LCP Pediatric Condylar Plate 90, 3.5 and 5.0. For distal femur osteotomies.

Transcription

1 LCP Pediatric Condylar Plate 90, 3.5 and 5.0. For distal femur osteotomies. Surgical Technique This publication is not intended for distribution in the USA.

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

3 Table of Contents Introduction LCP Pediatric Condylar Plate System 2 AO Principles 4 Indications 5 Clinical Cases 6 Surgical Technique Preoperative Planning 8 Patient Positioning and Approach 10 Guide Wire Insertion 11 Osteotomy 17 Distal Fixation 19 Reduction 27 Proximal Fixation 28 Medialization 34 Product Information Implants 38 Instruments 43 LCP Pediatric Plate System Module Overview 55 Bibliography 56 MRI Information 57 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 1

4 LCP Pediatric Condylar Plate 90, 3.5 and 5.0. For distal femur osteotomies. LCP Pediatric Condylar Plate System LCP Pediatric Condylar Plates are specifically designed locking compression plates for osteotomies of the distal femur in children and adolescents. The LCP features incorporated are fixed angle locking screws in the metaphysis and combi holes for the diaphysis that allow a choice of locked or cortical screws. LCP Pediatric Condylar Plates 3.5 and 5.0 have a universal design for the left and right femur. Osteotomies for correction in every plane can be stabilized with these plates. The LCP Pediatric Condylar Plate belongs to the family of LCP Pediatric Hip Plates and requires that instrumentation for its use. 2 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

5 Features and Benefits The LCP Pediatric Condylar Plate offers several advantages: Angular stability Reduces the risk of primary and secondary loss of correction. The angular stability eliminates the need for additional immobilization in the majority of cases. Easy and safe surgical technique Initial plate positioning with Kirschner wires allows easy adjustment with less bone damage. Medialization Medialization of the shaft can be achieved using the plate as an internal fixator, preventing golf club deformity of the distal femur. Anatomic design This plate fits the distal femur proximal to the growth plate allowing easy positioning. Low profile Plate design and locking construct minimize muscle disruption and reduce soft-tissue irritation. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 3

6 AO Principles Stable fixation The fixation of the LCP plate with angular stable screws reduces the risk of intra- and postoperative loss of correction in osteotomies. Preservation of blood supply The structure and nature of the pediatric periosteum allow blood supply to be maintained even if the periosteum is elevated. Early mobilization The use of LCP implants allows early and active mobilization, including cast-free postoperative management (3.5/5.0 system) in younger and handicapped children where appropriate. 4 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

7 Indications This surgical technique focuses on the LCP Pediatric Condylar Plate 90, 3.5 and 5.0 for deformity correction in the distal femur in all planes with or without additional rotation correc tion. The LCP Pediatric Condylar Plate is intended for use in pediatric patients up to adolescence and for small-stature adult patients. Specific indications include: Fixed flexion contracture of knee in neurological conditions Deformity correction in the distal femur Rotational malalignment of the femur (if distal correction preferred) Supracondylar fractures of the femur Important: Make sure to choose the appropriate plate for the patient s age, size and bone quality. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 5

8 Clinical Cases Case 1 * Preoperative, AP 10 years old male with spastic diplegia. Preoperative, lateral Fracture of the inferior pole of the patella as a sign of high stress caused by fixed flexion contracture of 30. Postoperative, AP and lateral Anatomical position of the plate in AP view following supracondylar extending osteotomy with 30 of extension and 15 of external rotation shown in lateral view. This procedure was combined with patellar tendon shortening. Case 2 * Preoperative, AP and lateral 8 year old girl with arthrogryposis multiplex congenita and bilateral severe, fixed knee flexion deformity. Postoperative, AP and lateral Eight weeks after bilateral supracondylar 25 extension osteotomy with complete consolidation. 6 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

9 Case 3 * Preoperative, AP and lateral 17 years old male with spastic diplegia and fixed flexion contracture of 25. Postoperative, AP and lateral Six weeks after bilateral supracondylar extension osteotomy of 25 and 20 of external rotation stable correction is shown. Postoperative, AP and lateral Complete consolidation after one year. * Images provide with permission from Prof. Dr Reinald Brunner and Dr Erich Rutz, MD Children s University Hospital of Basel, UKBB, Switzerland LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 7

10 Surgical Technique Preoperative Planning Preoperative planning of osteotomies of the distal femur is somewhat different from that for hip osteotomies. The principles, however, are identical: 1 Decide what corrections in what planes are required. This may be achieved by a combination of clinical examination, x-rays (for example long leg views for alignment), CT scans (to assess femoral torsion) or frequently through examination under anesthesia 2 Decide how the implant should be placed to achieve the correction e.g. bone wedges to be excised, opening wedges to be created (unusual in the distal femur due to the neurovascular structures), shortening of the femur required to relax for soft tissues (common in neurological disease with contracture) Note: The condylar plate is contoured such that distal screws will be at 90 to the midline of the shaft if the plate is fitted on the surface of the bone. Generally, the distal screws should be parallel to the growth plate in the coronal plane, although care must be taken to establish that there is no deformity of the distal fragment that would negate this assumption. 8 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

11 Plate type This technique guide focuses on the LCP Pediatric Condylar Plates 3.5 and 5.0 and describes the options of axial corrections in the distal femur. The pictures represent the LCP Pediatric Condylar Plate 3.5 (corresponding to implant Art. No ). The surgical technique involves the use of screw holes where applicable. Please see the designation of each hole as indicated. The surgical technique described is based on a 30 extension and 30 external rotation osteotomy C A D B A, B, C: Distal locking screws D: Positioning Kirschner wire 1, 2 and 3: Locking or cortical screws LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 9

12 Patient Positioning and Approach 1 Positioning and preparation of the patient The operation is performed with the patient supine on a radiolucent table. The whole leg is prepared up to the inguinal region. Note: In difficult cases it may be advisable to prepare both legs to allow a visual check of both legs. 2 Approach A standard lateral approach to the distal femur reflecting the vastus lateralis anteriorly should be used. The level of the incision should be determined under image intensifier control. Tip: The use of a sterile tourniquet may facilitate the approach. 11 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

13 Guide Wire Insertion 1 Localize the frontal plane of the distal femur Instrument Kirschner Wire B 2.0 mm with trocar tip, length 150 mm, Stainless Steel After subperiosteal preparation of the distal femur, place a Kirschner wire extra-periosteally over the front of the femur 1 cm above the physis or by rotating the leg under image intensifier control until the patella is perfectly anterior and in the midline. Check the alignment of the Kirschner wire in the frontal plane. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 11

14 Guide Wire Insertion 2 Insert positioning Kirschner wire in hole D 1 Instruments for 3.5 mm plate Aiming Block for Screws B 3.5 mm, for LCP Pediatric Hip Plates Positioner for Aiming Block Kirschner Wire B 2.0 mm with threaded tip, length 150/15 mm, Stainless Steel Instruments for 5.0 mm plate Aiming Block for Screws B 5.0 mm, for LCP Pediatric Hip Plates Positioner for Aiming Block Kirschner Wire B 2.0 mm with threaded tip, length 150/15 mm, Stainless Steel Assemble the positioner and the aiming block accordingly (1). Localize distal femoral growth plate under image intensifier control. 2 The insertion point for the positioning Kirschner wire depends on the age and size of the patient. For the 3.5 mm plate insertion is cm and the 5.0 mm plate cm above the distal physis. Note: In extension osteotomy the insertion point will need to be more proximal and more posterior as the plane of the two distal screws will not be parallel to the physis in the sagittal view (2). 11 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

15 Using the positioner/aiming block assembly to determine the angle for correction in the coronal (frontal) plane may prove difficult. This is because the cortex of the distal femur is at an angle to the line of the shaft due to the supracondylar flare. In the coronal (frontal) plane, the positioning wire is therefore inserted parallel to the physis and the positioner/ aiming block assembly is used to determine the angle of correction in the sagittal plane. 3 Insert the positioning Kirschner wire in the appropriate hole in the aiming block (hole D) so that it is parallel to the anterior surface orientation Kirschner wire and such that when the block is rotated for the correction in the sagittal plane there will be space for the main Kirschner wires that correspond to the screws (3; 4). When the positioning Kirschner wire is correctly positioned, remove the anterior orientation Kirschner wire LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 11

16 Guide Wire Insertion 3 Insert Kirschner guide wires for distal screws Instruments for 3.5 mm plate Aiming Block for Screws B 3.5 mm, for LCP Pediatric Hip Plates Kirschner Wire B 2.8 mm with spade point tip Positioner for Aiming Block Adapter for Kirschner Wires B 2.8 mm, for LCP Pediatric Hip Plates 3.5/ Screwdriver, hexagonal, small, B 2.5 mm, with Groove Positioning Plate, triangular, length 45 mm, 100 /60 / Positioning Plate, triangular, length 45 mm, 80 /70 / Positioning Plate, triangular, length 45 mm, 90 /50 /40 Instruments for 5.0 mm plate Aiming Block for Screws B 5.0 mm, for LCP Pediatric Hip Plates Kirschner Wire B 2.8 mm with spade point tip Positioner for Aiming Block Adapter for Kirschner Wires B 2.8 mm, for LCP Pediatric Hip Plates 3.5/ Screwdriver, hexagonal, small, B 2.5 mm, with Groove Positioning Plate, triangular, length 45 mm, 100 /60 / Positioning Plate, triangular, length 45 mm, 80 /70 / Positioning Plate, triangular, length 45 mm, 90 /50 /40 11 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

17 Rotate the aiming block and positioner into the correct position for the sagittal plane correction. This can be done by calculation but is more commonly achieved by placing the positioner in line with the tibia in the position of maximum achievable extension. 1 Insert the 2.8 mm Kirschner guide wires for plate holes A and B through the aiming block (1). LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 11

18 Guide Wire Insertion To prevent any interference with other wires, adjust the Kirschner wire adapter before inserting the Kirschner guide wire for hole B. (Insertion of wire for hole B shown in red in picture 2) DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

19 Osteotomy Instrument Positioner for Osteotomy 1 Level of the osteotomy The osteotomy needs to be at least 15 mm proximal to the aiming block for the 3.5 mm plate and 20 mm for the 5.0 mm plate. Make a mark with an oscillating saw (1). Important: Prior to cutting, the bone wires should be inserted to allow assessment and control of rotation. In the distal fragment the initial positioning wire is adequate. In the proximal fragment, a bicortical wire should be inserted such that it does not interfere with the osteotomy. It is helpful to calculate the rotational correction before inserting this wire so that after the osteotomy is fixed the wire lies parallel to the positioning wire in the distal fragment (2). If no rotational correction is planned, then clearly marking the femur with the saw may adequately control rotation. 2 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 11

20 Osteotomy The first cut of the osteotomy should be parallel to the Kirschner wires and sufficiently proximal to allow the third screw in hole C to gain adequate purchase (3). If considerable sagittal plane correction is planned then that must be taken into account. If the positioner for osteotomy is laid against the wires, this gives the minimum distance that will allow insertion of the screw in hole C. 3 4 Note: The cut is best made freehand under image intensifier control, keeping the blade parallel to the Kirschner wires in both planes. Opening wedge osteotomy can be used in deformity correction. It is generally not recommended when treating contracture in neurological conditions. A second cut to the osteotomy is therefore recommended in this situation and this should be made in the proximal fragment at a right angle to the line of the shaft in all planes (5). The size of the wedge is determined by preoperative planning and depending on the clinical situation. The resulting wedge is removed (6). Note: Before completing the distal cut, it is recommend to make the proximal cut to half the diameter of the bone (4). This guarantees optimal fit of both fragments after reduction. Note: Frequently some shortening is required, in which case the fragment of bone excised will be trapezoidal rather than wedge shaped DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

21 Distal Fixation 1 Position plate 1 Instruments for 3.5 mm plate Positioner for Osteotomy LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate Instruments for 5.0 mm plate Reduction Sleeve 4.3/ Positioner for Osteotomy LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm, for LCP Pediatric Hip Plate Insert the drill sleeves into plate holes A and B until they are completely gripped by the thread. Slide the plate over the Kirschner guide wires and the positioning Kirschner wire (1;2). Note for 5.0 mm plate: An additional reduction sleeve must be inserted in each LCP drill sleeve before sliding the plate over the wires. 2 Note: Fixation in the distal fragment must always be done with locking screws. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 11

22 Distal Fixation 2 Determine screw length and insert distal femoral locking screws A and B 1 Instruments for 3.5 mm plate Direct Measuring Device for Kirschner Wires B 2.8 mm, length 200 mm Positioner for Osteotomy Instruments for 5.0 mm plate Direct Measuring Device for Kirschner Wires B 2.8 mm, length 200 mm Reduction Sleeve 4.3/ Positioner for Osteotomy LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling Determine the screw length by measuring the insertion depth of the Kirschner guide wire with the direct measuring device for Kirschner guide wires. Slide the appropriate end of the measuring device over the Kirschner wire against the LCP drill sleeve and determine the proper screw length (1). Remove the Kirschner wire and the LCP drill sleeve in hole A. If necessary, use the wrench at one end of the positioner for osteotomy (2). 2 Insert the screw in hole A (see step 3 for insertion options). 22 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

23 Note for 5.0 mm plate: Remove the reduction sleeve and then measure the Kirschner wire length over the drill sleeve. Enlarge the hole from 2.8 to 4.3 mm with the LCP drill bit. Then remove the drill sleeve and insert the screw as above. Important: It is recommended to use a power tool to insert the self-tapping screw. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 22

24 Distal Fixation 3 Distal fixation Instruments for 3.5 mm plate Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive Screwdriver Shaft, hexagonal, small, B 2.5 mm Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling Handle for Torque Limiter Nos and Instruments for 5.0 mm plate Torque Limiter, 4 Nm, for Compact Air Drive and Power Drive Screwdriver Shaft 3.5, hexagonal, self-holding Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling Handle for Torque Limiter Nos and DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

25 Two options are available: Option A Manual insertion To insert the locking screw manually, attach the torque limiter handle corresponding to the plate size to the torque limiter and insert a screwdriver shaft. Insert the locking screw, and lock it in the plate. The optimum torque is reached after one click. 1 Option B Insertion with a power tool To insert the locking screw using a power tool, pick up the locking screw and insert it into the plate hole until the screw head is slightly above the plate. Do not fully tighten the screw with the power tool. Uncouple the power tool, fit the handle and tighten the screw manually. The optimum torque is reached after one click using the corresponding torque limiter. Insert the screw in hole B in the same way as in hole A (1;2). Note: Do not remove the positioning wire until the end of the proximal fixation. 2 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 22

26 Distal Fixation 4 Insert locking screw in hole C Instruments for 3.5 mm plate LCP Drill Bit B 2.8 mm with Stop, length 165 mm, 2-flute, for Quick Coupling LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive Screwdriver Shaft, hexagonal, small, B 2.5 mm Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling Handle for Torque Limiter Nos and Instruments for 5.0 mm plate LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm, for LCP Pediatric Hip Plate Depth Gauge for Screws B 4.5 to 6.5 mm, measuring range up to 110 mm Torque Limiter, 4 Nm, for Compact Air Drive and Power Drive Screwdriver Shaft 3.5, hexagonal, self-holding Screwdriver Stardrive 4.5/5.0, T25, with Groove, length 240 mm Handle for Torque Limiter Nos and DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

27 Mount the LCP drill sleeve onto hole C and drill the hole with the LCP drill bit through both cortices. Either read off the screw length from the calibrated drill or determine the screw length with the depth gauge (1). 1 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 22

28 Distal Fixation Insert the screw in hole C (2;3) DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

29 Reduction Instruments Bone Holding Forceps, self-centering, soft lock, length 239 mm Reduction Forceps, toothed, soft lock, length 250 mm Reduce the plate onto the femoral shaft and check the alignment on the image intensifier (1;2). Decide whether medialization will be required. Check visually that the plate is parallel to the shaft in the sagittal plane. 2 Important: After reduction, the initial positioning wire in the distal fragment lies parallel to the bicortical wire in the proximal part to achieve correct axial alignment (3). Note: If medialization is required, follow the steps as described on pages LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 22

30 Proximal Fixation Since this is an LCP plate, either locking or cortical screws can be used. After a locking screw has been inserted into in the proximal fragment it is not permissible to insert a cortical screw; locking screws can however be inserted after cortical screws. Option A: Proximal fixation with locking screws Insert screws in holes 1, 2 and 3. Instruments for 3.5 mm plate Screwdriver Shaft, hexagonal, small, B 2.5 mm Screwdriver Shaft Stardrive, 3.5, T15, self-holding, for AO/ASIF Quick Coupling Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive Handle for Torque Limiter Nos and LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate LCP Drill Bit B 2.8 mm with Stop, length 165 mm, 2-flute, for Quick Coupling Instruments for 5.0 mm plate Screwdriver Shaft 3.5, hexagonal, self-holding Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling Depth Gauge for Screws B 4.5 to 6.5 mm, measuring range up to 110 mm LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm, for LCP Pediatric Hip Plate LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling Torque Limiter, 4 mm, for Compact Air Drive and Power Drive Handle for Torque Limiter Nos and DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

31 Drill the screw hole 3 over the LCP drill sleeve using an appropriate drill bit. Either read off the screw length from the calibrated drill or determine the screw length with the depth gauge (1;2). 1 2 Insert screw in hole 3 (3). 3 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 22

32 Proximal Fixation Repeat this step for screw insertion in holes 1 and 2 (4). Then remove the initial positioning wire in the distal fragment and the bicortical positioning wire in the proximal part DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

33 Option B: Proximal fixation with cortical screws Insert screws in holes 1, 2 and 3. Instruments for 3.5 mm plate Drill Bit B 2.5 mm, length 110/85 mm, 2-flute, for Quick Coupling Screwdriver, hexagonal, small, B 2.5 mm, with Groove Screwdriver Shaft, hexagonal, small, B 2.5 mm Screwdriver Stardrive 3.5, T15, with Groove, length 200 mm Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm Double Drill Guide 3.5/ Universal Drill Guide 3.5 Instruments for 5.0 mm plate Drill Bit B 3.2 mm, length 145/120 mm, 2-flute, for Quick Coupling Screwdriver, hexagonal, large, B 3.5 mm, with Groove, length 245 mm Screwdriver Shaft 3.5, hexagonal, self-holding Screwdriver Stardrive 4.5/5.0, T25, with Groove, length 240 mm Screwdriver Shaft Stardrive 4.5 /5.0, T25, self-holding, for AO/ASIF Quick Coupling Double Drill Guide 4.5/ Depth Gauge for Screws B 4.5 to 6.5 mm, measuring range up to 110 mm Universal Drill Guide 4.5 /3.2, for neutral and load position LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 33

34 Proximal Fixation If cortical screw fixation is selected, this is generally because compression at the osteotomy site is desired. Using the spring-loaded drill guide without pressing the guide down on the plate, place the drill hole as proximally as possible in the combi-hole to achieve compression when the screw is tightened (1) DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

35 Choose the appropriate size drill bit. Measure the screw length with the depth gauge and place a self-tapping cortex screw in hole 1. 2 Repeat this step for screw insertion in holes 2 and 3. Then remove the initial positioning wire in the distal fragment and the bicortical positioning wire in the proximal part. (2) LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 33

36 Medialization Note: In order to facilitate medialization, locking screws must be used throughout. Instruments for 3.5 mm plate Screwdriver Shaft, hexagonal, small, B 2.5 mm Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive Instrument for medialization LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate LCP Drill Bit B 2.8 mm with Stop, length 165 mm, 2-flute, for Quick Coupling Handle for Torque Limiter Nos and Reduction Forceps, toothed, soft lock, length 250 mm Reduction Forceps, toothed, soft lock, length 194 mm Instruments for 5.0 mm plate Screwdriver Shaft 3.5, hexagonal, self-holding Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling Depth Gauge for Screws B 4.5 to 6.5 mm, measuring range up to 110 mm Torque Limiter, 4 Nm, for Compact Air Drive and Power Drive Instrument for medialization LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm, for LCP Pediatric Hip Plate LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling Handle for Torque Limiter Nos and Reduction Forceps, toothed, soft lock, length 250 mm Reduction Forceps, toothed, soft lock, length 194 mm 33 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

37 Attach the medialization instruments to holes 1 and 3. Turn the knob on the bars until the required amount is protruding. Then screw an LCP drill sleeve into LCP hole 2. Reduce the plate to the shaft of the femur until complete contact of the bars of the medialization device with the bone is achieved and hold it with the reduction forceps (1). 1 Drill the screw hole and remove the drill sleeve. Determine the screw length with the depth gauge and insert a locking screw (2). 2 Check the position throughout under image intensifier guidance to ensure satisfactory reduction and medialization. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 33

38 Medialization After the screw in hole 2 is securely fixed, remove the instrument for medialization in hole 1 and insert a drill sleeve. Predrill the screw hole and remove the drill sleeve. Determine the screw length with the depth gauge and insert a locking screw. Repeat step two for hole 3 (3). 3 Note: Tighten the screws manually with the torque limiter. 33 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

39 Additional medialization (if required) If the mechanical axis is not in line, additional medialization is required. 1. Remove screws in holes 1 and 3 2. Loosen screw in hole 2 if already inserted. It may be necessary to use a longer screw 3. Place positioning plates (triangles) over holes 1 and 3 to prevent protrusion of the bar into the pre-existing holes. 4. Further adjust the knob on both medialization instruments in holes 1 and 3 to the new correction level. 5. Tighten screw in hole Add screws 1 and 3. Note: Should the correction not turn out as planned, further correction may be achieved by re-positioning locking screws in the proximal fragment to correct unintended deviation. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 33

40 Product Information Implants Product range of LCP Pediatric Plates The product range consists of different plate sizes: LCP Pediatric Hip Plates 2.7 LCP Pediatric Hip Plates 3.5 and 5.0 LCP Pediatric Condylar Plates 3.5 and 5.0 Available sterile or unsterile packed For proximal femur Plates for varus osteotomies (2.7, 3.5 and 5.0) The plates are available with screw angles of 100 or 110, 130 and 2 (2.7) or 3 (3.5 / 5.0) distal fixation screws. Plates for valgization osteotomies (3.5 and 5.0) The plates are available with a screw angle of 140 and 3 distal fixation screws. Plates for fractures and rotation osteotomies (3.5 and 5.0) The plates are available with a screw angle of 130 and 3, 5, 7 or 9 distal fixation screws. For distal femur Plates for fractures and deformities (3.5 and 5.0) The plates are available with a screw angle of 90 and 3, 5 or 7 distal fixation screws. Overview of available technique guides: LCP Pediatric Hip Plate 3.5 and 5.0 for varus osteotomies (Art. No ) LCP Pediatric Hip Plate 2.7 for varus osteotomies (Art. No ) LCP Pediatric Hip Plate 3.5 and 5.0 for fracture treatment and rotation correction (Leaflet) (Art. No ) LCP Pediatric Hip Plate Straight Valgus 3.5 and 5.0 for valgus osteotomies (Art. No ) LCP Pediatric Condylar Plate 3.5 and 5.0 for distal femoral osteotomies (Art. No ) 33 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

41 For proximal femur Plates for varus osteotomies LCP Pediatric Hip Plate 2.7, 100, width 12 mm, length 46 mm LCP Pediatric Hip Plate 2.7, 110, width 12 mm, length 46 mm LCP Pediatric Hip Plate 3.5, 100, width 19 mm, length 73 mm LCP Pediatric Hip Plate 5.0, 100, width 23 mm, length 90 mm LCP Pediatric Hip Plate 3.5, 110, width 19 mm, length 73 mm LCP Pediatric Hip Plate 5.0, 110, width 23 mm, length 90 mm Plate for valgization osteotomy LCP Pediatric Hip Plate 3.5, 140, straight, width 19 mm, length 70 mm LCP Pediatric Hip Plate 5.0, 140, straight, width 23 mm, length 90 mm LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 39

42 Implants Plates for fractures and derotation osteotomies LCP Pediatric Hip Plate 2.7, 130, width 12 mm, length 46 mm LCP Pediatric Hip Plate 3.5, 130, width 19 mm, length 62 mm LCP Pediatric Hip Plate 5.0, 130, width 23 mm, length 79 mm LCP Pediatric Hip Plate 3.5, 130, width 19 mm, length 88 mm LCP Pediatric Hip Plate 5.0, 130, width 23 mm, length 111 mm LCP Pediatric Hip Plate 3.5, 130, width 19 mm, length 114 mm LCP Pediatric Hip Plate 5.0, 130, width 23 mm, length 143 mm LCP Pediatric Hip Plate 3.5, 130, width 19 mm, length 140 mm LCP Pediatric Hip Plate 5.0, 130, width 23 mm, length 175 mm 40 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

43 For distal femur Plates for supracondylar fractures and deformities LCP Pediatric Condylar Plate 3.5, 90, shaft 3 holes LCP Pediatric Condylar Plate 5.0, 90, shaft 3 holes LCP Pediatric Condylar Plate 3.5, 90, shaft 5 holes LCP Pediatric Condylar Plate 5.0, 90, shaft 5 holes LCP Pediatric Condylar Plate 3.5, 90, shaft 7 holes LCP Pediatric Condylar Plate 5.0, 90, shaft 7 holes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 41

44 Implants Screw overview Cortex screws, self-tapping, stainless steel Cortex Screws Stardrive B 2.7 mm, lengths 6 60 mm Cortex Screws B 3.5 mm, lengths mm Cortex Screws Stardrive B 3.5 mm, self-tapping, lengths mm Cortex Screws B 4.5 mm, self-tapping, lengths mm Locking screws, self-tapping, stainless steel Locking Screws Stardrive B 2.7 mm (head LCP 2.4), lengths 6 60 mm Locking Screws B 3.5 mm, lengths mm Locking Screws Stardrive B 3.5 mm, lengths mm Locking Screws B 5.0 mm, lengths mm Locking Screws Stardrive B 5.0 mm, lengths mm All implants are also available sterile packed. Add Suffix S to part number. 44 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

45 Instruments Aiming Blocks Aiming Block for Screws B 2.7 mm, for LCP Pediatric Hip Plates Aiming Block for Screws B 3.5 mm, for LCP Pediatric Hip Plates Aiming Block for Screws B 5.0 mm, for LCP Pediatric Hip Plates Positioners for Aiming Blocks Positioner for Aiming Block, for LCP Pediatric Hip Plates Positioner for Aiming Block LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 43

46 Instruments Positioners for Osteotomy Positioner for Osteotomy, for LCP Pediatric Hip Plates Positioner for Osteotomy 44 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

47 Drill Sleeves and Reduction Sleeve LCP Drill Sleeve 2.7, for Drill Bits B 2.0 mm, for LCP Pediatric Hip Plates LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm, for LCP Pediatric Hip Plate Reduction Sleeve 4.3/ Direct Measuring Device for Kirschner Wires B 2.0 mm, for LCP Pediatric Hip Plates Direct Measuring Device for Kirschner Wires B 2.8 mm, length 200 mm LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 45

48 Instruments Positioning Wires, Guide Wires and Adapter Kirschner Wire B 2.0 mm with trocar tip, length 150 mm, Stainless Steel Kirschner Wire B 2.0 mm with threaded tip, length 150 / 15 mm, Stainless Steel Guide Wire B 2.0 mm with threaded tip with trocar, length 230 mm, Stainless Steel Kirschner Wire B 2.8 mm with spade point tip Kirschner Wire Adaptor 46 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

49 Drill Bits Drill Bit B 2.0 mm, with double marking, length 140/115 mm, 3-flute, for Quick Coupling LCP Drill Bit B 2.8 mm with Stop, length 165 mm, 2-flute, for Quick Coupling Drill Bit B 2.5 mm, length 110/85 mm, 2-flute, for Quick Coupling Drill Bit B 2.7 mm, length 125/100 mm, 2-flute, for Quick Coupling Drill Bit B 3.2 mm, length 145/120 mm, 2-flute, for Quick Coupling LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 47

50 Instruments Drill Guides Double Drill Guide 2.7/ Universal Drill Guide Universal Drill Guide Double Drill Guide 3.5/ Double Drill Guide 4.5/ DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

51 Depth Gauges Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm Depth Gauge for MatrixMANDIBLE, measuring range from 6 to 40 mm Depth Gauge for Screws B 4.5 to 6.5 mm, measuring range up to 110 mm LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 49

52 Instruments Screwdrivers and Screwdriver shafts Screwdriver, hexagonal, small, B 2.5 mm, with Groove Screwdriver Stardrive, T8, cylindrical, with Groove, shaft B 3.5 mm Screwdriver Stardrive 3.5, T15, with Groove, length 200 mm Screwdriver Stardrive 4.5/5.0, T25, with Groove, length 240 mm Screwdriver, hexagonal, large, B 3.5 mm, with Groove, length 245 mm 50 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

53 Screwdriver Shaft Stardrive, T8, cylindrical, with Groove, shaft B 3.5 mm, for AO/ASIF Quick Coupling Screwdriver Shaft, hexagonal, small, B 2.5 mm Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling Screwdriver Shaft 3.5, hexagonal, self-holding LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 51

54 Instruments Bone Holding Forceps and Reduction Forceps Bone Holding Forceps, self-centering, soft lock, length 191 mm Bone Holding Forceps, self-centering, soft lock, length 239 mm Reduction Forceps, toothed, soft lock, length 194 mm Reduction Forceps, toothed, soft lock, length 250 mm 55 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

55 Torque Limiters Handle for Torque Limiters 0.4/0.8/1.2 Nm Handle for Torque Limiter Nos and Torque Limiter, 0.8 Nm, with AO/ASIF Quick Coupling Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive Torque Limiter, 4 Nm, for Compact Air Drive and Power Drive LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 53

56 Instruments Positioning Plates Positioning Plate, triangular, length 45 mm, 90 /50 / Positioning Plate, triangular, length 45 mm, 80 /70 / Positioning Plate, triangular, length 45 mm, 100 /60 /20 Others Instrument for Medialization Combined Holding Sleeve for Cortex Screws Stardrive B 2.4/2.7 mm, T8, for Screwdriver Shafts B 3.5 mm 54 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

57 LCP Pediatric Plate System Module Overview Modules for implants, standard Modular Tray for LCP Pediatric Plates 2.7, size 1/2, without Contents, Vario Case System Modular Tray for LCP Pediatric Plates 3.5, size 1/2, without Contents, Vario Case System Modular Tray for LCP Pediatric Plates 5.0, size 1/2, without Contents, Vario Case System Modules for instruments, standard Modular Tray for Instruments for LCP Pediatric Plates 2.7, size 1/2, without Contents, Vario Case System Labeling clips Labeling Clip for LCP Pediatric Plates 3.5, Vario Case System Labeling Clip for LCP Pediatric Plates 5.0, Vario Case System Labeling Clip for LCP Pediatric Plates 2.7, Vario Case System Labeling Clip for Instruments for LCP Pediatric Plates 3.5 and 5.0, Vario Case System Labeling Clip for Instruments for LCP Pediatric Plates 2.7, Vario Case System Labeling Clip for General Instruments, for LCP Pediatric Plates 3.5 and 5.0, Vario Case System Modular Tray for Instruments for LCP Pediatric Plates 3.5 and 5.0, size 1/1, without Contents, Vario Case System Modular Tray for General Instruments, for LCP Pediatric Plates 3.5 and 5.0, size 1/1, without Contents, Vario Case System LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 55

58 Bibliography Kay M.R., Rethlefsen P.T., Hale J.M, Skaggs D., Tolo V. (2003) J of Pediatric Orthopaedics 23: Comparison of Proximal and Distal Rotational Femoral Osteotomy in Children with Cerebral Palsy. Mortazavi S.M.J., Heidari P., Esfandiari H., Motamedi M. (2008). J of Haemophilia 4, Trapezoid supracondylar femoral extension osteotomy for knee flexion contractures in patients with haemophilia. Oppenheim W.L., Fischer S.R., Salusky I. (1997). J of Pediatric Orthopaedics 17: Surgical Correction of Angular Deformity of the Knee in Children with Renal Osteodystrophy. Piripiris M., Trivett A., Baker R., Rodda J., Nattrass G.R., Graham H.K. (2003). J of Bone and Joint Surgery Vol 85-B. No. 2. Femoral derotation osteotomy in spastic diplegia. Proximal or Distal? Hefti F et al. (1998) Kinderorthopädie in der Praxis. Berlin Heidelberg New York: Springer Morrissy RT, Weinstein SL (2001) Atlas of Pediatric Orthopedic Surgery. Philadelphia: Williams & Wilkins-Verlag Müller M.E., Schneider R. et al., AO manual of internal fixation. 3rd Edition ed. 1991, Berlin-Heidelberg-New York: Springer. 55 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique

59 MRI Information Torque, Displacement and Image Artifacts according to ASTM F , ASTM F e1 and ASTM F Non-clinical testing of worst case scenario in a 3 T MRI system did not reveal any relevant torque or displacement of the construct for an experimentally measured local spatial gradient of the magnetic field of 3.69 T/m. The largest image artifact extended approximately 169 mm from the construct when scanned using the Gradient Echo (GE). Testing was conducted on a 3 T MRI system. Radio-Frequency-(RF-)induced heating according to ASTM F a Non-clinical electromagnetic and thermal testing of worst case scenario lead to peak temperature rise of 9.5 C with an average temperature rise of 6.6 C (1.5 T) and a peak temperature rise of 5.9 C (3 T) under MRI Conditions using RF Coils [whole body averaged specific absorption rate (SAR) of 2 W/kg for 6 minutes (1.5 T) and for 15 minutes (3 T)]. Precautions: The above mentioned test relies on non-clinical testing. The actual temperature rise in the patient will depend on a variety of factors beyond the SAR and time of RF application. Thus, it is recommended to pay particular attention to the following points: It is recommended to thoroughly monitor patients undergoing MR scanning for perceived temperature and/or pain sensations. Patients with impaired thermo regulation or temperature sensation should be excluded from MR scanning procedures. Generally it is recommended to use a MR system with low field strength in the presence of conductive implants. The employed specific absorption rate (SAR) should be reduced as far as possible. Using the ventilation system may further contribute to reduce temperature increase in the body. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 55

60 DSEM/TRM/0815/ /15 Synthes GmbH Eimattstrasse Oberdorf Switzerland Tel: Fax: This publication is not intended for distribution in the USA. All surgical techniques are available as PDF files at DePuy Synthes Trauma, a division of Synthes GmbH All rights reserved