Handle If necessary, enlarge the femoral canal with the medullary reamer. The largest medullary reamer must be at least 1.0 mm greater than the nail diameter. Check fracture reduction under image intensifier. Use the reduction instrument for medullary nails to facilitate reduction. Note: For the detailed reaming procedure, please consult Syn Ream Surgical Technique. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 11

20 Opening the Femur Insert reaming rod Using the T-handle chuck or holding device, insert the reaming rod with ball tip into the medullary canal to the desired depth. 11 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

21 Beginning with the 8.5 mm diameter reaming head, ream to a diameter of at least 1.0 mm greater than the nail diameter. Ream in 0.5 mm increments and advance the reamer with steady, moderate pressure. Do not force the reamer. Partially retract the reamer often to clear debris from the medullary canal. The holding forceps can be used to control the rotation of the reaming rod. Technique tip: The reaming rod with ball tip can be removed through the cannulated adolescent lateral femoral nail. Reaming rod exchange is not required. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 11

22 Opening the Femur Option Use the reaming rod push rod to help retain the reaming rod during reamer extraction. 22 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

23 INSERTING THE NAIL 1 Assemble insertion instruments Instruments Connecting Screw, cannulated, with Internal M6x1 Thread and Insertion Handle, radiolucent, length 100 mm, for Expert ALFN or Connecting Screw, cannulated, for Expert Tibial and Femoral Nails, for No and Insertion Handle for Expert Adolescent Lateral Femoral Nail Rod Pusher for Reaming Rod with Hexagonal Screwdriver B 8.0 mm Screwdriver, hexagonal with spherical head B 8.0 mm or Screwdriver, hexagonal with spherical head B 8.0 mm, with T-Handle Match the tangs on the handle to the notches in the Expert Adolescent Lateral Femoral Nail. Place the connecting screw into the insertion handle and thread it into the proximal nail end, using the 8 mm hexa gonal screwdriver with spherical head. The Expert Adolescent Lateral Femoral Nails are labeled left or right on the proximal nail end. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 22

24 Inserting the Nail Slide the connecting screw onto the reaming rod push rod. Slide the assembly through the insertion handle and match the tangs on the handle to the nail. Tighten using the hex on the reaming rod push rod. Secure the assembly using the 8 mm hexagonal screwdriver with spherical head. 22 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

25 2 Insert nail Instruments Driving Cap with thread, for Insertion Handle and Combined Hammer, 500 g and Hammer Guide or Connector, for Insertion Handle and Combined Hammer 700 g, can be mounted, for No and Hammer Guide, for No Screwdriver, hexagonal with spherical head B 8.0 mm or Screwdriver, hexagonal with spherical head B 8.0 mm, with T-Handle Pin Wrench B 4.5 mm, length 120 mm Combination Wrench B 11.0 mm Shaft, hexagonal, B 8.0 mm, cannulated, short, length 125 mm Slide the connector into the groove on the insertion handle and secure it using the 11 mm ratchet wrench. If patient anatomy allows, attach the driving cap in the medial position. Orient the insertion handle in an anterior position. Use the C-arm to verify fracture reduction. Insert the nail as far as possible. The nail rotates approximately 90 during insertion. The insertion handle rotates from an anterior to a lateral position during insertion of the last one-third of the nail length. If the nail does not rotate to the lateral position, remove the nail and reinsert it with the handle slightly lateral to the sagittal plane. Monitor nail passage across the fracture, and control in two planes to avoid malalignment. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 22

26 Inserting the Nail If desired, insert the nail using light hammer blows. Lock the head of the hammer in place by tightening the nut onto the threads located below the hammer head. Use the pin wrench if necessary. Strike the driving cap directly. Optionally, the hammer guide can be threaded onto the driving cap and the hammer can be used as a slide hammer. Loosen the nut from the threads located below the hammer head and secure the nut onto the threads located above the handle. Precaution: Do not mount the aiming arm until the nail has been completely inserted. 22 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

27 3 Check proximal nail position Insert the nail until it is at or below the femoral opening. Check final nail position under image intensification in AP and lateral views. If primary compression or secondary dynamization is planned, it is recommended to overinsert the nail by more than 7 mm, which corresponds to the maximum distance between the positions in static and dynamic modes. Note: The distance between the markings on the insertion handle is 5 mm and corresponds to the extensions of the end caps. This feature can be used for overinsertion of the nail. 4 Check distal nail location Use image intensification to ensure the nail is centered in both AP and lateral views. Verify fracture alignment. Remove the reaming rod Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 22

28 LOCKING OPTIONS 130 CCD 120 Proximal locking with recon locking Proximal locking with 120 locking screw 22 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

29 Proximal locking with dynamization Proximal locking with static transverse locking screw Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 22

30 PROXIMAL LOCKING STANDARD 1 Choose locking option For standard locking, three targeted proximal locking options are possible: antegrade locking 2 Dynamic locking (LM) 3 Static locking (LM) For immediate dynamization, insert one proximal locking screw through the dynamic slot. If dynamization may be required in the future, use the dynamic locking option with the 120 antegrade locking hole. 2 Mount aiming arm Instruments Screwdriver, hexagonal with spherical head B 8.0 mm or Screwdriver, hexagonal with spherical head B 8.0 mm, with T-Handle Aiming Arm for Expert Adolescent Lateral Femoral Nail or Aiming Arm, radiolucent, for Expert Adolescent Lateral Femoral Nail Confirm that the nail is securely connected to the insertion handle using the 8 mm ball hex screwdriver. Mount the aiming arm to the insertion handle. 22 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

31 3 Insert trocar assembly Instruments Protection Sleeve 12.0/8.0, length 188 mm Drill Sleeve 8.0/3.2, for No Trocar B 3.2 mm, for No Insert the three-part trocar assembly (protection sleeve, drill sleeve and trocar) through the desired hole in the aiming arm, make a stab incision and insert the trocar to the bone. Remove the trocar. If using the 120 antegrade locking option, insert the trocar assembly through the hole labeled 120 on the insertion handle. Precaution: Do not exert forces on the aiming arm, protection sleeve, drill sleeves or drill bits. Such force may prevent accurate targeting through the proximal locking holes and damage the drill bits. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 22

32 Proximal Locking Standard 4 Drill and determine locking screw length Instrument Drill Bit B 3.2 mm, calibrated, length 340 mm, 3-flute, for Quick Ensure that the drill sleeve is pressed firmly to the lateral cortex. Drill through both cortices until the tip of the drill bit just penetrates the far cortex. Confirm drill bit position. Ensure that the drill sleeve is pressed firmly to the lateral cortex and read the measurement from the calibrated drill bit at the back of the drill sleeve. This measurement corresponds to the appropriate length locking screw. Remove the drill bit and drill sleeve. Alternative instrument Depth Gauge for Locking Screws, measuring range up to 110 mm, for No or Depth Gauge for Locking Screws, measuring range to 110 mm After drilling both cortices, remove the drill bit and drill sleeve. Disassemble the depth gauge into two parts: the outer sleeve and the measuring device with hook. Insert the measuring device into the protection sleeve. Make sure that the hook grasps the far cortex. Ensure that the protection sleeve is firmly pressed against the lateral cortex. Read the measurement from the back of the protection sleeve, which indicates the appropriate length locking screw. 33 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

33 Option: Locking with ASLS ASLS, the Angular Stable Locking System, can be used as an alternative to standard locking screws in any round hole of a Synthes cannulated titanium nail. For more details regarding the intramedullary fixator principle please consult the ASLS surgical technique ( ) and concept flyer ( ). Please note that for the use of ASLS special instruments are required. 3 Insert locking screw Instrument Screwdriver Stardrive, T25, length 330 mm or Screwdriver Stardrive, T25, self-holding, length 320 mm Insert the appropriate length locking screw through the protection sleeve using the Stardrive screwdriver. Verify locking screw length under image intensification. The tip of the locking screw should not project more than 2 mm to 4 mm beyond the far cortex. Note: A groove on the screwdriver provides a rough indication that the locking screw is fully inserted through the sleeve. Repeat for a second proximal locking screw if desired. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 33

34 Proximal Locking RECON (OPTIONAL) 1 Confirm nail position In the AP view, adjust the nail insertion depth to ensure that the two hip screws can be placed into the femoral head. Adjust nail position for correct anteversion through the lateral view.. Precaution: Adjusting for the correct anteversion before making a skin incision is crucial to allow uncomplicated guide wire and screw insertion. 2 Mount aiming arm Instruments Screwdriver, hexagonal with spherical head B 8.0 mm or Screwdriver, hexagonal with spherical head B 8.0 mm, with T-Handle Aiming Arm for Expert Adolescent Lateral Femoral Nail or Aiming Arm, radiolucent, for Expert Adolescent Lateral Femoral Nail Confirm that the nail is securely connected to the insertion handle using the screwdriver, hexagonal with spherical head B 8.0 mm. Mount the aiming arm to the insertion handle. 33 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

35 3 Insert guide wires for hip screws Instruments Protection Sleeve 11.5/8.5, for LFN Reconstruction Locking Drill Sleeve 8.5/3.2, for No Trocar B 3.2 mm, for No Guide Wire B 3.2 mm, length 400 mm Insert both three-part trocar combinations (protection sleeve, drill sleeve, and trocar) through the aiming arm. Make a stab incision and insert the trocars to the bone. Following the arrows on the aiming arm, rotate the cams so that the protection sleeves are locked in the aiming arm. This will ensure proper measurement for the hip screws. Remove the inferior trocar. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 33

36 Proximal Locking Recon (Optional) In case of an arrested or closed physis, insert a guide wire into the femoral head, stopping approximately 5 mm from the subchondral bone. If the physis in the femoral head is not fully arrested, stop the wire short of the physis. Check the guide wire placement radiographically in both planes. Remove the superior trocar and repeat steps for second guide wire. Precaution: Do not exert force on the aiming arm, protection sleeves, or drill sleeves. Such force may prevent accurate targeting through the locking holes. 33 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

37 4 Determine length and drill for inferior hip screw Instruments Direct Measuring Device for Guide Wires B 3.2 mm, length 400 mm or Direct Measuring Device for Guide Wires B 3.2 mm, length 400 mm Drill Bit B 3.2 mm, calibrated, length 474 mm, 3-flute, for Mini Quick Coupling, for Hip Screw Stardrive B 5.0 mm Fixation Sleeve, for No Measure for the inferior screw. Ensure the protection sleeve is pressed firmly to the lateral cortex. Remove the wire guide and insert the specialty measuring device over the guide wire, into the protection sleeve, and to the bone. Read the length of the required hip screw directly on the measuring device. Remove the measuring device and the inferior guide wire. Attach the fixation sleeve to the stepped drill bit for the appropriate length screw. Guide the stepped drill bit through the protection sleeve to the bone. Drill to the stop. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 33

38 Proximal Locking Recon (Optional) 5 Insert inferior hip screw Instrument Screwdriver Stardrive, T25, length 330 mm or Screwdriver Stardrive, T25, self-holding, length 440 mm Insert the appropriate hip screw through the protection sleeve into the femoral neck using the long T25 Stardrive screwdriver. Verify the position of the locking screw under image intensification in both planes. A groove on the screwdriver indicates when the locking screw is fully inserted. 6 Insert superior hip screw Repeat steps 3 through 5 for the superior hip screw. 33 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

39 DISTAL LOCKING 1 Distal locking There are two transverse distal locking holes. 2 Align image Check the reduction and correct alignment of the fragments and leg length before locking the nail. Align the C-arm with the hole in the nail closest to the fracture until a perfect circle is visible in the center of the screen. 3 Determine incision point Place a Kirschner wire on the skin over the center of the hole to mark the incision point and make a stab incision. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 33

40 Distal Locking 4 Drill Standard locking with locking screws Instrument Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, for Quick Coupling If using the standard freehand technique, insert the tip of the drill bit through the incision and down to the bone. Incline the drive so that the tip of the drill bit is centered over the locking hole. Hold the drill bit in this position and drill through both cortices. Technique tip: For greater drill bit control, discontinue drill power after perforating the near cortex. Manually guide the drill bit through the nail before resuming power to drill the far cortex. 33 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

41 Alternative instrument Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, with Coupling for RDL Using the radiolucent drive under image intensification, insert the tip of the drill bit through the incision and down to the bone. Incline the drive so that the tip of the drill bit is centered over the locking hole. The drill bit should almost completely fill the circle of the locking hole. Hold the drill bit in this position and drill through both cortices. Option: Locking with ASLS ASLS, the Angular Stable Locking System, can be used as an alternative to standard locking screws in any round hole of a Synthes cannulated titanium nail. For more details regarding the intramedullary fixator prin ciple please consult the ASLS surgical technique ( ) and concept flyer ( ). Please note that for the use of ASLS special instruments are required. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 33

42 Distal Locking 5 Determine locking screw length Instruments Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, with Coupling for RDL or Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, for Quick Coupling Depth Gauge for Locking Screws, measuring range to 110 mm or Depth Gauge for Locking Screws, measuring range up to 110 mm, for No Stop drilling immediately after penetrating the far cortex. Disassemble the power drive or radiolucent drive from the drill bit. Ensure the correct position of the drill bit in regard to the far cortex of the femur. Place the direct measuring device onto the drill bit. Read the graduation on the measuring device at the end of the drill bit. This corresponds to the appropriate locking screw length. Precaution: Drill bit location with respect to the far cortex is critical for measuring the appropriate locking screw length. Alternative instrument Direct Measuring Device for Drill Bits, length 145 mm or Direct Measuring Device for Drill Bits of length 145 mm, for Nos to Measure the locking screw length using the depth gauge for locking screws. Ensure the outer sleeve is in contact with the bone and the hook grasps the far cortex. 44 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

43 6 Insert locking screw Instruments Screwdriver Stardrive, T25, self-holding, length 320 mm or Screwdriver Stardrive, T25, length 330 mm Holding Sleeve, with Locking Device or Inter-Lock Screwdriver, combined, Stardrive, T25/hexagonal B 3.5, length 330 mm Figure 1 Figure 2 Insert the locking screw using the screwdriver, and the holding sleeve with locking device; if desired. Verify locking screw length under image intensification. The screw tip should be about 2 mm beyond the far cortex. If needed, a second locking screw may be inserted using the same technique. Figure 3 Use the holding sleeve as described below: Insert the holding sleeve onto the shaft of the screwdriver and place the tip of the screwdriver in the recess of the locking screw (Figure 1). Push the holding sleeve in the direction of the locking screw. The sleeve now holds the locking screw. Lock the holding sleeve by tightening it counterclockwise (Figure 2). After insertion of the locking screw, release the holding sleeve by loosening it clockwise and pulling it back (Figure 3). Read the locking screw length directly from the depth gauge at the back of the outer sleeve. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 44

44 END CAP INSERTION 1 Insert end cap Instruments Screwdriver Stardrive, T40, with spherical head, cannulated, length 280 mm or Screwdriver Stardrive, T40, cannulated length 300 mm Guide Wire B 3.2 mm, length 400 mm Choose an end cap with the appropriate extension; 0 mm if the nail is not overinserted, 5 mm, 10 mm or 15 mm if the nail is overinserted. The end caps are cannulated for use over a guide wire, if necessary. Remove the nail insertion instruments. Optionally, for insertion of the 0 mm end cap, remove the connecting screw only. The insertion handle can r emain to help align the end cap to the top of the nail. The 0 mm end cap fits through the barrel of the insertion handle. Insert the guide wire into the proximal end of the nail. Engage the end cap with the cannulated screwdriver by exerting axial pressure. To prevent cross-threading, align the end cap with the nail axis and turn the end cap counterclockwise, until the thread of the end cap aligns with that of the nail. Turn the end cap clockwise to thread the end cap into the nail. Remove the guide wire and screwdriver. 44 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

45 Alternative instruments Screwdriver Stardrive, T40, cannulated, length 190 mm, with Lever Arm Combination Wrench B 11.0 mm The cannulated Stardrive, screwdriver, T40, with lever handle, may be used with the 11 mm combination wrench to insert the end cap. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 44

46 IMPLANT REMOVAL 1 Remove end cap and locking screws Instruments Screwdriver Stardrive, T25,self-holding, length 320 mm or Screwdriver Stardrive, T25, length 330 mm Screwdriver Stardrive, T40, with spherical head, cannulated, length 280 mm or Screwdriver Stardrive, T40, cannulated, length 300 mm Guide Wire B 3.2 mm, length 400 mm Optional instruments Inter-Lock Screwdriver, combined, Stardrive, T25/hexagonal B 3.5, length 330 mm or Holding Sleeve, with Locking Device 44 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

47 2 Attach extraction screw and hammer guide Instruments Screwdriver Stardrive, T25, length 330 mm or Screwdriver Stardrive, T25,self-holding, length 320 mm Extraction Screw for AFN/DFN Hammer Guide, for No or Hammer Guide Before removing the final locking screw, screw the extraction screw into the nail and tighten it. The locking screw will prevent nail rotation as the extraction screw is tightened. Attach the hammer guide to the extraction screw. Remove the remaining locking screw with the screwdriver. Implant removal is an optional procedure. 3 Remove nail Instrument Combined Hammer 700 g, can be mounted, for No or Combined Hammer, 500 g Extract the nail by applying gentle blows with the hammer. Note: The nail will rotate about 90, similar to the movement during the insertion. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 44

48 Implant Removal Alternative Technique Extraction Hook For removal of broken nail Instruments * Extraction Hook B 3.7 mm, for Cannulated Nails Universal Chuck with T-Handle or Universal Chuck, small, with T-Handle Begin with Steps 1 and 2 of Implant Removal, then remove the extraction screw from the nail. * Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. 44 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

49 Option 1 1 Assemble extraction hook and universal chuck Insert the extraction hook into the universal chuck with T-handle. The hook should be parallel with the T-handle. This facilitates visualization of the hook position in the bone. 2 Insert extraction hook through nail Pass the extraction hook through the cannula of the nail, including the distant fragment. Precaution: Under image intensification, verify that the hook has passed through and engaged the distant end of the nail. 3 Extract nail Extract both nail fragments. Technique Tip: Keep the patient s limb restrained to increase the efficiency of the extraction force. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 44

50 Implant Removal Option 2 1 Remove near nail fragment Attach the appropriate extraction bolt or extraction screw to the nail. Remove the near nail fragment using the extraction bolt or extraction screw. Technique Tip: The extraction hook can be used as an alternative to extraction instrumentation. 2 Ream canal Ream the medullary canal 1 mm larger than the nail diameter to clear a path for the distant nail fragment. 3 Align extraction hook Insert the extraction hook and explanted near nail fragment into the medullary canal. The near nail fragment aligns the extraction hook with the cannulation of the distant nail fragment. 44 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

51 4 Engage distant fragment Pass the extraction hook through the cannula of the distant nail fragment. Precaution: Under image intensification, verify that the hook has passed through and engaged the distant end of the nail 5 Extract nail Extract both nail fragments. Technique Tip: Keep the patient s limb restrained to increase the efficiency of the extraction force. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 44

52 IMPLANTS Expert Adolescent Lateral Femoral Nail Available for left or right femur Anatomic nail design based on a femoral canal tracing study* 120 antegrade Recon locking 20.6 mm 12.5 mm mm 50 mm Material Titanium-6% aluminum 7% niobium alloy Diameters 8.2 mm, cannulated 9.0 mm, cannulated 10.0 mm, cannulated Dynamic transverse Static transverse 7 mm Lengths 240 mm through 400 mm in 20 mm increments Cross Section Helical fluted Proximal locking Dynamization slot (LM) Static transverse locking hole (LM) 120 antegrade locking Two recon locking holes Distal locking Two transverse locking holes (LM) LM * L. Ehmke, et al. LM 12 mm 42 mm 55 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

53 Expert Adolescent Lateral Femoral Nail, sterile Length (mm) B mm Right Left S S S S S S S S S S S S S S S S S S Length (mm) B mm Right Left S S S S S S S S S S S S S S S S S S Length (mm) B mm Right Left S S S S S S S S S S S S S S S S S S Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 55

54 Implants Expert End Cap for Adolescent Lateral Femoral Nail B 8.2 mm, Titanium Alloy (TAN), (dark purple)* Titanium alloy** Protect nail threads from tissue ingrowth Cannulated to allow insertion over a guide wire T40 Stardrive recess 0 mm: Sits flush with end of nail 5 mm, 10 mm and 15 mm extensions: Extend nail height if nail is overinserted Extension (mm) Hip Screw Stardrive B 5.0 mm, self-tapping, Titanium Alloy (TAN), (dark purple)* Titanium alloy** Lengths: 50 mm 125 mm (5 mm increments) 3.2 mm core diameter Partially threaded Self-tapping, blunt tip T25 Stardrive recess for improved torque transmission and self-retention on screwdriver Length (mm) Length (mm) * Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. ** Titanium 6% Aluminum 7% Niobium alloy 55 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

55 Locking Screw Stardrive B 4.0 mm, for Medullary Nails, Titanium Alloy (TAN), (dark blue)* Titanium alloy** Lengths: 18 mm 80 mm (2 mm increments) 3.3 mm core diameter Fully threaded Self-tapping, blunt tip T25 Stardrive recess for improved torque transmission and self-retention on screwdriver Length (mm) Length (mm) * Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. ** Titanium 6% Aluminum 7% Niobium alloy Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 55

56 INSTRUMENTS Standard instrumentation Combination Wrench B 11.0 mm Pin Wrench B 4.5 mm, length 120 mm Drill Bit B 13.0 mm, cannulated, length 290 mm, 3-flute, for Quick Coupling No Shaft, hexagonal, B 8.0 mm, cannulated, short, length 125 mm Guide Wire B 3.2 mm, length 400 mm Universal Chuck with T-Handle Extraction Screw 55 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

57 Radiographic Ruler for Expert Femoral Nails, length 475 mm Radiographic Ruler for Nail Diameters for Expert Femoral Nails, length 365 mm * Drill Bit B 3.2 mm, calibrated, length 340 mm, 3-flute, for Quick Coupling, for No Protection Sleeve 12.0/8.0, length 188 mm Drill Sleeve 8.0/3.2, for No Trocar B 3.2 mm, for No * Available nonsterile or sterile-packed. Add «S» to catalog number to order sterile product. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 55

58 Instruments Connecting Screw, cannulated, with Internal M6x1 Thread Depth Gauge for Locking Screws, measuring range up to 110 mm, for No Aiming Arm, radiolucent, for Expert Adolescent Lateral Femoral Nail Insertion Handle, radiolucent, length 100 mm, for Expert Adolescent Lateral Femoral Nail Cam-Lock Lever for Aiming Arm Handle, with Quick Coupling for Protection Sleeves Hammer Guide 51 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

59 Protection Sleeve 13.0 for Expert Adolescent Lateral Femoral Nail, with Quick Coupling Multihole Drill Guide for Protection Sleeve 13.0, for Expert Adolescent Lateral Femoral Nail Screwdriver, hexagonal B 8.0 mm, with T-Handle, with spherical head, length 322 mm Screwdriver Stardrive, T25, self-holding, length 320 mm Screwdriver Stardrive, T40, with spherical head, cannulated, length 280 mm Combined Hammer 500 g, mountable, for No Driving Cap with thread, for Insertion Handle Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 51

60 Instruments Optional instruments Tissue Protector Extraction Hook 3.7 mm, for Cannulated Nails Distal Depth Gauge for Locking screw, short Awl B 14.0/3.2 mm, cannulated Protection Sleeve 11.5/8.5, for LFN Reconstruction Locking Drill Sleeve 8.5/3.2, for No Trocar B 3.2 mm, for No DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

61 Fixation Sleeve, for No Rod Pusher for Reaming Rod with Hexagonal Screwdriver B 8.0 mm Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, with Coupling for RDL * Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, for Quick Coupling Screwdriver Stardrive, T40, cannulated, length 190 mm, with Lever Arm Drill Bit B 3.2 mm, calibrated, length 474 mm, 3-flute, for Mini Quick Coupling, for Hip Screw Stardrive B 5.0 mm * Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 55

62 Instruments Direct Measuring Device for Drill Bits, length 145 mm, for Nos to Inter-Lock Screwdriver, combined, Stardrive, T25/hexagonal B 3.5, length 330 mm Inter-Lock Screwdriver, combined, Stardrive, T25/hexagonal B 3.5, length 250 mm Handle for Scalpel, long Direct Measuring Device for Guide Wires B 3.2 mm, length 400 mm 11 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

63 Intramedullary Reduction Tool, curved, with Quick Coupling, Hex 12 mm T-Handle, cannulated, with Quick Coupling, Hex 12 mm Screwdriver Stardrive, T25, self-holding, length 250 mm Inter-Lock Screwdriver Stardrive, T40, length 380 mm Screwdriver Stardrive, T25, self-holding, length 440 mm Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 11

64 Instruments Alternative instruments Universal Chuck, small, with T-Handle Extraction Screw for AFN/DFN Hammer Guide, for No Trocar B 3.2 mm, length 172 mm, for No Drill Sleeve 13.0/3.2 for antegrade approach, for No Connecting Screw, cannulated, for Expert Tibial and Femoral Nails, for No Connector, for Insertion Handle Combined Hammer 700 g, can be mounted, for No DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

65 Depth Gauge for Locking Screws, measuring range up to 110 mm, for No Direct Measuring Device for Guide Wires B 3.2 mm, length 400 mm Screwdriver, hexagonal with spherical head B 8.0 mm Direct Measuring Device for Drill Bits of length 145 mm, for Nos to Screwdriver Stardrive, T25, length 330 mm Screwdriver Stardrive, T25, length 330 mm, long Screwdriver Stardrive, T40, cannulated, length 300 mm Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 66

66 Instruments Holding Sleeve, with Locking Device Insertion Handle for Expert Adolescent Lateral Femoral Nail Aiming Arm for Expert Adolescent Lateral Femoral Nail Protection Sleeve 15.5 mm/13.7 mm, length mm 66 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

67 Instruments COMPARISON TABLE Standard Article Alternative Article Standard Article Alternative Article Standard Article Alternative Article Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 15

68 Instruments Comparison Table Standard Article Alternative Article Standard Article Alternative Article Standard Article Alternative Article DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

69 Instruments HANDLING INFORMATION Insertion Handle ( ) Radiolucent Attachment for driving cap with threaded end ( ) Aiming Arm ( ) Easy snap-on and snap-off mechanism Friction and True locking Backward compatible with existing devices Radiolucent More soft tissue clearance Easy disassembly for cleaning 1. Some force is required to push the cam lock mechanism over the wings. 2. To fix the cam lock mechanism at the corresponding pins, the cam lock must be pushed back in open position. Inter-Lock Screwdriver Compatible with all Synthes T25 or 3.5 mm hexagonal recess. For further information, please refer to brochure Tear drop shape Silicon handle Precaution: When removing implants after longterm implantation, especially in the presence of large amounts of bony ingrowth, first use a solid screwdriver to loosen the screw. The inter-lock screwdriver can then be used to remove the screw from the surgical site. If using the inter-lock screwdriver with locking screws, use a solid screwdriver for final tightening. Scalpel Handle ( ) For channel cutting to minimize muscle force on the protection sleeves Yellow Silicon handle indicates sharpness of instrument 1. Attach a blade to the scalpel holding the end of the handle. 2. Pass the scalpel handle through the aiming arm holes and perform a minimally invasive and accurate incision. 3. Remove the scalpel from the aiming arm. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 11

70 Instruments Handling Information IMN Reduction Tool and T-Handle with Quick Coupling ( and ) Fracture Reduction Tool Flat curved tip to aid fragment alignment Supplied separately due to length T-Handle Can be added to the auxiliary bin in the Modular Femur Set 12 mm Hexagonal Quick Coupling with marking for orientation Multihole Drill Guide for Protection Sleeve ( ) Center hole and offset holes (4 mm and/or 6 mm) Color coded 1 2 If the initial Kirschner wire (1) is placed slightly offset, a second Kirschner wire (2) can be inserted to correct the placement. 18 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

71 SET LIST MODULAR CASES The modularity of the system enables sets to be configured according to the hospital s clinical needs. Each set configuration consists of basic instruments, dedicated system instruments and optional instruments (if required). For femoral nails (LFN, ALFN, R/AFN) the femur set must be added to the set configuration. New modular trays also contain the ASLS instruments. For further information about ASLS refer to pages 77 and 78. ETN R/AFN LFN ALFN Instruments for ETN Instruments for R/AFN Instruments for LFN Instruments for ALFN The instrument modules listed on the right side are available. ETN Aiming Arm (separate) Instruments for Expert Femoral Nail Basic Instruments for Expert Nail Additional Instruments for Expert Nail (Optional) For ease of use within the operating theatre, all modular trays have an additional marking: Mandatory modular trays have a solid white marking Optional trays have a hatched black marking Each system has a control picture for reference Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 19

72 Set List Modular Cases Modular ALFN Set Control Picture OPT ALFN BASIC FEMUR ALFN Instruments Tray ALFN Basic Instruments Tray BASIC Femur Instruments Tray FEMUR Optional Instruments Tray OPT 77 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

73 Modular Tray for ALFN Instruments Modular Tray for ALFN Instruments, size 1/1, without Contents, Vario Case System Modular Tray for Basic Expert Nail Instruments Modular Tray for Basic Instruments, for Expert Nail, size 1/1, without Contents, Vario Case System Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 11

74 Set List Modular Cases Modular Tray for Femur Expert Nail Instruments Modular Tray for Femur Nail Instruments, size 1/1, without Contents, Vario Case System Modular Tray for Optional Expert Nail Instruments Modular Tray, for Additional Instruments, for Expert, size 1/1, without Contents, Vario Case System 12 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

75 Set List VARIO CASES Expert Adolescent Lateral Femoral Nail Instrument Set in Vario Case Vario Case for Standard Instrument Set for Expert Adolescent Lateral Femoral Nail, without Lid, without Contents Drill Bit B 13.0 mm, cannulated, length 290 mm, 3-flute, for Quick Coupling No Combination Wrench B 11.0 mm Pin Wrench B 4.5 mm, length 120 mm Extraction Screw for AFN/DFN Hammer Guide, for No Trocar B 3.2 mm, length 172 mm, for No Guide Wire B 3.2 mm, length 400 mm Universal Chuck, small, with T-Handle Radiographic Ruler for Expert Femoral Nails, length 475 mm Radiographic Ruler for Nail Diameters for Expert Femoral Nails, length 365 mm Drill Sleeve 13.0/3.2, for antegrade approach Connecting Screw, cannulated, for Expert Tibial and Femoral Nails, for No Connector, for Insertion Handle Combined Hammer 700 g, can be mounted, for No * Drill Bit B 3.2 mm, calibrated, length 340 mm, 3-flute, for Quick Coupling, for No Protection Sleeve 12.0/8.0, lenght 188 mm Drill Sleeve 8.0/3.2, for No Trocar B 3.2 mm, for No Depth Gauge for Locking Screws, measuring range up to 110 mm, for No Protection Sleeve 11.5/8.5, for LFN Reconstruction Locking Drill Sleeve 8.5/3.2, for No Trocar B 3.2 mm, for No Fixation Sleeve, for No Direct Measuring Device for Guide Wires B 3.2 mm, length 400 mm Screwdriver, hexagonal with spherical head B 8.0 mm Rod Pusher for Reaming Rod with Hexagonal Screwdriver B 8.0 mm Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, with Coupling for RDL * Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, for Quick Coupling Direct Measuring Device for Drill Bits of length 145 mm, for Nos to Screwdriver Stardrive, T25, length 330 mm Screwdriver Stardrive, T25, length 330 mm, long Screwdriver Stardrive, T40, cannulated, length 300 mm Screwdriver Stardrive, T40, cannulated, length 190 mm, with Lever Arm Holding Sleeve, with Locking Device Insertion Handle for Expert Adolescent Lateral Femoral Nail Aiming Arm for Expert Adolescent Lateral Femoral Nail Drill Bit B 3.2 mm, calibrated, length 474 mm, 3-flute, for Quick Coupling, for Hip Screw Stardrive B 5.0 mm Protection Sleeve 15.5 mm/13.7 mm, length mm * Available nonsterile or sterile-packed. Add «S» to catalog number to order sterile product. Note: For additional information, please refer to package insert. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 77

76 Set List Vario Cases Expert Adolescent Lateral Femoral Nail Upgrade for LFN Instrument Set Vario Case for Expert Adolescent Lateral Femoral Nail, 1 Upgrade Instruments to Expert LFN, without Lid, without Content Drill Bit B 13.0 mm, cannulated, length 290 mm, 3-flute, 1 for Quick Coupling No Extraction Screw for AFN/DFN Trocar B 3.2 mm, length 172 mm, for No Drill Sleeve 13.0/3.2 for antegrade approach Drill Bit B 3.2 mm, calibrated, length 340 mm, 3-flute, 2 for Quick Coupling, for No Protection Sleeve 12.0//8.0, length 188 mm Drill Sleeve 8.0/3.2, for No Trocar B 3.2 mm, for No Rod Pusher for Reaming Rod with Hexagonal Screwdriver 1 B 8.0 mm Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, 2 with Coupling for RDL mm, 3-flute, with Coupling for RDL Screwdriver Stardrive, T40, cannulated, length 190 mm, 1 with Lever Arm Insertion Handle for Expert Adolescent Lateral Femoral Nail Aiming Arm for Expert Adolescent Lateral Femoral Nail Drill Bit B 3.2 mm, calibrated, length 474 mm, 3-flute, 1 for Quick Coupling, for Hip Screw Stardrive B 5.0 mm Protection Sleeve B 15.5 mm/13.7 mm, length mm Expert Adolescent Lateral Femoral Nail Instrument Set in Vario Case Expert Adolescent Lateral Femoral Nail Upgrade for LFN Instrument Set Optionally available Soft Tissue Protector Additionally available Ratchet Wrench B 11.0 mm S Reaming Rod B 2.5 mm, length 950 mm, with Olive & extension, sterile S Reaming Rod B 2.5 mm, length 950 mm, with Olive, sterile Combined Hammer 500 g, can be mounted, for No Universal Chuck with T-Handle Reduction Instrument for Medullary Nails Shaft, hexagonal, B 8.0 mm, cannulated, short, length 125 mm Hammer Guide for DFN, for no SynReam Reaming Rod B 2.5 mm, long, length 1150 mm SynReam Reaming Rod B 2.5 mm, short, length 950 mm SynReam Intramedullary Reaming System in Vario Case Large Distractor 77 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

77 Option: Modular Aiming Device ModAD Option for C-arm independent distal locking of nails for femur, tibia and humerus When using the ModAD for the interlocking of intramedullary nails, no image intensifier control is required. The system is especially suitable when no C-arm is available ModAD for Expert LFN und HN Sliding Carriage for Expert Tibial Nails, for Calibration Block No The ModAD for Expert LFN has to be used with the Sliding Carriage for Expert Tibial Nails. Distal locking is performed using the sliding carriage. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 77

78 Set List VARIO CASES Implant Set for Expert Adolescent Lateral Femoral Nail Screw Rack, 1/4, for Locking Screw Stardrive B 4.0 mm and Hip Screw Stardrive B 5.0 mm, including Module and Lid, without content Instrument Screw Forceps Implants Locking Screw Stardrive B 4.0 mm, for Medullary Nails, Titanium Alloy (TAN), dark blue, 2 each* Length (mm) Length (mm) Hip Screw Stardrive B 5.0 mm, self-tapping, Titanium Alloy (TAN), dark purple, for Expert Adolescent Lateral Femoral Nail, 4 each 5.0 mm Titanium Recon Screws*, with T25 StarDrive recess, for IM Nails, 4 ea. Length (mm) Length (mm) Optionally available Hip Screws Hip Screw Stardrive B 5.0 mm, self-tapping, length 50 mm, Titanium Alloy (TAN), dark purple, for Expert Adolescent Lateral Femoral Nail Hip Screw Stardrive B 5.0 mm, self-tapping, length 55 mm, Titanium Alloy (TAN), dark purple, for Expert Adolescent Lateral Femoral Nail Hip Screw Stardrive B 5.0 mm, self-tapping, length 125 mm, Titanium Alloy (TAN), dark purple, for Expert Adolescent Lateral Femoral Nail Instrument Locking Screw Stardrive B 4.0 mm, for Medullary Nails, Titanium Alloy (TAN), length 18 mm, dark blue Locking Screw Stardrive B 4.0 mm, for Medullary Nails, Titanium Alloy (TAN), length 20 mm, dark blue Locking Screw Stardrive B 4.0 mm, for Medullary Nails, Titanium Alloy (TAN), length 22 mm, dark blue Locking Screw Stardrive B 4.0 mm, for Medullary Nails, Titanium Alloy (TAN), length 24 mm, dark blue Expert End Cap for Adolescent Lateral Femoral Nail B 8.2 mm, Titanium Alloy (TAN), dark purple* Extension (mm) each * Available nonsterile or sterile-packed. Add «S» to catalog number to order sterile product. Note: For additional information, please refer to package insert. 77 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique

79 OPTIONAL: ANGULAR STABLE LOCKING SYSTEM (ASLS) What is ASLS? The Angular Stable Locking System (ASLS) provides the ability to create a fixed-angle construct to an intramedullary nail. Therefore, it combines the advantages of angular stability and a minimally invasive approach. ASLS together with an intramedullary nail form the principle of the Intramedullary Fixator. How does ASLS work? The system consists of a screw with three outer diameters and a resorbable sleeve. The resorbable sleeve is placed on the screw tip which has the smallest screw diameter and is pushed into the locking hole of the nail. During screw advancement, the resorbable sleeve is expanded by the larger middle diameter. Radial expansion of the sleeve and its fixation in the nail creates the angular stability. Expert Adolescent Lateral Femoral Nail Surgical Technique DePuy Synthes 77

80 ASLS screws Titanium alloy* Screws ASLS4: Length 26 mm 80 mm, are compa tible with Expert Adolescent Lateral Femoral Nails Fully threaded shaft with 3 diameters D1: Provides purchase in reamed near cortex D2: Expands sleeve, providing angular stability D3: Holds unexpanded sleeve for screw insertion, provides purchase in far cortex T25 Stardrive recess Sterile packaged D1 D2 D3 ASLS sleeves 70:30 poly (L-lactide-co-D,L-lactide) Bioresorbable, provides 80% decreased fracture site motion during first 12 weeks of healing Gradually degrades within 2 years (resorption rate varies per patient and implant site) Inner thread for secure fit to screw Expands in nail locking hole Available in diameters of 4.0 mm (ASLS4), 5.0 mm (ASLS5) and 6.0 mm (ASLS6) Sterile-packed Note: For more details regarding the intramedullary fixator principle please consult the ASLS surgical technique ( ) and concept flyer ( ). * Titanium 6% aluminum 7% niobium alloy 77 DePuy Synthes Expert Adolescent Lateral Femoral Nail Surgical Technique