COMPACT ANKLE FRACTURE SYSTEM

Transcription

1 COMPACT ANKLE FRACTURE SYSTEM Consolidated ankle fracture solution for surgery centers SURGICAL TECHNIQUE

2 TABLE OF CONTENTS INTRODUCTION Compact Ankle Fracture System 2 AO Principles 8 Indications 9 Clinical Cases 10 SURGICAL TECHNIQUE Preparation mm/3.5 mm LCP Lateral Distal Fibula Plate 12 Technique for Distal Fibula Fracture 3.5 mm LCP Hook Plate Technique 20 for Distal Fibula Fracture 4.0 mm Cannulated Screw Technique 26 for Medial Malleolus Fracture PRODUCT INFORMATION Implants 32 Instruments 36 Set List 42 Image intensifier control Compact Ankle Fracture System Surgical Technique DePuy Synthes Select

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4 CONSOLIDATED ANKLE FRACTURE SOLUTION FOR SURGERY CENTERS DePuy Synthes Select offers surgical device systems designed for use in the most common orthopedic and podiatric procedures performed in Ambulatory Surgery Centers (ASCs). The Select compact systems feature the same high-quality DePuy Synthes products used in hospitals, but combined into consolidated sets to help improve efficiency for our ASC customers. The configuration of the Compact Ankle Fracture System contains general instruments, Locking Compression Plates (LCP ) such as fibula plates, 1 /3 tubular plates, hook plate, as well as screws for syndesmotic repair and medial malleolus fractures. The LCP 1 /3 tubular plate is a commonly used implant for a high number of distal fibula fractures that results in a fixedangle construct and obtains fixation in osteoporotic bone. Additionally the LCP distal fibula plates are anatomically contoured and offer multiple screw options in the head of the plate. FLEXIBILITY IN THE OPERATING ROOM Color-coded layout for instrument identification Includes general instruments; all instrumentation is grouped by screw size, making it easier for surgical teams to quickly locate related components Contains precontoured fibula plates, 1 /3 tubular plates, and hook plates enabling surgeons to choose the appropriate option based on the complexity of the fracture Also contains solid and cannulated screws for syndesmotic repair and medial malleolus fractures Plates are designed to accomodate various fracture patterns and the patient s anatomy Locking and conventional screws allow for appropriate bone fixation Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 3

5 Compact Ankle Fracture System COLOR CODING A comprehensive color coding system highlights groups of instruments and associated screw sizes/types. Drill bits, drill guides, screwdriver shafts as well as the graphic case trays and screw racks are color-coordinated to facilitate pre-, intra-, and post-operative handling of the sets. In addition to the color for each screw size/type a band system distinguishes the drill size for the threaded hole (= one color band) and the gliding hole (= two color bands). The one band/two band principle is also replicated on the drill guides. Color Screw size (mm) Screw type Drill size (mm) Threaded hole = one color band Drill size (mm) Gliding hole = two color bands Shaft size Orange 2.7 Cortex T8 Yellow 3.5/4.0 Cortex/Cancellous mm Hex Black 3.5 Locking 2.8 T15 Gray 4.0 Cannulated mm Hex 4 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

6 Compact Ankle Fracture System ORDER OF USE LAYOUT The layout of instruments is focused on order of use to correlate with the surgical steps and therefore assist with the intra-operative sequence. Instruments are arranged by groups (general instruments, 2.7 mm screw instrumentation, etc.). The handling flows from left to right and from top to bottom. E.g. general instruments are typically used first and are therefore placed on the left. Hence, implant specific instruments are located on the right side in order of the surgical steps: Drill bit Drill guide Measuring device Screwdriver TLA 1. REDUCE 2. DRILL Left General instruments Right Implant specific instruments 2, 3, mm screw instruments 3. MEASURE 1 2, 3, mm cortex/ 4.0 mm cancellous screw instruments 2, 3, mm locking screw instruments 4. INSERT SCREW Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 5

7 Compact Ankle Fracture System IMPLANTS 2.7 MM/3.5 MM LCP LATERAL DISTAL FIBULA PLATE Anatomically contoured distal fibula plates Multiple screw options in the head of plate Locking screws offer a fixed-angle construct and obtain fixation in osteoporotic bone Coaxial screw holes help minimize screw head prominence and create a low profile construct Allows technique of clamp reduction, followed by independent lag screw, and neutralization plate placement in typical spiral fracture patterns For valgus failure fibular fractures with comminution and for bridge plating of comminuted fractures LCP ONE-THIRD TUBULAR PLATE Plate can be contoured to patient anatomy Locking screws offer a fixed-angle construct and obtain fixation in osteoporotic bone Available with 3 10 holes (33 mm 117 mm lengths) and 12 holes (141 mm) Plate contains only locking holes, that accept 3.5 mm locking screws, 3.5 mm cortex screws, and 2.7 mm cortex screws 6 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

8 Compact Ankle Fracture System Implants 3.5 MM LCP HOOK PLATE Low profile Hooks provide additional point of fixation Locking screws offer a fixed-angle construct and obtain fixation in osteoporotic bone Precontoured shape to provide spring-effect, to aid in reduction Dual hook configuration facilitates placement Nonlocking hole between the hooks allows fracture compression with a lag screw 4.0 MM CANNULATED SCREWS Used with 1.25 mm diameter guide wire Hemispherical head ensures optimal annular contact with washers and Synthes plates when screws are angled Low-profile head reduces possibility of soft tissue irritation Standard 2.5 mm hexagonal drive is compatible with screwdrivers in other commonly used Synthes sets Reverse-cutting flutes assist in screw removal Thread lengths: Short thread ( 1 /3 the screw length) Long thread ( 1 /2 the screw length) Cancellous thread profile uses deep cutting threads with a large pitch to increase resistance to pullout. The large pitch also accelerates screw insertion and removal Self-drilling, self-tapping screw tip facilitates screw insertion by eliminating the need for predrilling and tapping in most cases Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 7

9 AO PRINCIPLES In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation. 1 They are: Anatomic reduction Fracture reduction and fixation to restore anatomical relationships. Stable fixation Stability by 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. Early, active mobilization Early, active mobilization of the part and patient. 1 Müller ME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal Fixation. 3rd ed. Berlin Heidelberg New York: Springer DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

10 INDICATIONS 2.7 mm/3.5 mm LCP Distal Fibula Plate The 2.7 mm/3.5 mm LCP Distal Fibula Plates are indicated for fractures, osteotomies and nonunions of the metaphyseal and diaphyseal region of the distal fibula, especially in osteopenic bone. LCP One-Third Tubular Plates The LCP One-Third Tubular Plates are intended for fixation of fractures, osteotomies and nonunions of the clavicle, scapula, olecranon, humerus, radius, ulna, pelvis, distal tibia, and fibula, particularly in osteopenic bone. 3.5 mm LCP Hook Plate The 3.5 mm LCP Hook Plate is indicated for fractures, osteotomies and nonunions of small bones including the ulna, radius, tibia and fibula, particularly in osteoporotic bone. 4.0 mm Cannulated Screws For fracture fixation of small bones and small bone fragments. Warning: This device is not approved for screw attachment or fixation to the posterior elements (pedicles) of the cervical, thoracic or lumbar spine. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 9

11 CLINICAL CASES Case 1* 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plate Postoperative lateral Postoperative AP Case 2* LCP One-Third Tubular Plates Postoperative lateral Postoperative AP * Case studies are not necessarily predictive of results in other cases. Results in other cases may vary. 10 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

12 PREPARATION Required set ASC Ankle Fracture Set Complete the preoperative radiographic assessment and plan. Determine procedure, type of fixation, screw/plate size and implant locations to ensure proper implant selection and position. Use the appropriate method for surgical incision and exposure of the fracture as needed. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 11

13 2.7 MM/3.5 MM LCP LATERAL DISTAL FIBULA PLATE TECHNIQUE FOR DISTAL FIBULA FRACTURE The techniques for implanting the lateral distal fibula plate and one-third tubular plate are similar. The following describes implantation of a lateral distal fibula plate. 1 Reduce fibular fracture Instruments Reduction Forceps with points Reduction Forceps with serrated jaw mm Kirschner Wire, 150 mm mm Kirschner Wire, 150 mm mm Kirschner Wire, 150 mm Expose and clean the fracture site and reduce the fracture. It is critical that fibular length, alignment and rotation are accurately restored. In spiral or oblique fracture patterns, a clamp can be applied for reduction. Provisional reduction can be maintained with pointed reduction forceps or K-wires. 12 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

14 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plate Technique for Distal Fibula Fracture 1. Reduce fibular fracture continued Alternatively, in some fracture patterns, the plate can be used to assist with and guide the reduction. This may be especially important in comminuted fractures where a bridging technique is used. Technique tip: Application of an external fixator or distractor may facilitate obtaining fibular length, fracture reduction and visualization of the distal tibiofibular joint. Confirm the reduction with image intensification. Temporary reduction can be obtained with clamps, multiple Kirschner wires, or independent lag screws if the fracture pattern allows. K-wires can be placed through the distal end of the plate to assist with temporary maintenance of the reduction and for plate placement. Options for maintaining the reduction depend on the fracture configuration and include: Independent lag screws Lag screws through the plate Locking screws through the plate Locking screws do not provide interfragmentary compression; compression must be achieved with standard lag screws or by using the plate itself to compress the fracture. The fracture must be reduced and compressed before fixation of the LCP distal fibula plate with locking screws in simple fracture configurations. If a bridge plate technique is planned, the implant can be secured proximally and distally using locking screws, if the fibular length, alignment and rotation are correct. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 13

15 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plate Technique for Distal Fibula Fracture 2 Insert plate Expose the fibula proximally as needed for plate application. In the majority of circumstances, an open approach for plate application will be performed. Occasionally, a submuscular plate insertion will be performed using a minimally invasive technique. The plate can be slid along the lateral fibular shaft and positioned with the distal end of the plate approximately 5 mm from the tip of the fibula. 3 Position plate and fix provisionally Temporarily hold the plate in position using any of the following options. These options also prevent plate rotation while inserting the first locking screw: Standard plate holding forceps K-wires placed through the plate distally and/ or proximally 2.7 mm cortex screw placed in one of the distal holes 3.5 mm cortex screw placed in a Combi hole After plate insertion, check plate placement and alignment using fluoroscopy. Ensure proper reduction before inserting the first locking screw. Once locking screws are inserted, further reduction is not possible without loosening the locking screws. Verify plate placement under image intensification to determine if final screw and plate placement are acceptable. 14 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

16 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plate Technique for Distal Fibula Fracture 4 Distal screw insertion Determine the combination of screws to be used for fixation. If a combination of locking and cortex screws will be used, cortex screws should be inserted first. Note: To secure the plate to the fibula before locking screw insertion, it is recommended to pull the plate to the bone using a cortex screw. Nonlocking screw insertion fixation with 2.7 mm cortex screws Instruments mm Drill Bit, quick coupling, 125 mm, Orange mm Drill Bit, quick coupling, 100 mm, Orange mm Universal Drill Guide, Orange StarDrive Screwdriver Shaft, T8, Purple/Orange Handle, with quick coupling Depth Gauge Use the 2.0 mm drill bit through the 2.7 mm universal drill guide to predrill the bone. Measure for screw length using the depth gauge. Select and insert the appropriate 2.7 mm cortex screw using the StarDrive screwdriver shaft. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 15

17 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plate Technique for Distal Fibula Fracture 4. Distal screw insertion continued Locking screw insertion fixation with 2.7 mm locking screw If a locking screw will be used as the first screw, be sure the fracture is reduced and the plate is held securely to the bone. This prevents plate rotation as the screw is locked to the plate. Instruments mm Drill Bit, quick coupling, 125 mm, Orange StarDrive Screwdriver Shaft, T8, Purple/Orange Holding Sleeve for StarDrive Screwdriver Shaft, T Handle, with quick coupling Drill Guide Depth Gauge Torque Limiting Attachment, 0.8 Nm, quick coupling Insert the 2.0 mm threaded drill guide into a 2.7 mm locking hole until fully seated. Use the 2.0 mm drill bit to drill to the desired depth. Remove the 2.0 mm threaded drill guide. Use the depth gauge to determine screw length. Select and insert the appropriate 2.7 mm locking screw using the StarDrive screwdriver shaft. 16 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

18 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plate Technique for Distal Fibula Fracture 5 Shaft screw insertion Nonlocking screw insertion fixation with 3.5 mm cortex screws Instruments Handle, with quick coupling Holding Sleeve Depth Gauge mm Drill Bit, Yellow mm Drill Bit, Yellow Small Hexagonal Screwdriver Shaft, Yellow/Gray mm Universal Drill Guide, Yellow Use the 2.5 mm drill bit through the 3.5 mm universal drill guide to predrill the bone. For the neutral position, press the drill guide down in the nonthreaded hole. To obtain compression, place the drill guide at the end of the nonthreaded hole away from the fracture (do not apply downward pressure on the spring-loaded tip). Measure for screw length using the depth gauge. Select and insert the appropriate 3.5 mm cortex screw using a small hexagonal screwdriver shaft. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 17

19 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plate Technique for Distal Fibula Fracture 5. Shaft screw insertion continued Locking screw insertion fixation with 3.5 mm locking screw Instruments StarDrive Screwdriver Shaft, T15, Black mm Drill Bit, Black mm Threaded Drill Guide Depth Gauge Torque Limiting Attachment, 1.5 Nm, quick coupling Insert the 2.8 mm threaded drill guide into a locking hole or Combi hole until fully seated. Use the 2.8 mm drill bit to drill to the desired depth. Remove the drill guide. Use the depth gauge to determine screw length. Select and insert the appropriate 3.5 mm locking screw using the StarDrive screwdriver shaft. 18 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

20 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plate Technique for Distal Fibula Fracture 6 Confirm reduction and fixation Carefully assess the final reduction and fixation via direct visualization and image intensification. Confirm the stability of the fixation and that there is unrestricted motion at the ankle joint. Using AP and lateral fluoroscopic visualization, confirm reduction and appropriate positioning of the plate and screws. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 19

21 3.5 MM LCP HOOK PLATE TECHNIQUE FOR DISTAL FIBULA FRACTURE 1 Fracture reduction and primary fixation Instrument mm Kirschner Wire, 150 mm In multifragmentary fractures, care must be taken to avoid excessive stripping of the periosteum as well as devascularization of the fragments. Indirect reduction usually is obtained by longitudinal traction, either on the foot, or of the main distal fragment using a bone hook. If the distal fragment is large enough, insert one or two K-wires to hold the reduction. The correct length, rotation and alignment must be checked under image intensification. 20 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

22 3.5 mm LCP Hook Plate Technique for Distal Fibula Fracture 2 Position plate Instruments mm Drill Bit, quick coupling, 125 mm, Orange mm Universal Drill Guide, Orange mm Kirschner Wire Bending Iron for 2.7 mm and 3.5 mm Plates Bending Iron for 2.7 mm and 3.5 mm Plates Contour the plate to fit the bone using the bending irons. Place the tip of the hooks inside the bone as distally as possible. Optionally predrill two holes for hook placement using the plate as a guide. Be careful not to damage the surgical gloves or the patient s surrounding soft tissues with the sharp hooks. Note: If required, the plate can be bent using bending pliers. Pay attention not to bend the plate over the Combi holes to prevent deformity of the locking portion. The plate hooks must not be bent. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 21

23 3.5 mm LCP Hook Plate Technique for Distal Fibula Fracture 3 Insert cortex screws Determine the combination of screws to be used for fixation. If a combination of locking and cortex screws will be used, cortex screws should be inserted first. Note: To secure the plate to the fibula before locking screw insertion, it is recommended to pull the plate to the bone using a cortex screw. Instruments mm Drill Bit, quick coupling, 110 mm, Yellow mm Drill Bit, quick coupling, 110 mm, Yellow mm Universal Drill Guide, Yellow mm/2.5 mm Insert, Yellow Small Hexagonal Screwdrive Shaft, Yellow/Grey Handle with Quick Coupling Holding Sleeve Depth Gauge Use the 2.5 mm drill bit through the 3.5 mm universal drill guide to predrill the bone. Measure for screw length using the depth gauge. Select and insert the appropriate 3.5 mm cortex screw using the small hexagonal screwdriver shaft and the handle with quick coupling. Note: In osteopenic bone, a 4.0 mm cancellous screw may also be used in this step. 22 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

24 3.5 mm LCP Hook Plate Technique for Distal Fibula Fracture 4 Insert screw between hooks (optional) Instruments mm Drill Bit, quick coupling, 110 mm, Yellow mm Drill Bit, quick coupling, 110 mm, Yellow mm Universal Drill Guide, Yellow mm/2.5 mm Insert, Yellow Countersink for 3.5 mm Cortex and 4.0 mm cancellous Screws, Yellow Small Hexagonal Screwdrive Shaft, Yellow/Grey Handle with Quick Coupling Holding Sleeve Depth Gauge Drill a screw hole between the hooks with the 2.5 mm drill bit. Be sure to angle the drill away from the long axis of the plate to avoid colliding with other screws in the plate. Measure for screw length, using the depth gauge. Ensure that the screw will not collide with the reduction Kirschner wires. Insert and tighten a 3.5 mm cortex screw using the small hexagonal screwdriver shaft and the handle with quick coupling. Alternatively, use a 2.7 mm cortex screw in this hole. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 23

25 3.5 mm LCP Hook Plate Technique for Distal Fibula Fracture 5 Insert locking screws Instruments mm Drill Bit, quick coupling, 165 mm, Black mm Threaded Drill Guide Stardrive Screwdriver Shaft, T15, Black Handle with Quick Coupling Depth Gauge Torque Limiting Attachment, 1.5 Nm, quick coupling Insert the threaded drill guide into the locking portion of an open elongated Combi hole in the plate shaft until fully seated. Use the 2.8 mm drill bit to the desired depth. Remove the drill guide and use the depth gauge to determine the screw length. Insert a 3.5 mm locking screw using the StarDrive screwdriver shaft with torque limiting attachment and the handle with quick coupling. Remove the 1.6 mm Kirschner wires. Note: Always use a torque limiting attachment when using power to insert screws. Alternatively, follow the appropriate steps for inserting a 3.5 mm cortex screw into this hole. 24 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

26 3.5 mm LCP Hook Plate Technique for Distal Fibula Fracture 6 Confirm reduction and fixation Carefully assess the final reduction and fixation via direct visualization and image intensification. Confirm the stability of the fixation and that there is unrestricted motion at the ankle joint. Using AP and lateral fluoroscopic visualization, confirm reduction and appropriate positioning of the plate and screws. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 25

27 4.0 MM CANNULATED SCREW TECHNIQUE FOR MEDIAL MALLEOLUS FRACTURE 1 Reduction Instrument Reduction Forceps with Points, broad Reduce the fracture anatomically with the use of small pointed reduction forceps, taking care with the soft tissues. Do not strip the periosteum more than necessary. 26 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

28 4.0 mm Cannulated Screw Technique for Medial Malleolus Fracture 2 Insert guide wires Instruments mm/1.25 mm Double Drill Sleeve, Grey mm Threaded Guide Wire Insert the 1.25 mm guide wires through the 2.7 mm/ 1.25 mm double drill sleeve to the appropriate depth. Check placement of the wire under image intensification. Remove the drill sleeve. As decided in preoperative planning, these K-wires should occupy the future position of the lag screws. The direction of the k-wires/screws should be as perpendicular as possible to the fracture plane. 3 Predrill (optional) Instruments mm/1.25 mm Double Drill Sleeve, Grey mm Cannulated Drill Bit, Grey In dense bone, it may be helpful to use a 2.7 mm cannulated drill bit to penetrate the near cortex prior to screw insertion. Use the 2.7 mm cannulated drill bit with the 2.7 mm/ 1.25 mm double drill sleeve to drill the near cortex only. Use image intensification if necessary. Care must be taken to avoid penetration of the ankle joint. In some cases, especially in cancellous bone, the self-drilling flutes of the 4.0 mm cannulated screw make predrilling unnecessary. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 27

29 4.0 mm Cannulated Screw Technique for Medial Malleolus Fracture 4 Measure Instrument Cannulated Screw Measuring Device The length of the screw shaft must be chosen so that the threaded part of the screw lies fully within the opposite bone fragment, but does not penetrate beyond the denser epiphyseal cancellous bone. Slide the tapered end of the cannulated screw measuring device over the guide wire, down to the bone. Read the scale at the end of the guide wire to determine appropriate screw length. This reading will place the screw 5 mm short of the tip of the guide wire, allowing the threaded portion of the guide wire to remain in the bone during screw insertion. 28 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

30 4.0 mm Cannulated Screw Technique for Medial Malleolus Fracture 5 Insert screw Instruments Cannulated 2.5 mm Hexagonal Screwdriver Shaft, Grey Holding Sleeve for Cannulated 2.5 mm Hexagonal Screwdriver Handle with quick coupling Place the appropriate length screw over the guide wire. Use the cannulated hexagonal screwdriver shaft, and holding sleeve to insert the screw. Insert the screw without excessive tightening. The screw should come to rest with its threads completely beyond the fracture line. Remove and discard the guide wire. Notes If using power to insert screws, use of the holding sleeve will reduce the risk of stripping the hex recess To prevent the screw head from sinking into the thin malleolar cortex, the use of a washer is recommended, especially in osteoporotic bone Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 29

31 4.0 mm Cannulated Screw Technique for Medial Malleolus Fracture 6 Confirm reduction and fixation Carefully assess the final reduction and fixation via direct visualization and image intensification. Confirm the stability of the fixation and that there is unrestricted motion at the ankle joint. Using AP and lateral fluoroscopic visualization, confirm reduction and appropriate positioning of the screws. 30 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

32 4.0 mm Cannulated Screw Technique for Medial Malleolus Fracture 7 Cleaning cannulations Instruments mm Cleaning Brush mm Cleaning Sylet Note: Cleaning the cannulation in each instrument is imperative for proper function and component life. Instruments should be cleared intraoperatively with the cleaning stylet to prevent accumulation of debris in the cannulation and potential binding of the instruments about the guide wire. Instruments should be cleaned postoperatively with both the stylet and cleaning brush. Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 31

33 IMPLANTS 2.7 mm Locking Screws, self-tapping 1,3 Threaded, conical head locks securely into the threaded holes in the plate to provide angular stability Locked screws allow unicortical screw fixation and load transfer to the near cortex T8 StarDrive recess 2.7 mm Cortex Screws, self-tapping 1,3 For use in round or Combi holes Used to provide compression or neutral fixation T8 StarDrive recess 3.5 mm Locking Screws, self-tapping 1,3 Threaded, conical head locks securely into the threaded holes in the plate to provide angular stability Locked screws allow unicortical screw fixation and load transfer to the near cortex T15 StarDrive recess 3.5 mm Low-profile Cortex Screws, self-tapping 1,2 For use in round or Combi holes Used to provide compression or neutral fixation 2.5 mm Hex recess 4.0 mm Cancellous Bone Screws 1,2 For use in round or Combi holes Used to provide compression or neutral fixation Fully or partially threaded shaft 2.5 mm Hex recess Screws are available in: L stainless steel 2. commercially pure (CP) titanium 3. titanium alloy (Ti-6AI-7Nb) 32 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

34 Implants 4.0 mm Cannulated Screws, short thread 1,3 Cannulated shaft accepts 1.25 mm diameter guide wires Thread length = 1 /3 screw length 2.5 mm Hex recess Washer, 7.0 mm 1,3 To prevent screw head from sinking into osteoporotic bone Screws are available in: L stainless steel 2. commercially pure (CP) titanium 3. titanium alloy (Ti-6AI-7Nb) Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 33

35 Implants 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plates 2,4 Right and left designs Lengths from 86 mm to 151 mm LCP One-Third Tubular Plates, with collar 1,3 Available with 4 10 holes (45 mm 117 mm lengths) Plate contains only locking holes, that accept 3.5 mm locking screws, 3.5 mm cortex screws, 2.7 mm cortex screws and 4.0 mm cancellous screws Plates are available in: L stainless steel 2. 22Cr-13Ni-5Mn stainless steel 3. commercially pure (CP) titanium 4. titanium alloy (Ti-6AI-7Nb) 34 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

36 Implants 3.5 mm LCP Hook Plate 1,3 One plate design for right and left 3 Shaft holes Length 62 mm Plates are available in: L stainless steel 2. 22Cr-13Ni-5Mn stainless steel 3. commercially pure (CP) titanium 4. titanium alloy (Ti-6AI-7Nb) Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 35

37 INSTRUMENTS mm Drill Bit, quick coupling, 110 mm, Yellow mm Drill Bit, quick coupling, 110 mm, Yellow Countersink for 3.5 mm Cortex and 4.0 mm Cancellous Screws, Yellow mm/2.5 mm Insert, Yellow Small Hexagonal Screwdriver Shaft, Yellow/Grey Holding Sleeve for Cannulated 2.5 mm Hexagonal Screwdriver Stardrive Screwdriver Shaft, T15, Black 36 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

38 Instruments mm Universal Drill Guide, Yellow mm Drill Bit, quick coupling, 125 mm, Orange mm Drill Bit, quick coupling, 100 mm, Orange Countersink for 2.7 mm Cortex Screws, Purple/Orange mm Universal Drill Guide, Orange Stardrive Screwdriver Shaft, T8, 105 mm, Purple/Orange mm/1.25 mm Double Drill Sleeve, Grey Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 37

39 Instruments mm Cannulated Drill Bit, quick coupling, 160 mm, Grey Cannulated Countersink for 5.0 mm and 4.0 mm cannulated screws, Grey Cannulated 2.5 mm Hexagonal Screwdriver Shaft, Grey mm Drill Bit, quick coupling, 165 mm, Black mm Kirschner Wire, 150 mm, trochar point mm Kirschner Wire, 150 mm, trochar point mm Kirschner Wire, 150 mm, trochar point 38 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

40 Instruments Handle with quick coupling mm Threaded Drill Guide Drill Sleeve for 2.0 mm Drill Bit Holding Sleeve Holding Sleeve for Depth Gauge for 2.7 mm and 3.5 mm Cortex and 4.0 Cancellous Screws Cannulated Screw Measuring Device for 3.5 mm and 4.0 mm screws Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 39

41 Instruments mm Cleaning Brush mm Cleaning Stylet Sharp Hook Screw Forceps Push-Pull Reduction Device Bending Iron for 2.7 mm and 3.5 mm Plates Bending Iron for 2.7 mm and 3.5 mm Plates Reduction Forceps with Points, broad 40 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

42 Instruments Hohmann Retractor, 8 mm width Periosteal Elevator, 6 mm width, round edge, curved blade Hohmann Retractor, 15 mm width Reduction Forceps with serrated jaw Torque Limiting Attachment, 1.5 Nm, quick coupling Torque Limiting Attachment, 0.8 Nm, quick coupling mm Threaded Guide Wire, 150 mm Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 41

43 COMPACT ANKLE FRACTURE INSTRUMENT AND IMPLANT SET ASC ( ) Graphic Case Compact Ankle Fracture Graphic Case ASC Instruments mm Drill Bit, quick coupling, 110 mm, Yellow, 2 ea mm Drill Bit, quick coupling, 110 mm, Yellow, 2 ea Countersink for 3.5 mm Cortex and 4.0 mm Cancellous Screws, Yellow mm/2.5 mm Insert, Yellow Small Hexagonal Screwdriver Shaft, Yellow/Grey Holding Sleeve for Cannulated 2.5 mm Hexagonal Screwdriver Stardrive Screwdriver Shaft, T15, Black mm Universal Drill Guide, Yellow mm Drill Bit, quick coupling, 125 mm, Orange, 2 ea mm Drill Bit, quick coupling, 100 mm, Orange, 2 ea Countersink for 2.7 mm Cortex Screws, Purple/Orange mm Universal Drill Guide, Orange Stardrive Screwdriver Shaft, T8, 105 mm, Purple/Orange mm/1.25 mm Double Drill Sleeve, Grey mm Cannulated Drill Bit, quick coupling, 160 mm, Grey, 2 ea Cannulated Countersink for 5.0 mm and 4.0 mm Cannulated Screws, Grey Cannulated 2.5 mm Hexagonal Screwdriver Shaft, Grey mm Drill Bit, quick coupling, 165 mm, Black, 2 ea. For detailed cleaning and sterilization instructions, please refer to: In Canada, the cleaning and sterilization instructions will be provided with the Loaner shipments. 42 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

44 Compact Ankle Fracture Instrument and Implant Set ASC ( ) Instruments continued mm Kirschner Wire, 150 mm, trochar point, 10/pkg mm Kirschner Wire, 150 mm, trochar point, 10/ pkg mm Kirschner Wire, 150 mm, trochar point, 10/pkg Handle with quick coupling, 2 ea mm Threaded Drill Guide, 2 ea Drill Sleeve for 2.0 mm Drill Bit, 2 ea Holding Sleeve Holding Sleeve for Depth Gauge for 2.7 mm and 3.5 mm Cortex, and 4.0 Cancellous Screws Cannulated Screw Measuring Device for 3.5 mm and 4.0 mm screws mm Cleaning Brush mm Cleaning Stylet Sharp Hook Screw Forceps Push-Pull reduction device Bending Iron for 2.7 mm and 3.5 mm Plates Bending Iron for 2.7 mm and 3.5 mm Plates Reduction Forceps with Points, broad Hohmann Retractor, 8 mm width, 2 ea Periosteal Elevator, 6 mm width, round edge, curved blade Hohmann Retractor, 15 mm width, 2 ea Reduction Forceps with serrated jaw Torque Limiting Attachment, 1.5 Nm, quick coupling Torque Limiting Attachment, 0.8 Nm, quick coupling mm Threaded Guide Wire, 150 mm, 10 ea. 22Cr-13Ni-5Mn stainless steel. Plates are also available in titanium alloy (Ti-6Al-7Nb). * 316L stainless steel. Plates/screws are also available in Commercially pure (CP) titanium. ** 316L stainless steel. Plates/screws are also available in titanium alloy (Ti-6Al-7Nb). Implants 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plates Stainless steel Holes Length (mm) right left right left right left right left LCP One-Third Tubular Plates, with collar Stainless steel* Holes Length (mm) mm LCP Hook Plate Stainless steel* Holes Length (mm) mm Locking Screws, self-tapping, with T8 StarDrive recess, 5 ea. Length Length Stainless steel** (mm) Stainless steel (mm) Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 43

45 Compact Ankle Fracture Instrument and Implant Set ASC ( ) Implants continued 2.7 mm Cortex Screw, self-tapping, with T8 StarDrive recess, 3 ea. Length Length Stainless steel** (mm) Stainless steel** (mm) mm Locking Screws, self-tapping, with StarDrive recess, 3 ea. Length Length Stainless steel** (mm) Stainless steel** (mm) mm Cortex Screws, with low-profile head, self-tapping, hex drive recess Stainless steel* Length (mm) Qty * 316L stainless steel. Plates/screws are also available in Commercially pure (CP) titanium. ** 316L stainless steel. Plates/screws are also available in titanium alloy (Ti-6Al-7Nb). 44 DePuy Synthes Select Compact Ankle Fracture System Surgical Technique

46 Compact Ankle Fracture Instrument and Implant Set ASC ( ) Implants continued 4.0 mm Cancellous Bone Screws, fully threaded, 3 ea. Length Length Stainless steel* (mm) Stainless steel* (mm) Also available Titanium Compact Ankle Fracture Instrument and Implant Set 4.0 mm Cancellous Bone Screws, partially threaded, 3 ea. Length Length Stainless steel* (mm) Stainless steel* (mm) mm Cannulated Screws, short thread, 3 ea. Length Length Stainless steel** (mm) Stainless steel** (mm) Washer, 7.0 mm Stainless steel** Qty * 316L stainless steel. Plates/screws are also available in Commercially pure (CP) titanium. ** 316L stainless steel. Plates/screws are also available in titanium alloy (Ti-6Al-7Nb). Compact Ankle Fracture System Surgical Technique DePuy Synthes Select 45

47 Synthes Inc Wrights Lane East West Chester, PA Telephone: (610) To order: (800) Synthes (Canada) Ltd Meadowpine Boulevard Mississauga, Ontario L5N 6P9 Telephone: (905) To order: (800) Fax: (905) DePuy Synthes Trauma, a division of DOI All rights reserved. J12439-A 9/13