MatrixRIB. Stable fixation of normal and osteoporotic ribs.

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1 MatrixRIB. Stable fixation of normal and osteoporotic ribs. Technique Guide CMF Matrix

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3 Table of Contents Introduction MatrixRIB 2 AO Principles 4 Indications 5 Surgical Technique Patient Positioning 5 Plating Rib 6 Splint Insertion 14 Product Information Implants 21 Instruments 22 Set Lists 26 References 31 MatrixRIB Technique Guide Synthes

4 MatrixRIB The Synthes MatrixRIB Fixation System consists of precontoured locking plates, locking screws, and intramedullary splints for the fixation and stabilization of ribs. Although some rib fractures are treated with pain management and bracing, as well as endotracheal intubation and mechanical ventilation if necessary, some patients could benefit from surgical stabilization (osteosynthesis). Potential benefits of surgical stabilization of fractures include reduced duration of mechanical ventilation support, shortened ICU stays and hospitalization, better secretion management through efficient cough, and minimized chest wall deformities resulting from trauma. 1,2 Features Designed to be used without removing periosteum, to maximize blood supply to the bone All implants are manufactured from titanium alloy* for flexibility and strength Drill bit with stop to prevent over-drilling Self-retaining screwdriver blades Right plates Locking holes In-plane radius R3 R4-5 Longitudinal twist R6-7 R8-9 Locking screws Screws work with self-retaining screwdriver blades to reduce cam-out Locking design for increased stable fixation One screw diameter for use with all plates and splints * Ti-6Al-7Nb 2 Synthes MatrixRIB Technique Guide

5 Locking plates Plates are precontoured to fit an average rib shape, which minimizes intraoperative bending 3 Locking plate construct provides stable fixation Low-profile 1.5 mm thick plates Plates are color-coded to distinguish left and right designs Plates are etched on medial end to indicate the corresponding rib curvature A universal plate with 8 holes is available R3 R4-5 R6-7 rib 3 rib 4 rib 5 rib 6 rib 7 rib 3 rib 4 rib 5 rib 6 rib 7 L3 L4-5 L6-7 rib 8 rib 8 R8-9 rib 9 rib 9 L8-9 Left plates L3 Etching Out of plane radius L4-5 L6-7 Tubular radius L8-9 Intramedullary splints Intramedullary splints allow minimally invasive procedures Three widths available (3 mm, 4 mm, 5 mm) Only one screw needed to secure splint MatrixRIB Technique Guide Synthes 3

6 AO Principles In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation.* Anatomic reduction Fracture reduction and fixation to restore functional anatomical relationships. Stable fixation Stability by rigid fixation or splintage, as the personality of the fracture and the injury requires. Preservation of blood supply Preservation of the blood supply to soft tissue and bone by careful handling and gentle reduction techniques. Early, active mobilization Early and safe mobilization of the part and patient. * M. E. Müller, M. Allgöwer, R. Schneider, and H. Willenegger. Manual of Internal Fixation, 3rd Edition. Berlin: Springer-Verlag Synthes MatrixRIB Technique Guide

7 Indications The Synthes MatrixRIB Fixation System is indicated for the fixation and stabilization of rib fractures, fusions and osteotomies of normal and osteoporotic bone. Patient Positioning Position patient Position the patient to optimize access to the rib to be repaired. For pure lateral chest injuries, a lateral thoracotomy may be used with the patient in a lateral decubitus position, and the arms abducted 90 on padded arm rests. Anterolateral chest injuries may be approached with an anterolateral thoracotomy with the patient in a supine position, with both arms abducted 90. MatrixRIB Technique Guide Synthes 5

8 Plating Rib 1 Expose fractured rib Make an incision over the fracture area. Expose the rib to allow a minimum of three screws on each side of the fracture. Remove any nonviable bone. Caution: Avoid significant muscle division to preserve as much respiratory function as possible. The serratus anterior muscle insertions on the chest wall are generally the only muscle fibers that are divided for anterolateral injuries. Notes: For lateral chest wall injuries, the anterior aspect of the latissimus dorsi can be dissected to gain access to the fracture. Removal of the periosteum is not required. 2 Measure rib thickness Instrument Caliper Optional instrument Universal Caliper Make a small incision in the intercostal space at the superior border of the rib to allow insertion of the caliper tip. Insert the caliper tip through the incision and measure the rib thickness. Note: If an existing access into the intercostal space is available for measuring the rib thickness, it is recommended to insert the caliper tip using the existing access. To select the appropriate drill bit with stop and the appropriate screw length, add 2 mm to the measurement to allow for the plate thickness. Caution: Take care to avoid damaging the nerve and vessel bundle at the inferior border of the rib. 6 Synthes MatrixRIB Technique Guide

9 3 Approximate broken rib segments Instrument Reduction Forceps with points, narrow, ratchet, 132 mm length Use the forceps to approximate the broken rib segments. 4 Cut and contour plate template (optional) Instrument Bending Template for MatrixRIB Locking Plates Cut the bending template to a length that allows placement of a minimum of three screws on each side of the fracture. Contour the template to the rib. MatrixRIB Technique Guide Synthes 7

10 Plating Rib continued 5 Select and cut plate (optional) Instrument Plate and Rod Cutter Use the plate template contoured in Step 4 to select the best matching plate. Notes: Position the precontoured plate with the marking toward the sternum. A universal plate is available for use in place of a precontoured plate (see implants on page 21). If necessary, cut the plate to the desired length. Caution: Use a minimum of three screws on each side of the fracture, to properly secure the plate. 8 Synthes MatrixRIB Technique Guide

11 6 Contour plate (optional) Instrument Combination Bending Pliers Using the bending pliers, contour the plate to match the template. Caution: If contouring is necessary, avoid sharp bends, reverse bends, or bending the implant at a screw hole. Avoid notching or scratching the implant. These factors may produce internal stresses which may become the focal point for eventual breakage of the implant. MatrixRIB Technique Guide Synthes 9

12 Plating Rib continued 7 Position plate Instrument MatrixRIB Plate Holding Forceps, small Optional instruments MatrixRIB Plate Holding Forceps, small, with ball tips MatrixRIB Plate Holding Forceps, large, with ball tips Position the plate on the rib over the fracture, allowing a minimum of three screws on each side of the fracture. Verify that the contour of the plate matches the rib. Using the plate holding forceps, hold the plate on the rib. Caution: It is recommended to insert the forceps from the superior border of the rib to avoid damaging the nerve and vessel bundle located at the inferior border of the rib. 10 Synthes MatrixRIB Technique Guide

13 8 Drill Instruments mm Threaded Drill Guide for MatrixRIB Locking Plates mm Drill Bits with stop, Stryker J-latch mm to 14 mm stop Thread the drill guide into the plate. This will help ensure safe drilling and alignment of the drill hole with the plate hole. Select the drill bit with stop as determined in Step 2 and drill. Drill bits with stop are available with stop lengths ranging from 6 mm to 14 mm, in 2 mm increments, matching the locking screw lengths. Irrigate during drilling to avoid thermal damage to the bone. Caution: Do not drill any deeper than necessary, to avoid the risk of pneumothorax. Remove the 2.2 mm drill guide after drilling. MatrixRIB Technique Guide Synthes 11

14 Plating Rib continued 9 Select and insert screw Instruments Depth Gauge for 2.7 mm and larger screws with zero offset MatrixMANDIBLE/ THORAX Self-Retaining Screwdriver Blade, medium Ratcheting Screwdriver Handle Optional instrument MatrixMANDIBLE/ THORAX Self-Retaining Screwdriver Blade, long Use the depth gauge through the plate to confirm the appropriate screw length determined in Step 2. Caution: Do not extend the tip of the depth gauge too far beyond the posterior cortex of the rib. Select the proper length screw. Caution: The screw should be no longer than necessary to engage the posterior cortex, to avoid deeper injury. The tip of the screw should not extend more than 1 mm beyond the posterior cortex. Screws can be measured using the screw length indicator on the module. Insert the locking screw through the plate and tighten until secure. Optionally, 10 and 12 mm nonlocking screws are available to ensure the plate sits flush with the bone. These nonlocking screws are for temporary fixation and will need to be replaced with locking screws before closure. 12 Synthes MatrixRIB Technique Guide

15 10 Drill and place remaining screws Verify proper reduction of the fracture. Insert a second screw on the opposite side of the fracture following Steps 8 and 9. Insert remaining screws in the same manner. Note: If nonlocking screws were used, remember to replace with the proper locking screw. MatrixRIB Technique Guide Synthes 13

16 Splint Insertion Intramedullary splints require smaller incisions and improve the ability to fix posterior rib fractures. The intramedullary splints have a rectangular profile for rotational stability within the canal, and a locking feature to limit migration and rotation of the implant. Intramedullary splints Intramedullary splints allow minimally invasive procedures Three widths available (3 mm, 4 mm, 5 mm) Only one screw needed to secure splint 1 Expose fractured rib Make incisions over the fractured area. Expose the fractured rib to allow splint head placement. A minimum of 50 mm on the medial side of the fracture is recommended. Remove any nonviable bone. Notes: It is recommended to minimize the dissection of the soft tissue on the lateral side of the fracture. Removal of the periosteum is not recommended. Caution: Avoid significant muscle division to preserve as much respiratory function as possible. 14 Synthes MatrixRIB Technique Guide

17 2 Measure rib thickness Instrument Caliper Optional instrument Universal Caliper Make a small incision in the intercostal space at the superior border of the rib to allow insertion of the caliper tip. Insert the caliper tip through the incision and measure the rib thickness. Note: If an existing access into the intercostal space is available for measuring the rib thickness, it is recommended to insert the caliper tip using the existing access. To select the appropriate drill bit with stop and the appropriate screw, add 1 mm to the measurement to allow for the splint thickness. Caution: Take care to avoid damaging the nerve and vessel bundle at the inferior border of the rib. MatrixRIB Technique Guide Synthes 15

18 Splint Insertion continued 3 Prepare splint insertion hole Instruments mm Drill Guide for MatrixRIB Intramedullary Splints mm Drill Bit with stop, Stryker J-latch MatrixRIB Plate Holding Forceps, small Optional instruments MatrixRIB Intramedullary Splint Driver mm Drill Guide for MatrixRIB Intramedullary Splints, without handle Insert the hook end of the drill guide into the intramedullary canal of the medial segment until it is seated fully on the rib. Notes: It is recommended to insert the hook near the superior edge of the rib, and to drill an entry hole in the upper 2 /3 of the rib. The small plate holding forceps can be used to hold the drill guide against the rib during drilling. Caution: If the drill guide without handle is used, ensure the tapered end, labeled Fracture, is aligned with the fracture to ensure the hole is approximately 30 mm from the fracture line. Note: The splint driver may be threaded into the drill guide to act as a handle, as needed. Ensure the medial end of the drill guide contacts the bone. Using the 5.5 mm drill bit with stop, drill monocortically. Irrigate during drilling to avoid thermal damage to the bone. Remove the drill guide and verify the hole is approximately 30 mm from the fracture line. Note: Ensure the lateral fracture segment is long enough to accommodate the insertion length of the splint before drilling. 16 Synthes MatrixRIB Technique Guide

19 4 Select splint Instruments MatrixRIB Intramedullary Splint Driver MatrixRIB Intramedullary Splint Template, small MatrixRIB Intramedullary Splint Template, medium Mallet, 200 g Reduction Forceps with points, narrow, ratchet, 132 mm length The splint template is used to prepare the canal and select the correct size of splint. It is recommended to start with the small template before using the medium template. Thread the splint driver into the splint template and insert the template into the insertion hole prepared in Step 3. Remove the splint template. Fully insert the template into the canal of the lateral fracture segment. Remove the splint template. Notes: If the small template fits snugly, use the 3 mm wide splint. If the medium template fits snugly, use the 4 mm wide splint. If the medium template fits loosely, use the 5 mm wide splint. Use the mallet to assist insertion of the splint template, if needed. Use bone reduction forceps to hold the rib segment during splint template insertion. MatrixRIB Technique Guide Synthes 17

20 Splint Insertion continued 5 Insert splint Instruments MatrixRIB Intramedullary Splint Driver Mallet, 200 g Reduction Forceps with points, narrow, ratchet, 132 mm length Thread the splint driver into the splint selected in Step 4, with the splint marking facing up toward the handle. Insert the splint through the insertion hole prepared in Step 3. Drive the splint across the fracture line and into the canal of the lateral segment. The splint is fully inserted when the head of the splint rests flush on the outside of the rib. Remove the splint driver after the splint is fully seated. Caution: To prevent additional injuries to the rib, do not insert the splint head further once it is seated in the insertion hole. Note: The mallet can be used to assist insertion of the splint, if needed. 18 Synthes MatrixRIB Technique Guide

21 6 Drill screw hole Instruments mm Threaded Drill Guide for MatrixRIB Locking Plates mm Drill Bits with stop, Stryker J-latch mm to 14 mm stop Thread the drill guide into the splint. This will help ensure safe drilling and alignment of the screw with the splint locking hole. Select the drill bit with stop as determined in Step 2 and drill. Drill bits with stop are available with stop lengths ranging from 6 mm to 14 mm, in 2 mm increments, matching the locking screw lengths. Irrigate during drilling to avoid thermal damage to the bone. Caution: Do not drill any deeper than necessary, to avoid the risk of pneumothorax. Remove the 2.2 mm drill guide after drilling. MatrixRIB Technique Guide Synthes 19

22 Splint Insertion continued 7 Select and insert screw Instruments Depth Gauge for 2.7 mm and larger screws with zero offset MatrixMANDIBLE/THORAX Self Retaining Screwdriver Blade, medium Ratcheting Screwdriver Handle Optional instruments Universal Caliper MatrixMANDIBLE/ THORAX Self-Retaining Screwdriver Blade, long Use the depth gauge through the splint to confirm the screw length determined in Step 2. Caution: Do not extend the tip of the depth gauge too far beyond the posterior cortex of the rib. Select the proper length screw. Caution: The screw should be no longer than necessary to engage the posterior cortex, to avoid deeper injury. The tip of the screw should not extend more than 1 mm beyond the posterior cortex. Screws can be measured using the screw length indicator on the module. Insert the locking screw through the splint and tighten until secure. 20 Synthes MatrixRIB Technique Guide

23 Implants Titanium MatrixRIB Pre-Contoured Plates holes, for left rib holes, for right rib holes, for left ribs 4 and holes, for right ribs 4 and holes, for left ribs 6 and holes, for right ribs 6 and holes, for left ribs 8 and holes, for right ribs 8 and 9 Left plate (light blue) Right plate (rose red) Titanium MatrixRIB Universal Plate, 8 holes Titanium MatrixRIB Intramedullary Splints Small, 3 mm width Medium, 4 mm width Large, 5 mm width 2.9 mm Titanium MatrixRIB Locking Screws,* self-tapping mm mm mm mm mm 2.9 mm Titanium MatrixRIB Non-locking Screws, * self-tapping mm mm *For screws in packs of 5, replace suffix.01 with.05. MatrixRIB Technique Guide Synthes 21

24 Instruments Depth Gauge for 2.7 mm and larger screws with zero offset MatrixRIB Plate Holding Forceps, small, with ball tips MatrixRIB Plate Holding Forceps, large with ball tips MatrixRIB Intramedullary Splint Driver mm Threaded Drill Guide for MatrixRIB Locking Plates mm Drill Bits with stop, Stryker J-latch mm to 14 mm stops (2 mm increments) 22 Synthes MatrixRIB Technique Guide

25 mm Drill Guide for MatrixRIB Intramedullary Splints MatrixRIB Intramedullary Splint Template, small MatrixRIB Intramedullary Splint Template, medium Caliper Mallet, 200 g mm Drill Bit with stop, Stryker J-latch, 125 mm MatrixRIB Technique Guide Synthes 23

26 Instruments continued MatrixRIB Plate Holding Forceps, small Bending Template for MatrixRIB Locking Plates Universal Caliper * 5.5 mm Drill Guide for MatrixRIB Intramedullary Splints, without handle MatrixMANDIBLE/THORAX Self-Retaining Screwdriver Blades Medium Long In sets and * In set Synthes MatrixRIB Technique Guide

27 Ratcheting Screwdriver Handle Combination Bending Pliers Plate and Rod Cutter Reduction Forceps with points, narrow, ratchet, 132 mm length MatrixRIB Technique Guide Synthes 25

28 MatrixRIB Fixation System Set ( ) Graphic Case Graphic Case with Lid for MatrixRIB Fixation System Instruments Depth Gauge for 2.7 mm and larger screws with zero offset MatrixRIB Plate Holding Forceps, small, with ball tips, 2 ea MatrixRIB Plate Holding Forceps, large, with ball tips, 2 ea MatrixRIB Intramedullary Splint Driver mm Threaded Drill Guide for MatrixRIB Locking Plates, 2 ea. 2.2 mm Drill Bits, Stryker J-latch, 135 mm, 2 ea with 6 mm stop with 8 mm stop with 10 mm stop with 12 mm stop with 14 mm stop mm Drill Guide, for MatrixRIB Intramedullary Splints MatrixRIB Intramedullary Splint Template, small MatrixRIB Intramedullary Splint Template, medium Caliper Mallet, 200 g mm Drill Bit with stop, Stryker J-latch, 125 mm, 2 ea MatrixRIB Plate Holding Forceps, small, 2 ea Bending Template, for MatrixRIB Locking Plates, 2 ea MatrixMANDIBLE/ THORAX Self-Retaining Screwdriver Blade, medium, 2 ea MatrixMANDIBLE/ THORAX Self-Retaining Screwdriver Blade, long, 2 ea Ratcheting Screwdriver Handle, 2 ea Combination Bending Pliers, for 2.0 mm 2.4 mm plates Plate and Rod Cutter Reduction Forceps with points, narrow, ratchet, 132 mm length, 2 ea. Note: For additional information, please refer to package insert. For detailed cleaning and sterilization instructions, please refer to Sterilization.aspx or to the below listed inserts, which will be included in the shipping container: Processing Synthes Reusable Medical Devices Instruments, Instrument Trays and Graphic Cases DJ1305 Processing Non-sterile Synthes Implants DJ Synthes MatrixRIB Technique Guide

29 Implants Titanium MatrixRIB Pre-Contoured Plates, 2 ea holes, for left rib holes, for right rib holes, for left ribs 4 and holes, for right ribs 4 and holes, for left ribs 6 and holes, for right ribs 6 and holes, for left ribs 8 and holes, for right ribs 8 and Titanium MatrixRIB Universal Plate, 8 holes, 4 ea. MatrixRIB Intramedullary Splints, 6 ea Small, 3 mm width Medium, 4 mm width Large, 5 mm width 2.9 mm Titanium MatrixRIB Locking Screws, self-tapping, 5/pkg mm, 6 pkgs mm, 10 pkgs mm, 10 pkgs mm, 10 pkgs mm, 6 pkgs mm Titanium MatrixRIB Non-Locking Screws, self-tapping, 10 mm, 2 pkgs. of 5 MatrixRIB Technique Guide Synthes 27

30 MatrixRIB Compact Plate and Splint System ( ) Graphic Case MatrixRIB Compact Graphic Case, without tray MatrixRIB Compact Insert Tray, plate and splint Screw Length Markers mm mm mm mm mm Instruments MatrixRIB Plate Holding Forceps, small, with ball tips, 2 ea MatrixRIB Intramedullary Splint Driver mm Threaded Drill Guide for MatrixRIB Locking Plates, 2 ea. 2.2 mm Drill Bits, Stryker J-latch, 135 mm, 2 ea with 6 mm stop with 8 mm stop with 10 mm stop with 12 mm stop with 14 mm stop MatrixRIB Intramedullary Splint Template, small MatrixRIB Intramedullary Splint Template, medium Mallet, 200 g mm Drill Bit with stop, Stryker J-latch, 125 mm, 2 ea MatrixRIB Plate Holding Forceps, small, 2 ea Universal Caliper mm Drill Guide, for MatrixRIB Intramedullary Splints, without handle MatrixMANDIBLE/THORAX Self-Retaining Screwdriver Blade, medium, 2 ea MatrixMANDIBLE/THORAX Self-Retaining Screwdriver Blade, long, 2 ea Ratcheting Screwdriver Handle, 2 ea Reduction Forceps with points, narrow, ratchet, 132 mm length, 2 ea Synthes MatrixRIB Technique Guide

31 Implants Titanium MatrixRIB Universal Plate, 8 holes, 3 ea. Titanium MatrixRIB Intramedullary Splints, 4 ea small, 3 mm width medium, 4 mm width large, 5 mm width 2.9 mm Titanium MatrixRIB Locking Screws, self-tapping, 5/ pkg mm, 2 pkgs mm, 5 pkgs mm, 6 pkgs mm, 5 pkgs mm, 2 pkgs. MatrixRIB Technique Guide Synthes 29

32 MatrixRIB Compact Plate System ( ) Graphic Case MatrixRIB Compact Graphic Case, without tray MatrixRIB Compact Insert Tray, plate only Screw Length Markers mm mm mm mm mm Instruments MatrixRIB Plate Holding Forceps, small, with ball tips, 2 ea mm Threaded Drill Guide for MatrixRIB Locking Plates, 2 ea. 2.2 mm Drill Bits, Stryker J-latch, 135 mm, 2 ea with 6 mm stop with 8 mm stop with 10 mm stop with 12 mm stop with 14 mm stop MatrixRIB Plate Holding Forceps, small, 2 ea Universal Caliper MatrixMANDIBLE/THORAX Self-Retaining Screwdriver Blade, medium, 2 ea MatrixMANDIBLE/THORAX Self-Retaining Screwdriver Blade, long, 2 ea Ratcheting Screwdriver Handle, 2 ea Reduction Forceps with points, narrow, ratchet, 132 mm length, 2 ea. Implants Titanium MatrixRIB Universal Plate, 8 holes, 6 ea. 2.9 mm Titanium MatrixRIB Locking Screws, self-tapping, 5/ pkg mm, 2 pkgs mm, 5 pkgs mm, 6 pkgs mm, 5 pkgs mm, 2 pkgs. 30 Synthes MatrixRIB Technique Guide

33 Also Available 5.5 mm Drill Bit with stop, AO Quick Coupling, 125 mm 2.2 mm Drill Bits, AO Quick Coupling, 135mm with 6 mm stop with 8 mm stop with 10 mm stop with 12 mm stop with 14 mm stop MatrixMANDIBLE/THORAX Self-Retaining Fixed Handle Screwdriver 2.9 mm Titanium MatrixRIB Locking Screws, self-tapping, 1/ pkg mm mm mm mm mm 2.9 mm Titanium MatrixRIB Non-Locking Screws, self-tapping, 1/pkg mm mm mm Titanium MatrixRIB Non-Locking Screws, self-tapping, 12 mm, 5/pkg S Battery Pack, sterile, for Battery Powered Driver Hand Piece, for Battery Powered Driver References 1. Z. Ahmed, Z. Mohyuddin. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg Dec; 110(6): H. Tanaka, T. Yukioka, Y. Yamaguti, S. Shimizu, H. Goto, H. Matsuda, S. Shimazaki. Surgical stabilization of internal pneumatic stabilization. A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52(4): ; discussion M. Mohr, E. Abrams, C. Engel, W.B. Long, M. Bottlang. Geometry of Human Ribs Pertinent to Orthopaedic Chest-Wall Reconstruction. J Biomech. 2007;40(6): MatrixRIB Technique Guide Synthes 31

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36 Synthes CMF 1302 Wrights Lane East West Chester, PA Telephone: (610) To order: (800) Fax: (610) Synthes (Canada) Ltd Meadowpine Boulevard Mississauga, Ontario L5N 6P9 Telephone: (905) To order: (800) Fax: (905) Synthes, Inc. or its affiliates. All rights reserved. Synthes is a trademark of Synthes, Inc. or its affiliates. Printed in U.S.A. 9/11 J8654-D

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