Pelvic Implants and Instruments. A dedicated system for reconstructive pelvic and acetabular surgery.

Transcription

1 Pelvic Implants and Instruments. A dedicated system for reconstructive pelvic and acetabular surgery. Surgical Technique This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation.

2 Image intensifier control Warning This description alone does not provide sufficient background for direct use of 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 Pelvic Implants and Instruments 2 Implant Specifications 4 AO Principles 6 Indications 7 Instruments Standard 8 Retractors 10 Reduction 12 Surgical Technique Plate Contouring 14 In-situ Plate Contouring 16 Fracture Fixation A. Pubic Symphysis Fractures 18 B. Iliac Fractures 22 C. Acetabulum Two Column Fractures 28 Product Information Plates 38 Screws 43 Instruments 44 Optional Implants 51 Optional Screws 53 Optional Instruments 54 Other Available Pelvic Instruments and Implants 59 from Synthes MRI Information 65 Pelvic Implants and Instruments Surgical Technique DePuy Synthes 1

4 Pelvic Implants and Instruments. A dedicated system for reconstructive pelvic and acetabular surgery. Essential equipment for the surgical treatment of pelvic fractures The complex anatomy of the pelvic ring and acetabulum involve complex surgical exposures and demands exact anatomical reduction to achieve positive functional results. The AO and Synthes took this into consideration in developing the Pelvic Implant and Instrument Sets. The Pelvic Implant and Instrument Sets contain a wide range of implants, reduction instruments, retractors and instruments for screw and plate fixation for the operative treatment of pelvic and acetabular fractures. All implants are available in 316L implant stainless steel, sterile and non sterile packaged. Reconstruction Plate and Screw Set The pelvic and acetabular low profile implants offer preshaped plate designs. Additional trays with locking compression, wide angle (acetabular) and J-plates (pelvic brim) are also available. All plates can be three-dimensionally contoured allowing them to be closely adapted to pelvic bone surfaces. Bending templates allow for easy manual adaptation of the plates. Pelvic Standard Instrument Set The Pelvic Instrument Set has a wide range of standard instruments for screw insertion, plate adaptation (bending instruments) and fixation during reduction for preliminary and definitive stabilization of pelvic and acetabular fractures. 2 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

5 Pelvic Retractor Set A wide range of retractors (pelvic, Hohmann, sciatic nerve and malleable) within the Pelvic Retractor Set provide more options to aid the surgeon in achieving good visibility within the chosen approach. Pelvic Reduction Instrument Set The pelvic reduction forceps and other reduction instruments within the Pelvic Reduction Instrument Set are designed to aid the surgeon with fracture reduction of pelvic injuries. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 3

6 Implant Specifications Reconstruction Plates Occasionally, pelvic osteosyntheses can be carried out using screws alone, but in the majority of cases lag screw fixations must be supplemented by one or more plates. Uniform cross-section Improved contourability The bone surfaces in the pelvic region have a very complex topography. In order to achieve accurate fixation, the plates should be contoured to the bone surface. Poorly contoured plates can lead to fracture displacement when the screws are fully tightened through the plate. The design of the reconstruction plates allow for contouring in all three planes. Reconstruction Plates 3.5 with wide Angle Reconstruction Plates 3.5 with low profile Low profile: 2.7 mm Screw angulation: up to 25 Holes: 3 20 (straight), 6 16 (curved), (J-shaped) Reconstruction Plate with low profile, curved: Available in two radii (88 mm and 108 mm) to fit the average pelvis of a female or male, respectively Allows the use of cortex screws and/or pelvic cortex screws 3.5 mm Reconstruction Plate with low profile, J-shaped: hybrid of curved and straight: One leg of the plate is straight, while the other leg is bent with a radius of 88 mm Left and right Fits along pelvic brim, from the pubic rami (curved part of the plate) to the SI joint (straight end of the plate) Profile: 3.7 mm Screw angulation: up to 30 Holes: 3 20 (straight) Allow the use of cortex screws and/or pelvic cortex screws 3.5 mm 4 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

7 Coaxial combi-holes in locking plates Allow the use of locking screws or cortex screws in the same round conical plate hole. Low profile and rounded edges Reduce the risk of soft tissue irritation. Locking Reconstruction Plate 3.5 Pubic Symphysis Plates 3.5 Spring Plate 3.5 Profile: 3.7 mm Screw angulation: up to 12 (cortex screws) Holes: 3 20 (straight), (J-shaped) Features coaxial combi-holes (this means the plate can be used with standard cortex screws 3.5 as well as with 3.5 locking screws) Fits the anatomy of the pubic s y m p h y s i s Coaxial combi-holes accept 3.5 locking screws as well as standard/pelvic cortex screws (3.5) Radius of 60 mm Reinforced midsection of plate 3 small holes in midsection can be used to attach sutures 4 versions: 4 coaxial combi-holes 6 coaxial combi-holes 2 DCU holes and 2 coaxial combi-holes* 2 DCU holes and 4 coaxial combi-holes* * DCU: Dynamic Compression Unit Reduces and stabilizes small bone fragments that are too small for screws. Can be used individually or with a 3.5 mm reconstruction plate. Pre-bent convex shape with two sharp spikes on the bottom surface. Reduction is achieved by sinking spikes into small fragments while tightening a screw through one of the screw holes. Convex shape for better bone retention. Small fragments are preloaded once a screw is inserted which allows the plate to adapt better to bony, uneven surfaces. Allows the use of cortex screws and/or pelvic cortex screws 3.5 mm. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 5

8 AO Principles In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation: 1, 2 Those principles as applied to the Pelvic Implants and Instruments are: Anatomic reduction Fracture reduction and fixation to restore anatomical relationships. Stable fixation Stability by screw only or screw and plate fixation, as the personality of the fracture and the injury requires. The products provide purchase for required compression and stability. Preservation of blood supply Preservation of the blood supply to soft tissue and bone by careful handling and atraumatic surgery. Use of surgical technique that minimizes disruption of soft tissue and preserves vascular blood flow for bone healing. Early, active mobilization Early and safe patient mobilization. The implants, combined with AO technique, provide stable fracture fixation with minimal trauma to vascular supply. Plate features combined with AO technique create an environment for bone healing, expediting return to function. 1 Müller ME, Allgöwer M, Schneider R, Willenegger H (1995) Manual of Internal Fixation. 3rd, expanded and completely revised ed Berlin, Heidelberg, New York: Springer 2 Rüedi TP, Buckley RE, Moran CG (2007) AO Principles of Fracture Management. 2nd expanded ed Stuttgart, New York: Thieme 6 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

9 Indications Symphysis fractures Pubic Symphysis Plates 3.5 Pelvic brim fractures Reconstruction Plates 3.5 with low profile Straight Plates Curved Plates (88 mm radius, 108 mm radius) J-Plates Locking Reconstruction Plates 3.5 Straight Plates J-Plates Reconstruction Plates 3.5 with wide Angle Straight Plates Ilium/Iliac wing fractures Reconstruction Plates 3.5 with low profile Straight Plates Curved Plates (88 mm radius, 108 mm radius) Locking Reconstruction Plates 3.5 Straight Plates Low Profile Reconstruction Plates 3.5 with wide Angle Straight Plates Acetabulum fractures Reconstruction Plates 3.5 with low profile Straight Plates Curved Plates (88 mm radius, 108 mm radius) Reconstruction Plates 3.5 with wide Angle Straight Plates Pelvic Implants and Instruments Surgical Technique DePuy Synthes 7

10 Instruments Standard Instruments for screw fixation Screw fixation of the pelvis requires the use of extra-long screws and corresponding instruments. The following instruments are part of the Pelvic Instrument Set: Extra-long 3-fluted calibrated drill bit Extra-long taps, calibrated with depth markings Extra-long screwdrivers (hexagonal and Stardrive) and screwdriver shafts (hexagonal and Stardrive) Extra-long depth gauge Bending instruments The bending pliers should be used as the primary bending instrument. A smooth bend is best achieved by the introduction of many small bends. Bending irons, designed specifically for use with the reconstruction plates, are also available. 8 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

11 In-situ bending instruments In-situ bending instruments allow precise intraoperative adaptation of the pre-bent reconstruction plate to the bone anatomy. The in-situ bending and twisting handles with different tips (straight, 90, 120 ) allow use in different surgical approaches In-situ Bender In-situ Bending and Twisting Handle, straight In-situ Bending and Twisting Handle, In-situ Bending and Twisting Handle, 120 Bending templates Malleable bending templates are available for all reconstruction plate shapes (straight, curved, J-shaped). These can be fitted to the reduced bone and then a plate is shaped to fit the template. This helps to avoid repeated plate bending, which can cause micro cracks, therefore weakening the plate. The templates can also be used to determine plate lengths. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 9

12 Instruments Retractors A wide range of malleable, blunt, spoon shaped, pelvic, Hohmann and sciatic nerve retractors provide more options to aid the surgeon with the chosen approach. 11 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

13 Radiolucent retractors Radiolucent retractors allow for the passage of x-rays without having to remove the instrumentation in order to visualize the implant underneath. Another advantage of these retractors is their light weight. In an effort to accommodate the surgeon needs, Synthes has redesigned several retractors in aluminum, thus making them radiolucent. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 11

14 Instruments Reduction Pelvic reduction forceps The pelvic reduction forceps are designed to maximize the potential of the ilioinguinal and Kocher-Langenbeck approaches. The jaws of all the larger forceps are long enough to accommodate the innominate bone, from the iliac crest to the pelvic brim, and can be used without exerting excess pressure on the iliac vessels. Pelvic reduction forceps are equipped with features to improve handling characteristics during reduction maneuvers. Pointed-ball tips prevent penetration of bone with a thin cortex. Longer spikes with sharper points provide a secure hold on the pelvic surfaces. Increased selection of forceps, including Handles and jaws of different lengths Straight and oblique versions Ball spikes with pointed ball tip The straight ball spikes facilitate reduction of bone fragments. They feature a spike to reduce the risk of the instrument slipping off the bone and a pointed-ball tip to prevent penetration of bone with a thin cortex. Round and rectangular disks Disks can be used in conjunction with the reduction forceps with pointed ball-tips or the ball spike instruments. In poor quality bone (osteoporotic), they can aid in distributing the applied forces over a larger surface area in effort to prevent iatrogenic or compression fractures. 11 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

15 Pelvic reduction forceps for screws All forceps have been designed for use with 3.5 mm / 4.5 mm screws inserted on opposite sides of a fracture line, which allows the application of considerable reduction forces and manipulation in all three planes. The large forceps have long handles for the transferal of large forces. The Farabeuf forceps can be either used with screws or as general bone forceps, i.e. to grasp and manipulate the iliac wing. Jungbluth large (330 mm), small (250 mm), for B 3.5 mm screws Farabeuf medium (250 mm), small (190 mm), for Cortex Screws B 3.5 and 4.5 mm Reduction forceps with points These standard forceps can be applied directly to the bone s surface, or be used with shallow drill holes or anchoring rings and hooks. Medium and large bone hooks The bone hooks are designed to allow the surgeon to manipulate the bone or bone fragments in order to ensure proper alignment and to achieve an anatomical reduction. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 11

16 Plate Contouring 1 Contour plate 1 Instruments Bending Pliers for Reconstruction Plates Bending Pliers for Reconstruction Plates 2.7 and 3.5 For plate contouring, place a plate between the ledge and the groove of the bending pliers. Place the concave surface on the side of pliers with the ledge. Squeeze the handles gradually and bend the plate as appropriate. (1) For in-plane bending, place a plate into the groove of the bending pliers. Squeeze the handles gradually and bend the plate as appropriate. (2) 2 11 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

17 2 Twist plate Instruments Bending Pliers for Reconstruction Plates Bending Iron for Reconstruction Plates 3.5 and 4.5, length 190 mm Bending Pliers for Reconstruction Plates 2.7 and 3.5 Hold the plate using the plier grips and twist the plate by using an additional bending iron. Important: Avoid repeated bending and over bending as it weakens the plate. For reconstruction plates with coaxial combi-holes: use threaded pin to avoid screw hole deformation during bending. Note: The bending pliers ( ) are intended for use with the Reconstruction Plates 3.5 contained in the Low Profile 3.5 mm Pelvic System. The bending pliers ( ) are intended for use with the standard Reconstruction Plates 3.5. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 11

18 In-situ Plate Contouring In-situ bending instruments adjust the pre-bent, reconstruction plates on the bone to match relevant patient anatomy during a surgical procedure. Using this instruments helps decrease the surgical time by reducing the need for repeated cycles of plate positioning and removal until the plate has been sufficiently shaped. Indications The instruments are intended for use with the following plate systems: Reconstruction Plates 3.5 with low profile (straight, curved and J-shaped) Reconstruction Plates 3.5 with wide Angle DCP Reconstruction Plates 3.5, straight and curved Contraindications Plates with locking and coaxial combi-holes. In particular: Locking Reconstruction Plates 3.5 Pubic Symphysis Plates 3.5 Spring Plates 3.5 Reconstruction Plates 3.5 with coaxial combi-holes Other plate sizes than 3.5 mm Note: Preoperative pre-bending of the reconstruction plates is always required before in-situ plate bending. The in-situ bending instruments are intended for detailed and accurate adaptation of the plates to the local anatomy. Notes Do not bend the plate at the level of the holes. Do not bend the plate multiple times at the same level to avoid weakening of the plate. 11 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

19 1 Contour plate: in-situ bending or correction of the bending radius Instrument In-situ Bender Grasp the preliminary fixated plate with the in-situ bender. The nose and counter-bearing mouth of the bender must sit in the notches of the reconstruction plate. Squeeze the handles and bend the plate as required. 2 Bend or twist plate Instruments In-situ Bending and Twisting Handle, straight In-situ Bending and Twisting Handle, In-situ Bending and Twisting Handle, 120 Use two straight In-situ Bending and Twisting Handles. Place the tip of each handle in the plate hole. One handle is used for holding the plate while the second handle is manipulated to bend or twist the plate accordingly. Note: The In-situ Bending and Twisting Handle, straight can be combined with the In-situ Bending and Twisting Handle, 90 or 120 where appropriate. Note: Ensure that the tip of the instrument is properly attached to the plate to prevent slippage. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 11

20 Fracture Fixation Note: The following cases of fracture fixation represent possible uses of pelvic instruments. Several applications are shown but other applications are possible. A. Pubic Symphysis Fractures 1 Approach Use an anterior approach (e.g. Pfannenstiel or Stoppa). 11 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

21 2 Reduce fracture 1 Instruments Reduction Forceps, large, with Points, ratchet lock, length 200 mm Pelvic Reduction Forceps, for use with Cortex Screws B 3.5 and 4.5 mm Pelvic Reduction Forceps, large, adjustable, speed lock, length 300 mm Achieve reduction of the pubic symphysis by using the large reduction forceps with points. (1) 2 Alternatively, achieve reduction by inserting two screws anteriorly and using pelvic reduction forceps ( / ). (2,3) 3 Pelvic Implants and Instruments Surgical Technique DePuy Synthes 11

22 Fracture Fixation 3 Fix plate Instruments Ratcheting Handle with AO/ASIF Quick Coupling Screwdriver Shaft, hexagonal, for Screws B 3.5 mm, length 250 mm Drill Bit B 2.8 mm, with Scale, length 200/100 mm, 3-flute, for Quick Coupling Tap for Cortex Screws B 3.5 mm, calibrated, length 175 mm Pre-drilling: B 2.5 mm LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm Holding Sleeve, for Nos , and Screwdriver, hexagonal, small, B 2.5 mm, length 270 mm for Screws B 3.5 mm Drill Bit B 2.5 mm, calibrated, length 230/205 mm, 3-flute, for Quick Coupling Depth Gauge for Cortex Screws B 3.5 mm, measuring range up to 150 mm Torque Limiter, 1.5 Nm, for AO/ASIF Quick Coupling Alternative instruments Screwdriver Shaft Stardrive Screwdriver Stardrive 3.5, SD15 22 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

23 Place the Pubic Symphysis Plate 3.5 over the symphysis joint and make a temporary fixation (e.g. with plate holding forceps). 1 2 According to preoperative planning and plate selection (locking/non-locking), use B 3.5 mm cortex screws and/or B 3.5 mm locking screws to fix the plate. If compression is needed between the symphysis joint, use the plate with DCU holes. Insert the first cortex screw in the lateral part of DCU hole (eccentric). Insert the second cortex screw eccentrically into the DCU hole of the contralateral side of the pubic symphysis. (1,2) Alternate tensioning of the screws results in compression of the symphysis. Refer to the DCP and LC-DCP Systems technique guide ( ) for more detailed steps during screw insertion and plate fixation. 3 Additional locking screws should be inserted according to the LCP Locking Compression Plate technique guide ( ). (3) Notes The x-ray template indicates locking screw directions. Refer to the DCP and LC-DCP Systems ( ) and/ or LCP Locking Compression Plate ( ) technique guides for independent lag screw placement and plating. Screwdriver Shaft Stardrive ( ) and Screwdriver Stardrive 3.5, SD15 ( ) are used for B 3.5 mm Stardrive screws. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 22

24 Fracture Fixation B. Iliac Fractures 1 Approach Use an anterior or posterior approach appropriate for the fracture pattern. The following example of an iliac fracture shows a possible fracture treatment using a posterior (Kocher Langenbeck) approach. 2 Reduce fracture Instruments Pelvic Reduction Forceps, small, length 190 mm, for use with Cortex Screws B 3.5 and 4.5 mm Reduction Forceps with Points, ratchet lock, length 200 mm Confirm anatomical reduction of the anterior aspect of the iliac wing by finger palpation. To reduce the iliac bone, use reduction forceps on the iliac crest and the posterior iliac wing. 22 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

25 Alternative technique 1 Instruments Tap for Cortex Screws B 3.5 mm, calibrated, length 175 mm Pre-drilling: B 2.5 mm Screwdriver, hexagonal, small, B 2.5 mm, length 270 mm for Screws B 3.5 mm Drill Bit B 2.5 mm, calibrated, length 230/205 mm, 3-flute, for Quick Coupling Depth Gauge for Cortex Screws B 3.5 mm, measuring range up to 150 mm Pelvic Reduction Forceps, medium, length 250 mm, for use with Cortex Screws B 3.5 and 4.5 mm Pelvic Reduction Forceps, large, adjustable, speed lock, length 300 mm Reduction Forceps with Points, ratchet lock, length 200 mm Alternatively, insert two temporary cortex screws on either side of the fracture line and gain compression using pelvic reduction forceps: Farabeuf (1) or , Jungbluth (2). Pelvic Implants and Instruments Surgical Technique DePuy Synthes 22

26 Fracture Fixation 3 Fix plate on posterior inferior ilium Instruments Ratcheting Handle with AO/ASIF Quick Coupling Screwdriver Shaft, hexagonal, for Screws B 3.5 mm, length 250 mm Tap for Cortex Screws B 3.5 mm, calibrated, length 175 mm Pre-drilling: B 2.5 mm Holding Sleeve, for Nos , and Screwdriver, hexagonal, small, B 2.5 mm, length 270 mm for Screws B 3.5 mm Drill Bit B 2.5 mm, calibrated, length 230/205 mm, 3-flute, for Quick Coupling Depth Gauge for Cortex Screws B 3.5 mm, measuring range up to 150 mm Bone Holding Forceps, self-centering, soft lock, length 191 mm Reduction Forceps, large, with Points, ratchet lock, length 200 mm Alternative instruments Screwdriver Shaft Stardrive Screwdriver Stardrive 3.5, SD15 22 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

27 Insert a screw through the 4-hole low profile pelvic reconstruction plate into the body of the ilium, close to the sciatic notch. (1) 1 2 To reduce the posterior iliac fragment, insert a temporary screw into the posterior superior iliac spine. (2) Compress the fracture using the bone holding forceps. The forceps is therefore hooked into the most posterior plate hole and the temporary screw on the other side of the fracture line is used as a counter bearing. (3) After additional screw fixation through the plate, remove the temporary screw. (4) Notes During fixation close to the greater sciatic notch, control drill bit penetration and screw lengths with two-finger palpation to prevent damage to the nerve or vessels. Refer to the DCP and LC-DCP Systems ( ) and/or LCP Locking Compression Plate ( ) technique guide for independent lag screw placement and plating. 3 4 Pelvic Implants and Instruments Surgical Technique DePuy Synthes 22

28 Fracture Fixation 4 Fix plate on iliac crest Instruments Ball Spike, straight, with pointed ball tips B 6.5 mm, length 300 mm Ratcheting Handle with AO/ASIF Quick Coupling Screwdriver Shaft, hexagonal, for Screws B 3.5 mm, length 250 mm Tap for Cortex Screws B 3.5 mm, calibrated, length 175 mm Pre-drilling: B 2.5 mm Holding Sleeve, for Nos , and Screwdriver, hexagonal, small, B 2.5 mm, length 270 mm for Screws B 3.5 mm Drill Bit B 2.5 mm, calibrated, length 230/205 mm, 3-flute, for Quick Coupling Depth Gauge for Cortex Screws B 3.5 mm, measuring range up to 150 mm Reduction Forceps, large, with Points, ratchet lock, length 200 mm Alternative instruments Screwdriver Shaft Stardrive Screwdriver Stardrive 3.5, SD15 22 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

29 Place a low profile pelvic reconstruction plate posterior to the iliac crest, and fix it with B 3.5 mm cortex screws. The ball spike with pointed ball tip may also be used to achieve reduction. Note: Refer to the DCP and LC-DCP Systems ( ) and/or LCP Locking Compression Plate ( ) technique guide for independent lag screw placement and plating. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 22

30 Fracture Fixation C. Acetabulum Two Column Fractures 1 Approach Use an ilioinguinal approach. 22 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

31 2 Reduce fracture in iliac crest 1 Instruments Ball Spike, straight, long, with pointed ball tips B 6.5 mm, length 400 mm Schanz Screw B 6.0 mm, length 190/50 mm, Stainless Steel Pelvic Reduction Forceps, small, length 190 mm, for use with Cortex Screws B 3.5 and 4.5 mm Reduction Forceps, large, with Points, ratchet lock, length 200 mm 2 Insert a Schanz screw into the proximal femur to allow intraoperative manual traction. (1) Confirm anatomic reduction of the different fracture fragments. Fragments may be temporarily fixated with Kirschner wires. (2) Different reduction instruments (e.g. ball spike, reduction forceps) may aid in achieving appropriate reduction. (2,3) 3 Pelvic Implants and Instruments Surgical Technique DePuy Synthes 22

32 Fracture Fixation 3 Insert screw in iliac crest Instruments Ratcheting Handle with AO/ASIF Quick Coupling Screwdriver Shaft, hexagonal, for Screws B 3.5 mm, length 250 mm Drill Bit B 3.5 mm, length 195/170 mm, 2-flute, for Quick Coupling Tap for Cortex Screws B 3.5 mm, calibrated, length 175 mm Pre-drilling: B 2.5 mm Holding Sleeve, for Nos , and Screwdriver, hexagonal, small, B 2.5 mm, length 270 mm for Screws B 3.5 mm Drill Bit B 2.5 mm, calibrated, length 230/205 mm, 3-flute, for Quick Coupling Depth Gauge for Cortex Screws B 3.5 mm, measuring range up to 150 mm Pelvic Reduction Forceps, small, length 190 mm, for use with Cortex Screws B 3.5 and 4.5 mm Reduction Forceps, large, with Points, ratchet lock, length 200 mm Alternative instruments Screwdriver Shaft Stardrive Screwdriver Stardrive 3.5, SD15 33 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

33 According to the DCP and LC-DCP Systems ( ) technique guide for independent lag screw placement, insert a B 3.5 mm cortex screw (lag screw) into the iliac crest. Use the pelvic reduction forceps and/or the large reduction forceps with points to maintain reduction. Note: Use oscillating mode while drilling to avoid soft tissue damage and penetration of the anterior or posterior iliac cortex. 4 Insert screw in body of ilium Instrument Pelvic Reduction Forceps, with pointed ball tips B 6.5 mm, length 400 mm Insert a second lag screw into the body of the ilium perpendicular to the fracture line. Use the pelvic reduction forceps to maintain reduction. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 33

34 Fracture Fixation 5 Reduce posterior column Instrument Reduction Forceps, large, with Points, ratchet lock, length 200 mm Use the reduction forceps with points to reduce the fragment of the quadrilateral surface. The forceps bridge from the pelvic brim to the quadrilateral surface. Alternative technique Instruments Pelvic Reduction Forceps, with pointed ball tips B 6.5 mm, length 250 mm Pelvic Reduction Forceps, angled, with pointed ball tips B 6.5 mm, length 240 mm Bone Hook, medium, long, length 330 mm Spiked Disc, round, hole 6.5 mm Collinear Reduction Clamp (Sliding Mechanism) Pelvic Arm, for Collinear Reduction Clamp Alternatively the pelvic reduction forceps with pointed ball tips (straight or angled) can be used to reduce the fracture. If necessary, spiked discs can be used with all pelvic reduction forceps with ball tips. (1) 33 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

35 The collinear reduction clamp with pelvic arm is useful to reduce the posterior column. (2) 2 The bone hook placed beneath the ischial spine may also be used to reduce the posterior column. (3) 3 Pelvic Implants and Instruments Surgical Technique DePuy Synthes 33

36 Fracture Fixation 6 In-situ plate contouring If preoperative bending is insufficient after plate positioning, insertion and tightening of the first screws, the in-situ bending instruments can be used to further adapt the plate to the local anatomy. Instruments In-situ Bender In-situ Bending and Twisting Handle, straight In-situ Bending and Twisting Handle, In-situ Bending and Twisting Handle, 120 If in-situ plate adaptation is required, use the in-situ bender as described on page DePuy Synthes Pelvic Implants and Instruments Surgical Technique

37 If plate needs to be bent or twisted to fit the local anatomy, the in-situ bending and twisting handles should be used as described on page 17. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 33

38 Fracture Fixation 7 Fix plate on pelvic brim Instruments Ball Spike, straight, long, with pointed ball tips B 6.5 mm, length 400 mm Ratcheting Handle with AO/ASIF Quick Coupling Screwdriver Shaft, hexagonal, for Screws B 3.5 mm, length 250 mm Tap for Cortex Screws B 3.5 mm, calibrated, length 175 mm Pre-drilling: B 2.5 mm Holding Sleeve, for Nos , and Collinear Reduction Clamp (Sliding Mechanism) Screwdriver, hexagonal, small, B 2.5 mm, length 270 mm for Screws B 3.5 mm Drill Bit B 2.5 mm, calibrated, length 230/205 mm, 3-flute, for Quick Coupling Depth Gauge for Cortex Screws B 3.5 mm, measuring range up to 150 mm Pelvic Arm, for Collinear Reduction Clamp Alternative instruments Screwdriver Shaft Stardrive Screwdriver Stardrive 3.5, SD15 33 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

39 Fix a J-plate with B 3.5 mm cortex screws on the pelvic brim according to the DCP and LC-DCP Systems ( ) technique guide. Lag screws through the plate help to achieve a stable fixation between the anterior and posterior column. 8 Fix plate on pubic rami Insert additional screws through the plate into the pubic rami to maintain reduction and stable fixation of the anterior column. Note: Refer to the DCP and LC-DCP Systems ( ) and/or LCP Locking Compression Plate ( ) technique guide for lag screw placement and plating. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 33

40 Plates Reconstruction Plate 3.5 with low profile, straight* Stainless steel Art. No. Holes Length (mm) Reconstruction Plate 3.5 with low profile, curved (radius 108 mm)* Stainless steel Art. No. Holes Length (mm) * All implants are available sterile packed. For sterile implants add suffix S to article number. 33 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

41 Reconstruction Plate 3.5 with low profile, curved (radius 88 mm)* Stainless steel Art. No. Holes Length (mm) Reconstruction J-Plate 3.5 with low profile* Stainless steel Art. No. Direction Holes Length (mm) right right right right left left left left * All implants are available sterile packed. For sterile implants add suffix S to article number. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 33

42 Plates Symphyseal Plate 3.5 with coaxial combi-holes* Stainless steel Art. No. Holes Length (mm) Symphyseal Plate 3.5 with coaxial combi-holes and 2 DCP* Stainless steel Art. No. Holes Length (mm) Reconstruction J-Plate 3.5 with coaxial combi-holes (radius 88 mm)* Stainless steel Art. No. Direction Holes Length (mm) right right right right left left left left * All implants are available sterile packed. For sterile implants add suffix S to article number. 44 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

43 Reconstruction Plate 3.5 with coaxial combi-holes, straight* Stainless steel Art. No. Holes Length (mm) * All implants are available sterile packed. For sterile implants add suffix S to article number. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 44

44 Plates Reconstruction Plate 3.5 with wide Angle, straight* Stainless steel Art. No. Holes Length (mm) Spring Plate 3.5* Stainless steel Art. No. Holes Length (mm) * All implants are available sterile packed. For sterile implants add suffix S to article number. 44 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

45 Screws Cortex Screw Stardrive B 3.5 mm, self-tapping, length mm, Stainless Steel* Pelvic Cortex Screw B 3.5 mm, self-tapping, head height 2.75 mm, length mm, Stainless Steel* Cortex Screw B 3.5 mm, selftapping, length mm, Stainless Steel* Locking Screw B 3.5 mm, selftapping, length mm, Stainless Steel* Threaded Pin Stardrive B 3.5 mm, Stainless Steel* Locking Screw Stardrive B 3.5 mm, self-tapping* Stainless steel Art. No. Length (mm) Art. No. Length (mm) * All implants are available sterile packed. For sterile implants add suffix S to article number. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 44

46 Instruments Pelvic Retractor, medium, length 268 mm Pelvic Retractor, large, length 323 mm Retractor for Sciatic Nerve Retractor for Sciatic Nerve, long Retractor, malleable, width 20 mm, length 330 mm Retractor, malleable, width 30 mm, length 330 mm Retractor, malleable, width 40 mm, length 330 mm 44 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

47 Radioluscent Pelvic Retractor, blunt, length 274 mm, Aluminium Radioluscent Hohmann Retractor, width 35 mm, length 275 mm, Aluminium Radioluscent Hohmann Retractor, width 18 mm, length 240 mm, Aluminium Radioluscent Hohmann Retractor, width 24 mm, length 267 mm, Aluminium Radioluscent Pelvic Retractor, medium, length 268 mm, Aluminium Radioluscent Pelvic Retractor, large, length 323 mm, Aluminium Pelvic Retractor, blunt Bone Lever, long narrow tip, width 18 mm, length 235 mm Ball Spike, straight, with pointed ball tips B 6.5 mm, length 300 mm Ball Spike, straight, long, with pointed ball tips B 6.5 mm, length 400 mm Pelvic Implants and Instruments Surgical Technique DePuy Synthes 44

48 Instruments Pelvic Reduction Forceps with pointed ball tips B 6.5 mm, length 250 mm Pelvic Reduction Forceps with pointed ball tips B 6.5 mm, length 400 mm Pelvic Reduction Forceps, angled, with pointed ball tips B 6.5 mm, length 200 mm Pelvic Reduction Forceps, angled, with pointed ball tips B 6.5 mm, length 240 mm Pelvic Reduction Forceps, asymmetric, with pointed ball tips B 6.5 mm Disc, round, hole B 6.5 mm Disc, rectangular, hole B 6.5 mm Spiked Disc, round, hole 6.5 mm Spiked Disc, rectangular, hole B 6.5 mm Pelvic Reduction Forceps, small, length 190 mm, for use with Cortex Screws B 3.5 and 4.5 mm 44 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

49 Pelvic Reduction Forceps, medium, length 250 mm, for use with Cortex Screws B 3.5 and 4.5 mm Pelvic Reduction Forceps, large, adjustable, speed lock, length 300 mm Pelvic Reduction Forceps, small, for Screws B 3.5 mm, length 250 mm Reduction Forceps, large, with Points, ratchet lock, length 200 mm Bone Hook, medium, long, length 330 mm Bone Hook, large, long, length 330 mm Bone Hook, sharp, medium, length 230 mm Bone Hook, sharp, large, length 200 mm Bending Pliers for Reconstruction Plates Bending Iron for Reconstruction Plates 3.5 and 4.5, length 190 mm Pelvic Implants and Instruments Surgical Technique DePuy Synthes 44

50 Instruments In-situ Bender In-situ Bending and Twisting Handle, straight In-situ Bending and Twisting Handle, In-situ Bending and Twisting Handle, Bending Template for Low Profile 3.5 Reconstruction Plates, straight, 20 holes Bending Template for Low Profile 3.5 Reconstruction J-Plates, 16 holes Bending Template for Low Profile 3.5 Reconstruction Plates, curved (R88), 16 holes Bending Template for Low Profile 3.5 Reconstruction Plates, curved (R108), 16 holes 48 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

51 Plate Holder with thread B 3.5 mm, long LCP Drill Sleeve 3.5, short, with thread, for Drill Bits B 2.8 mm LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm Drill Bit B 2.5 mm, calibrated, length 230/205 mm, 3-flute, for Quick Coupling Drill Bit B 2.5 mm, calibrated, length 300 mm, with Quick Coupling, for Percutaneous Insertion Drill Bit B 2.8 mm, with Scale, length 200/100 mm, 3-flute, for Quick Coupling Drill Bit B 2.8 mm, length 165 mm, for AO/ASIF Quick Coupling Drill Bit B 3.5 mm, length 195/170 mm, 2-flute, for Quick Coupling Depth Gauge for Cortex Screws B 3.5 mm, measuring range up to 150 mm Tap for Cortex Screws B 3.5 mm, calibrated, length 175 mm Handle with Quick Coupling Pelvic Implants and Instruments Surgical Technique DePuy Synthes 44

52 Instruments Ratcheting Handle with AO/ASIF Quick Coupling Screw Forceps, self-holding, length 85 mm Holding Sleeve, for Nos , and Screwdriver, hexagonal, small, B 2.5 mm, length 270 mm Screwdriver Shaft, hexagonal, for Screws B 3.5 mm, length 250 mm Screwdriver Stardrive 3.5, SD Screwdriver Shaft Stardrive 3.5, SD15, self-holding, for AO/ASIF Quick Coupling Screwdriver Shaft Stardrive 3.5, SD15, length 250 mm, for AO/ASIF Quick Coupling Torque Limiter, 1.5 Nm, for AO/ASIF Quick Coupling Universal Chuck with T-Handle Pliers for Screw Removal, length 205 mm 55 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

53 Optional Implants DCP 4.5, narrow* Stainless steel Art. No. Holes Length (mm) LC-DCP 4.5, narrow* Stainless steel Art. No. Holes Length (mm) Reconstruction Plate 4.5, straight* X = 2: Stainless steel X = 4: Titanium Art. No. Holes Length (mm) X X X X X X X Art. No. Holes Length (mm) X X X X X X X * All implants are available sterile packed. For sterile implants add suffix S to article number. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 55

54 Optional Implants Reconstruction Plate 3.5, straight* X = 2: Stainless steel X = 4: Titanium Art. No. Holes Length (mm) X X X X X X X X X X X X Pelvic Reconstruction Plate 3.5, curved* X = 2: Stainless steel X = 4: Titanium Art. No. Holes Length (mm) X X X X X X X * All implants are available sterile packed. For sterile implants add suffix S to article number. 55 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

55 Optional Screws Cortex Screws* X = 2: Stainless steel X = 4: Titanium X Cortex Screw B 3.5 mm, self-tapping, length mm X Cortex Screw B 4.5 mm, self-tapping, length mm Cancellous Bone Screws* X = 2: Stainless steel X = 4: Titanium X Cancellous Bone Screw B 4.0 mm, fully threaded, length mm X Cancellous Bone Screw B 4.0 mm, short thread, length mm X Cancellous Bone Screw B 6.5 mm, thread length 16 mm, length mm X Cancellous Bone Screw B 6.5 mm, thread length 32 mm, length mm X Cancellous Bone Screw B 6.5 mm, fully threaded, length mm * Schanz Screw B 6.0 mm, length 190/50 mm, Stainless Steel X19.980* Washer B 7.0/3.6 mm, for Screws B 2.7 to 4.0 mm * All implants are available sterile packed. For sterile implants add suffix S to article number. Pelvic Implants and Instruments Surgical Technique DePuy Synthes 55

56 Optional Instruments Pelvic Retractor, blunt Spiked Disc, for Reduction Forceps Disc for Reduction Forceps, rectangular Pelvic Reduction Forceps, asymmetric, with pointed ball tips, length 400 mm Pelvic Reduction Forceps, angled, small, with pointed ball tips, speed lock, length 190 mm Pelvic Reduction Forceps, angled, large, with pointed ball tips, speed lock, length 230 mm Pelvic Reduction Forceps, long, with pointed ball tips, speed lock, length 400 mm Pelvic Reduction Forceps, long, with three pointed ball tips, speed lock, length 400 mm Pelvic Reduction Forceps, with angled pointed ball tips, speed lock, length 250 mm 55 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

57 Ball Spike, with pointed ball tip, length 300 mm Reduction Forceps, large, with Points, soft lock, length 222 mm Pelvic Osteotomy Chisel, width 15 mm, length 304/134 mm Pelvic Osteotomy Chisel, width 20 mm, length 304/134 mm Bending Pliers for Reconstruction Plates 2.7 and Bending Template for Straight Reconstruction Plates Bending Template for Curved Reconstruction Plates Bending Template for Straight Reconstruction Plates 4.5, to be cut Shortcut 2.7 to 4.5, without rasp, for Reconstruction Plates 2.7 to 4.5, required in pairs Shortcut 2.7 to 4.5, with Rasp, for Reconstruction Plates 2.7 to 4.5, required in pairs Pelvic Implants and Instruments Surgical Technique DePuy Synthes 55

58 Optional Instruments Drill Bit B 2.5 mm, length 180/155 mm, 3-flute, for Quick Coupling Drill Bit B 2.5 mm, length 110/85 mm, 3-flute, for Quick Coupling Drill Bit B 3.2 mm, calibrated, length 230/205 mm, 3-flute, for Quick Coupling Drill Bit B 3.2 mm, length 180/165 mm, 2-flute, for Jacobs Chuck Drill Bit B 3.2 mm, length 130/115 mm, 2-flute, for Jacobs Chuck Drill Bit B 3.2 mm, length 195/170 mm, 3-flute, for Quick Coupling Drill Bit B 3.2 mm, length 145/120 mm, 3-flute, for Quick Coupling Drill Bit B 3.5 mm, length 110/85 mm, 3-flute, for Quick Coupling 55 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

59 Drill Bit B 4.5 mm, length 130/115 mm, 2-flute, for Jacobs Chuck Drill Bit B 4.5 mm, length 195/170 mm, 2-flute, for Quick Coupling Drill Bit B 4.5 mm, length 180/165 mm, 2-flute, for Jacobs Chuck Drill Bit B 4.5 mm, length 145/120 mm, 3-flute, for Quick Coupling Drill Bit B 4.5 mm, length 195/170 mm, 3-flute, for Quick Coupling Depth Gauge for Long Screws B 3.5 mm, measuring range up to 110 mm Tap for Cortex Screws B 3.5 mm, length 110/50 mm Tap for Cortex Screws B 3.5 mm, length 180/110 mm Pelvic Implants and Instruments Surgical Technique DePuy Synthes 55

60 Optional Instruments Tap for Cortex Screws B 4.5 mm, length 125/70 mm Tap for Cortex Screws B 4.5 mm, length 180/110 mm Tap for Cortex Screws B 4.5 mm, calibrated, length 175 mm Screwdriver Shaft, hexagonal, small, B 2.5 mm Screwdriver, hexagonal, small, B 2.5 mm, with Groove Screwdriver Shaft, hexagonal, small, B 2.5 mm, length 165 mm, for Quick Coupling Screwdriver Shaft, hexagonal, large, B 3.5 mm Screwdriver, hexagonal, large, B 3.5 mm, with Groove, length 300 mm Holding Sleeve, large, for Nos , , , and Screwdriver Shaft, hexagonal, large, B 3.5 mm, length 165 mm, for Quick Coupling 55 DePuy Synthes Pelvic Implants and Instruments Surgical Technique

61 Other Available Pelvic Instruments and Implants from Synthes Collinear Reduction Clamp Set The Collinear Reduction Clamp assists in achieving and maintaining fracture reduction in minimally invasive techniques. The system consists of sliding mechanism, attachable arms and reduction attachments according to the clinical needs. Refer to technique guide: Cannulated Percutaneous Guiding System Set The Cannulated Percutaneous Guiding System is a soft tissue protector to assist in pelvic and acetabular reconstructive surgery. It allows for less invasive placement of 3.5 mm cortex or pelvic screws as well as 4.0 cancellous screws. It accepts temporary fixation with Kirschner wires / guide wires up to B 2.8 mm. Refer to technique guide: Pelvic Implants and Instruments Surgical Technique DePuy Synthes 55

62 Other Available Pelvic Instruments and Implants from Synthes Pelvic C-Clamp The Pelvic C-Clamp is an emergency stabilization instrument for unstable injuries and fractures of the pelvic ring. Unstable pelvic ring fractures can be associated with massive loss of blood that can cause terminal shock. The Pelvic C-Clamp allows rapid reduction and stabilization of these unstable pelvic ring fractures, thus assisting the surgeon to gain control of the shock reaction. This neither delays nor hinders subsequent diagnosis and therapy. Note: The Pelvic C-Clamp is not contained in the pelvic sets. See separate Synthes publication Pelvic C-Clamp. Refer to technique guide: Large External Fixator Indications for stabilizing the anterior pelvic ring with a large external fixator are: Unstable fractures in the anterior pelvic ring, or symphysis fractures with or without participation of the posterior pelvic ring. This type of stabilization is also possible in emergencies such as polytrauma, open wounds and, where appropriate, as an alternative to internal osteosynthesis. The pelvis can be stabilized with an external fixator both at the iliac crest and the supraacetabular region. The clamps are magnetic resonance conditional. This allows magnetic resonance examinations of patients who have been stabilized with the external fixator. Refer to technique guide: DePuy Synthes Pelvic Implants and Instruments Surgical Technique

63 Sacral Bars The Synthes 6.0 mm Threaded Sacral Bars offer an additional option for stabilization of the posterior pelvic ring. Two threaded bars are therefore drilled through the posterior iliac crests and by compression of the nuts, bridging and compression of the posterior pelvic ring is achieved. Note: Two 6.0 mm Threaded Sacral Bar Kits are necessary to build the construct described in the technique guide ( Sacral Bar Set, Bar Length 200 mm, sterile or Sacral Bar Set, Bar Length 260 mm, sterile). Also, bolt cutters capable of cutting a 6.0 mm bar will be necessary to complete the procedure (Rod Cutter is available). Refer to technique guide: Spring Plate 3.5 The Synthes Spring Plate 3.5 is intended for reduction and fixation of small bone fragments. In pelvic and acetabular surgery, it is often difficult to reduce and fix small bone fragments with screws because the fragments may break into even smaller pieces. Mainly in the joint areas (acetabulum) it is essential that even small fragments are anatomically reduced and help to achieve again a homogenous joint congruency. The 3.5 Spring Plates are intended to reduce and stabilize bone fragments that are too small for screws. They can be used individually or in con-junction with a 3.5 mm reconstruction plate. Refer to technique guide: Pelvic Implants and Instruments Surgical Technique DePuy Synthes 66