Titel. *smith&nephew MODULAR-PLUS. Text. Cementless Modular Revision System. Surgical Technique

Transcription

1 Titel Surgical Technique Text *smith&nephew MODULAR-PLUS Cementless Modular Revision System

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3 MODULAR-PLUS Table of Contents Introduction... 3 Concept... 4 Indications...7 Preoperative Planning...7 Surgical Technique Further Procedure Revision of the MODULAR-PLUS Stem Implants Instrumentation Sterilization Nota Bene The technique description herein is made available to the healthcare professional to illustrate the authors suggested treatment for the uncomplicated procedure. In the final analysis, the preferred treatment is that which addresses the needs of the patient. 1

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5 Introduction The MODULAR-PLUS stem is a further treatment option for the revision of extensive bone defects, and completes the SL-PLUS and SLR-PLUS stem range used for the past 12 and 13 years respectively. With the introduction of the new MODULAR-PLUS generation, we have almost achieved our aim of providing a comprehensive cement-free system for all indications. The basis for a rapid osseointegration is a sufficient primary stability, thus the principle with the proven, conical, rectangular anchorage of the basic stem is maintained. However, the design of the MODULAR-PLUS system has been adapted for difficult revision conditions. The goal remains the functional restoration of an optimal stem/cup geometry. In the case of large meta-diaphyseal bone defects, the MODULAR-PLUS stem is anchored in the distal half of the femur, thereby extending the range of indications to serious revision cases. The stem can be implanted covered, as the system is modular and the bone s antecurvation is taken into account. A flexible, conical spiral reamer system which fits the anatomical form of the femur enables precise conical bone preparation. A rigid rasp could cause the stem to crack in the curved IM canal after a certain distance. The in situ assembly of the stem helps to ensure correct, stable positioning of the implant, as the anchoring depth of the distal module can first be determined independently from the proximal part. We regard the new MODULAR-PLUS stem system as a suitable option for the reconstruction of extremely serious hip revisions. Prof. Dr. med. K. Zweymüller September

6 Concept The MODULAR-PLUS system consists of two individual components of different sizes: a distal anchoring module and a proximal module, connected by means of a multiconical coupling. The distal anchorage module has an anterior, convex curve corresponding to the antecurvation of the femur. The edges are sharp and have a double profile, so as to prevent sinking and rotation. The proximal module allows an individual adjustment of the anatomical antetorsion. With 24 distal and 9 proximal modules, there are 72 different, anatomically fitted stem combinations for the left and right hip. The stems are divided into 3 groups A, B and C. The proximal and distal modules can be combined as required within each group. Group A Group B Group C Implant Material and Surface The MODULAR-PLUS stem system is made of the titanium alloy Ti6Al4V (ISO and ASTM F 136). The surface is roughened, and offers ideal conditions for rapid osseointegration and long-term stability of the implant. 4

7 Individually Adjustable Proximal Modules The longitudinal marking with the arrow serves to set the rotation between the distal and proximal module. The antetorsion is fully adjustable to ensure an optimal stem/cup geometry. The different lengths of the modules enable individual anatomical adaptation to the patient s circumstances. The implant shows a theoretical anteversion of 12 when the middle sections of the distal and proximal modules are aligned. (Attention! Check the definitive position of the distal module.) Offset (center M) Neck The surgeon can select from S, M, and L ballhead neck lengths for metal or ceramic balls. In exceptional cases, XL and XXL metal balls may also be used. Proximal parts: 126 Ø prox L D Art. No. size L offset neck D Ø prox AS AL AX BS BL BX CS CL CX The CCD angle is 126 in all proximal modules. Rotation-Stable Distal Modules As they are curved, the distal modules follow the femur s antecurvation. This design allows a covered implantation. The edges of the stem right angle cut into the cortical bone. Their double-profile design increases the area of contact with the bone. Thus, rotational stability is achieved in three ways: 1. as a result of the curvation of the prosthesis cor responding to the antecurvation of the femur; 2. by the four double edges of the prosthesis block; 3. by the very extensive cone fit of the prosthesis. 5

8 Connection The long-term durability of the stem system has been proven in fatigue tests according to the ISO standard with an implant depth of 80 mm run out run out Detailed drawing of the cone. Force [N] run out run out The graph on the right shows the so-called Wöhler curve for the cone connection of the MODULAR-PLUS stem Number of cycles B6 B5 B8 Flexible Spiral Reamer A conical spiral reamer which follows the curvature of the femur is used to prepare the bone bed. The preparation of the bone must be sufficiently deep. B7 B6 B5 Vorschub Min. motion der of Marke the minimum marking mm/ Markierungen markings Konisch Conical vorbereitete prepared zone Zone While preparing the bone with the spiral reamers, the area must be irrigated so as to avoid heat damage. Reaming is carried out until a sufficiently long area of cortical contact is achieved; in any case up to the largest possible size. This ensures the preparation of the diaphyseal cortical bone, while scar and granulation tissue on the surface of the IM canal are removed. It is advisable to first ream manually and then to use a multipurpose drill for larger sizes. Do not select the reverse setting when removing, as the spiral reamer could otherwise jam. The position markings on the spiral reamers correspond to the shoulder position of the short proximal implants (S modules). The spiral reamer s olive-shaped rounded tip allows the instrument to be directed through the IM canal, thus helping to prevent perforation. Thanks to the olive-shaped, rounded-off point, the reamer is inserted surely into the bone bed and helps to avoid perforations. 6

9 Indications Difficult Cases > 11 cm 1 /3 2 /3 3 /3 1 /4 2 /4 3 /4 > 11 cm The majority of revisions can be carried out with the SLR-PLUS revision stem. There are, however, many indications where the required metaphyseal anchoring zone is no longer available. The MODULAR-PLUS system, which is anchored into the femoral shaft has been developed for these cases. This revision system is indicated in cases where the second third or third quarter of the shaft has at least 11 cm of sustainable cortical bone, which is the requirement for minimal anchoring. 4 /4 Preoperative Planning B5 B6 B7 B8 Preoperative X-ray planning on the outer cortical bone by means of X-ray templates in 2 planes (frontal and sagittal) is essential for revision surgery. Please note, however, that sizes measured using templates can only be approximate values, as it is virtually impossible to assess the actual bone consistency preoperatively. 7

10 Use of the MODULAR-PLUS X-ray Template for Preoperative Planning Planning the conical preparation of the diaphysis: Meticulous preoperative planning is essential to the successful application of the MODULAR-PLUS revision system. Problems can be assessed prior to surgery and in some cases resolved. If these are not identified at the planning stage, the same problems encountered during surgery can lead to mistakes and thus to a poorer clinical outcome. X-rays in both planes are required: General overview of the pelvis AP view of the femur requiring revision with both femoral condyles Axial view of the femur requiring revision including the knee and the anterior curvation of the femur In order to determine the enlargement factor, the X-rays should be recorded with an X-raymeasuring rule, which should, if possible, be affixed to the patient s leg at the femur. A On the AP view, mark the location of the planned center of the new ball head, or simply mark the center of the old implant head. B Examine the X-ray to assess the quality and strength of the diaphyseal cortex and mark the position at which load-bearing should begin for anchorage of the prosthesis. From this point distally, a tapering bone bed extending circumferentially over 11 cm of the femur must be prepared. C Compare the relationship between the marked external lines of the diaphysis on the X-ray with the two external cortex lines reproduced on the X-ray template (3). If the external cortex lines on the template (3) are clearly narrower than on the diaphysis, use the next larger X-ray template. The correct stem length corresponds to a cortical line on the template that is identical in size, or slightly smaller than the diaphysis at the point marked by you. D Check your selection against the axial X-ray. If the diaphysis is flattened, i.e. appears smaller in the axial view, select the smaller X-ray template. E Ensure that the selected medullary probe can be inserted easily into the medullary canal, i.e. with clearance. If the lines of the medullary probe on the X-ray template reveal constriction or deformation of the medullary canal, widen the latter using the corresponding smaller size of tapered spiral reamer. 8

11 If the medullary canal is sealed off by a socket beneath the tip of the previous stem, open up the canal using a flexible 9 mm intramedullary drill and then widen the medullary cavity with spiral reamer A. D In most cases the spiral reamer matching the planned stem size can be used directly. F Planning the preparation of the anchoring section D 1. Mark the distal point at which the outline of the spiral reamer (4) becomes narrower than the medullary canal. D 2. Using the enlarged centimeter scale (enlargement factor 1.15:1) of the X-ray template, measure the distance between this marking and the marking you previously made with the aid of the external cortex lines of the template (3). D This distance which should be a minimum of 11 cm determines the scheduled section of tapered reaming required for implantation of the planned stem size. 9

12 7. Outline of the proximal module, long 1. Level of the center of the head (ball head M) on the proximal standard module, short 3. External cortex line 2. Determining the size of the medullary probe 4. Outline of the section reamed with the spiral reamer (corresponds to the diagonal mass of the distal module) 6. Outline of the implanted distal module (AP view) 5. Enlarged cm scale 1.15:1 10

13 1 Level of the center of the headneck (ball head M) on the proximal standard module, short This is the starting point for planning. Align the template in relation to the prosthesis head to be revised (± 10 mm), or better still in relation to the planned center of the new joint cup. 2 Lines of the medullary probe Indicate the size of spiral reamer that can easily be inserted into the medullary cavity. Minor irregularities in the medullary cavity or the need for a special technique/procedure are identified at this point. 3 External cortex lines Used to determine the size of the prosthesis the length of the tapered anchoring zone (min. 11 cm) and also to ascertain whether the cortex surrounding the stem will be thick enough after reaming with the spiral reamer. Prevent selection of an excessively small prosthesis and facilitate identification of borderline and high-risk cases. Assist in the identification of the load-bearing section of the diaphysis. 4 Outline of the reaming with the spiral reamer Shows the tapering cavity that would be achieved after completion of the preparation of the respective distal module. Permits identification of the anchoring section in which a tapered anchorage of at least 11 cm in load-bearing cortex is achievable. Corresponds to the outline of the rectangular stem viewed diagonally. 5 Enlarged cm scale 1.15:1 Facilitates measuring on the X-ray and during planning, particularly planning of the tapered anchoring zone of 11 cm to be prepared starting from the load-bearing cortex. 6 Outline of the implanted distal module Intended for follow-up check X-rays rather than preoperative planning. A stem with a rectangular crosssection implanted in a circular bony bed looks narrower in the AP view than when viewed diagonally. The four double edges, however, remain in close contact with the bone, producing a rotationally stable, tapered fit over a large area. 7 Outline of the proximal module, long Shows the distance that can be offset by this module if any deviations from the preoperative planning arise during surgery. The long proximal module corresponds to the difference in length between two sizes of distal module that can be implanted in the same bony bed. 11

14 Surgical Technique Cup Implantation The cup implantation is to be carried out first. A trial insert should always be used, so as to ascertain exactly which insert should be used: a standard, an antiluxation, or perhaps even a retention insert. Protection We recommend the use of at least one titanium cerclage band (Gundolf CCG cerclage) on the diaphysis. This can be fitted either before reaming or (at the latest) before the trial stem is impacted. If there are already fissures or spiral fractures on the femur, the titanium cerclage band must be applied before reaming. Preparing the Stem For the implantation, the IM canal must be completely free of any obstruction. If the IM cavity is evenly formed, no special measures are required. Obstacles include eccentric obstructions, asymmetrical formation of sockets caused by previous slackening, cement residues, etc. In these cases, the IM canal must be carefully cleared using either the IM reamer or the cement removal tool. If there is a fracture in the upper half of the shaft, the proximal fragment is folded back to the point of fracture. The diaphysis is then processed distally starting from the fracture site. Accessibility of the IM Canal Once the IM canal has been cleared of all cement residues and granulation tissue, and all obstructions have been removed, the overall accessibility is checked once again with the IM probe using the olive-shaped tip. The spiral reamer only works if the olive has unobstructed passage. 12

15 Preparing the Bone Bed Always start the reaming procedure with the smallest size (A system), even if the IM canal is very wide. The preoperative plan will indicate whether a long or short distal module should be used. Following the plan therefore, begin with the smallest reamer for the long or the short distal modules, and then work upward consistently to the next size in the appropriate line (long or short). If a larger module is required, the larger spiral reamer (B system) is used, and, if necessary, the C-system spiral reamer. Preparation of the intact bone canal must be continued up to the cortical bone. The implant must be anchored in the cortical bone and not in the spongiosa or the connective tissue. A C-arm may be useful, especially to determine the position of the tip of the spiral reamer in relation to the knee joint. B8 B7 B6 B5 Operation of the spiral reamer is started using the handle, and then continued with a motor. Sufficient cooling must be ensured during the clearing process! When removing the reamer, turn it clockwise only. The ring-shaped markings on the spiral reamer indicate the shoulder heights of the proximal module and the height of the greater trochanter (e.g., marking 3 corresponds to size 3A). Product Overview with Implant Sequence Short module, distal: 1AS, 2AS, 3AS, 4AS Spiral reamer A short (Art. No ) 5BS and 6BS Spiral reamer 5BS/6BS (Art. No ) 7BS and 8BS Spiral reamer 7BS/8BS (Art. No ) 9CS and 10CS Spiral reamer 9CS/10CS (Art. No ) 11CS and 12CS Spiral reamer 11CS/12CS (Art. No ) Long module distal: 1AL, 2AL, 3AL, 4AL Spiral reamer A long (Art. No ) 5BL, 6BL, 7BL, 8BL Spiral reamer B5 8 (Art. No ) 9CL and 10CL Spiral reamer C9 10 (Art. No ) 11CL and 12CL Spiral reamer C11 12 (Art. No ) 13

16 The IM canal can only be successfully prepared if maximum proximal pressure is exerted on the spiral reamer. A conical bone bed can thus be prepared over a sufficient distance for the distal implant. Allowing the reamer to run loose without pressure prevents precise preparation of the cortical bone. The flexibility of the instrument enables it to follow the curvature of the femur. Clockwise rotation (according to the direction of the arrows on the spiral reamer prevents blocking. As soon as the pressure is reduced, the instrument retracts. To respect the bone s viscoelasticity, take short breaks between individual reaming procedures. The bone should be prepared to a sufficient depth. The spiral reamer should prepare an anchoring bed of a depth of at least 11 cm. It is important that the 8 sharp edges can settle in the contact area of the hollow bone, so that the implant is rotationally stable. Overview of Impactors Left: Metal impactor with thread to impact and extract distal trial inserts and distal implants (3 sizes A, B, C). Center: Plastic impactor for distal trial inserts and distal implants. Right: Plastic impactor with a metal point for extracorporeally assembled implants (proximal and distal). Only for impacting! Art. No (A) (B) (C) Art. No Art. No

17 In situ Insertion of the Trial Prosthesis Hammer the distal trial module into the IM canal with the impactor (Art. No ), until a snug fit is attained and a cortical sound can be heard. For optimal seating of the prosthesis, it is recommended to insert the distal trial module three times. Once even forceful impacting does not drive in the trial module deeper, the procedure is complete. Ensure that the stem is in the same position each time it is impacted, as an error in the rotation could result in different insertion depths. The distal modules (trials and implants) are inserted and extracted with the impactor for distal modules. The instrument is screwed into the distal section and tightened up to the marking Trials with the torque screwdriver (Art. No ). Insertion and extraction with the extractor for trials (Art. No ). Warning Impactors must be fully tightened, as the thread could otherwise be stripped! After each impact, make sure that the impactor has not loosened. 15

18 The plastic impactor (Art. No ) is used for additional impacting of the distal module, if required. It does not need to be screwed into the thread. Placing the corresponding proximal PEEK module. Rotational setting can be adjusted as required. The proximal module is secured with the trial screw. The tightening torque can be countered by the brace (Art. No ) on the ball cone. The marking Trials on the screwdriver (Art. No ) indicates the correct torque for the trial screws. If the distal trial module is too deep in the IM canal after impacting, the module must be removed and the bone must be prepared for the next size with the spiral reamer. If the proximal third of the femur is missing, preparation can be carried out with both modules from the start. By marking the bone, the rotational position for the subsequent insertion of the distal implant with its anatomical antecurvation can be referenced. The rotational position of the proximal trial module is also marked on the bone (use the side of the body as a reference for this line). 16

19 Repositioning after Placing the Ball Head Using the short (S) proximal module: If satisfactory soft-tissue tension is only achieved with M or L heads, the next largest proximal module (L) should be used. This is in case the stem goes a little deeper than the trial when impacting the actual implant. The same procedure applies to the use of the L module. Using the extra long (XL) proximal module: If repositioning stability for the soft tissue can only be achieved using M or L ball heads, the next stem size should be selected, e.g. from 4A to 5B. The trial stem 5B is either placed directly in the bone track or is first prepared with the size B spiral reamer. Example: Height Translations when Switching from System A to B A proximal BS module with S ball head is 11 mm deeper than a proximal AX module with L ball head, if the area is not reamed when switching from distal module 4A to 5B. Example: Height Translations when Switching from System B to C A proximal CS module with S ball head is 6.5 mm deeper than a proximal BX module with L ball head, if the area is not reamed when switching from distal module 8B to 9C. 17

20 Once the correct ball head size has been determined, the trial prosthesis can be extracted in its entirety. Warning The trial screw must be securely tightened for this procedure. The thread could otherwise be stripped! By turning the push-out screw clockwise with the screwdriver, the two trial parts are separated. This can be done in situ or extracorporeally. In situ: to use the next proximal size. Extracorporeally: to prepare the trial proximal module for the trial with the final distal implant. Both trial parts can be separated using the push-out screw. Screw Art. No fits all A sizes Screw Art. No fits all B and C sizes The torque can be countered by the brace (Art. No ). 18

21 Assembly of the MODULAR-PLUS Stem The MODULAR-PLUS stem can be assembled in situ or extracorporeally with the assembly clamp. It is recommended, however, to carry out the assembly in situ, as with this method the appropriate proximal module can be selected for the firmly implanted distal module. With both techniques, care must be taken to ensure that the step cone is not damaged due to mechanical influence. In situ assembly Impactor with thread Hammer the distal implant into the IM canal with the impactor with thread or the plastic impactor until a snug fit is obtained and a cortical sound can be heard. Hammering can be carried out with considerable force, as the safety cerclage should prevent the bone from fracturing. Plastic impactor Insertion and extraction are both carried out using the trial extractor (Art. No ). 19

22 Femur Grössenkontrolle The manipulation on the final distal implant is carried out in the same way as the first one. The proximal trial modules are set distally on the positioned implant. The separation of both parts is also carried out in the same way as the separation of the two trial components. In this separation process the final distal implant is not separated from the bone, as would be the case if it were separated using an impactor. The cone area of the final distal implant is not damaged by the proximal PEEK piece. 20

23 Assembly Process Assembly clamp and accessories: Assembly clamp (Art. No ) Screws A, B, C (Art. No , , ) Push the sleeve (Art. No ) onto the corresponding screw (A, B, C). The initial position for the assembly clamp is open, the adjustment screw is low, and the distal adapter is screwed proximally. Insert the screw with the sleeve from proximal to distal in the assembly clamp. Once it has been thoroughly cleaned, the proximal module is pushed onto the distal module by hand, exerting slight pressure. (This prevents unintentional twisting of the proximal implant.) Take care to ensure that no tissue is trapped. The screw of the assembly clamp is screwed distally into the positioned and slightly pressurised proximal module. With the grips of the assembly clamp fully open, distally screw in the adapter. Raise the adjustment screw (a) and turn it 90. Squeeze the grips three times to the stop (assembly force = 5,000 N). Remove the screw and the assembly clamp. (If the screw can still be slightly turned after the assembly, the grips can be squeezed once more.) The proximal and distal implants are now firmly connected. 21

24 Fügevorgang Repeat the placement of the trial ball head for fine-tuning of the neck length. The implant screw can now be screwed in and tightened with the torque screwdriver to the marking Implants. Place the final ball head. Extracorporeal Assembly Immerse the stepped cone of the distal module in Ringers Lactate (sterile saline solution/ NaCl) before attaching the proximal module by hand and transferring the selected antetorsion angle from the trial stem to the implant. If the antetorsion angle is correct, the proximal module is then pressed into place by hand. Both pieces are then assembled with the assembly forceps. The assembled prosthesis is then inserted into the femur by hand with slight twisting motions (marking!) and pressed in. It is then hammered into position using the impactor (Art. No ). The hammer blows must be sufficiently forceful, but controlled. A tight, cortical fit must be attained to ensure optimal primary stability of the implant. To attain optimal distal anchoring, make sure that the proximal module does not touch the bone. The trial ball heads are once again used for fine-tuning of the neck length. Only then is the final ball head set in position and the implant screw tightened to the marking Implants with the torque screwdriver. 22

25 Separating the Proximal and Distal Module To remove the proximal module after it has been assembled, the following procedure is recommended: Assemble the corresponding implant pushout screw (one screw for each proximal size) with the handle (Art. No ) and screw it into the thread of the proximal module. Caution The implant push-out screw has to be inserted carefully into the proximal module through the guide cylinder to prevent jamming when it is screwed into position. Never impact the implant push-out screw into the proximal module with a hammer or other instrument. The distal module is separated from the proximal module by turning it clockwise and applying great force. The high torque must be countered using the brace (Art. No ). During the process, check repeatedly if the proximal module is released. 23

26 Extracting the Entire Assembled Revision Stem The plastic extractor (Art. No ) is used to extract the fully mounted implant without causing damage. The plastic extractor is used with the extraction screw (Art. No ) and the slap hammer (Art. No ) from the SL-PLUS tray. Initial position of the extraction instrument is open. First, the extraction screw is screwed into the thread with approximately two revolutions. The two outer parts must be folded inwards; first the plastic part and then the metal part. The two plastic parts form a bed for the 12/14 cone; the metal part covers the plastic part, clamping it tight. Place the folded instrument over the cone. The extraction screw must always face the axial direction. 24

27 Fügevorgang Attach the slap hammer. Tighten the screw with the attached slap hammer and ensure that the tip of the extraction screw is sunk into the respective opening in the plastic piece. Warning If the MODULAR-PLUS stem is removed in one piece in this way and then reinserted (e.g., if the rotational setting of the distal module was not exact), it must be reassembled using the assembly clamp (Art. No ) before it is again impacted, as the cone connection may have loosened during extraction. Further Procedure Redon drains Wound closure Mobilisation Postoperative rehabilitation 25

28 Revision of the MODULAR-PLUS Stem On request, the following revision sets can be borrowed from Smith & Nephew Orthopaedics AG in Rotkreuz, Switzerland: Set Revision of old A modules (including chisel blades from set ) Reference Surgical technique Lit. No Set Revision of well-osseointegrated stems with chisel blades and impactor Reference Surgical technique Lit. No Set In situ separation of first-generation proximal modules Reference Surgical technique Lit. No

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30 Implants Proximal Module with Screw Art. No. Art. No. Ø S&N PO Size Length (L) Offset Neck D prox AS 43.0 mm AL 58.4 mm AX 73.7 mm BS 52.3 mm BL 71.0 mm BX 89.7 mm CS 63.8 mm CL 86.4 mm CX mm Distal Module Art. No. Art. No. S&N PO Size Length (L) Ø max. Ø min AL mm AS mm AL mm AS mm AL mm AS mm AL mm AS mm BL mm BS mm BL mm BS mm BL mm BS mm BL mm BS mm CL mm CS mm CL mm CS mm CL mm CS mm CL mm CS mm

31 Offset (center M) A B C AS AL AX BS BL BX L M S Ø 28 CS CL Neck CX Ø prox L D prosthesis length (head center M to tip) length 1A 2A 3A 4A 5B 6B 7B 8B 9C 10C 11C 12C 0 Ø max Ø min. prosthesis length (head center M to tip) Distal/proximal length Prosthesis length 1AS+AS/1AL+AS 222/253 2AS+AS/2AL+AS 227/260 3AS+AS/3AL+AS 233/267 4AS+AS/4AL+AS 238/275 5BS+BS/5BL+BS 243/290 6BS+BS/6BL+BS 249/298 7BS+BS/7BL+BS 255/306 8BS+BS/8BL+BS 261/315 9CS+CS/9CL+CS 267/332 10CS+CS/10CL+CS 273/341 11CS+CS/11CL+CS 280/350 12CS+CS/12CL+CS 287/360 CCG is a registered trademark of Dr. A. Wurzinger, Maria Enzersdorf, Austria. 29

32 Instrumentation SET OVERVIEW Set MODULAR-PLUS Standard Kit, 7 trays Lit. No Set MODULAR-PLUS Optional (Hollow Reamers) part of 7/7 Lit. No Set MODULAR-PLUS Chisel blades 1 tray Lit. No MODULAR-PLUS Standard Kit Set No Art. No. Art. No. S&N PO Description Tray 1/7 Trial Modules Proximal Lid Trial modules proximal AS Trial modules proximal AL Trial modules proximal AX Trial modules proximal BS Trial modules proximal BL Trial modules proximal BX Trial modules proximal CS Trial modules proximal CL Trial modules proximal CX Trial screw AS Trial screw AL Trial screw AX Trial screw BS Trial screw BL Trial screw BX Trial screw CS Trial screw CL Trial screw CX Long hexagonal wrench A, B, C Long hexagonal wrench to revise old prox. B modules Long hexagonal wrench to revise old prox. C modules Push-out screw AS/AL Push-out screw B/C Handle 30

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34 Art. No. Art. No. S&N PO Description Tray 2/7 Miscellaneous Lid Reamer handle Extractor Extraction screw Implant push-out screw AS Implant push-out screw AL Implant push-out screw AX Implant push-out screw BS Implant push-out screw BL Implant push-out screw BX Implant push-out screw CS Implant push-out screw CL Implant push-out screw CX Brace Trial ball head 28/14 S Trial ball head 28/14 M Trial ball head 28/14 L Trial ball head 28/14 XL Trial ball head 28/14 XXL Trial ball head 32/14 S Trial ball head 32/14 M Trial ball head 32/14 L Trial ball head 32/14 XL Trial ball head 32/14 XXL 32

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36 Art. No. Art. No. S&N PO Description Tray 3/7 Trial Modules Distal L Lid Trial module distal 1AL Trial module distal 2AL Trial module distal 3AL Trial module distal 4AL Trial module distal 5BL Trial module distal 6BL Trial module distal 7BL Trial module distal 8BL Trial module distal 9CL Trial module distal 10CL Trial module distal 11CL Trial module distal 12CL 34

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38 Art. No. Art. No. S&N PO Description Tray 4/7 In situ Clamp Lid In situ clamp sleeve Screw A Screw B Screw C Weight Impactor (extra corporeal) Impactor for trial and implant (in situ) Trial extractor with nut 36

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40 Art. No. Art. No. S&N PO Description Tray 5/7 Trial Modules Distal S Lid Trial module distal 1AS Trial module distal 2AS Trial module distal 3AS Trial module distal 4AS Trial module distal 5BS Trial module distal 6BS Trial module distal 7BS Trial module distal 8BS Trial module distal 9CS Trial module distal 10CS Trial module distal 11CS Trial module distal 12CS 38

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42 Art. No. Art. No. S&N PO Description Tray 6/7 Spiral Reamers Lid IM canal probe C Spiral reamers B Spiral reamers C

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44 Art. No. Art. No. S&N PO Description Tray 6/7 Spiral Reamers Spiral reamers A long Spiral reamers A short Spiral reamers 5BS/6BS Spiral reamers 7BS/8BS Spiral reamers 9CS/10CS Spiral reamers 11CS/12CS Spiral reamers C IM canal probe A+B 42

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46 Art. No. Art. No. S&N PO Description Tray 7/7 Impactors Lid Impactor for distal A modules Impactor for distal B modules Impactor for distal C modules 44

47 OPTIONAL 45

48 MODULAR-PLUS Optional (Hollow Reamers) Set No Art. No. Art. No. S&N PO Description Hollow reamer A module Hollow reamer B module Hollow reamer C module Guiding rod A module Guiding rod B module Guiding rod C module Fastening screw A module Fastening screw B module Fastening screw C module MODULAR-PLUS Optional (Chisel Blades) Set No Art. No. Art. No. S&N PO Description Handle with snap closure Small impactor Chisel blade Chisel blade Chisel blade Chisel blade Chisel blade Chisel blade Chisel blade Chisel blade

49 Sterilization Implants All the implants described in this Surgical Technique are sterile when they are delivered by the manufacturer. Resterilization is not allowed. Instruments System components and instruments are not sterile when they are delivered. Before use they must be cleaned by the usual methods in accordance with internal hospital regulations and sterilized in an autoclave in accordance with the legal regulations and guidelines applicable in the relevant country. (For detailed information please refer to leaflet Lit. No ) The correct settings are given in the instructions for use issued by the autoclave manufacturer. Instrument manufacturers and dealers accept no responsibility for sterilization of products by the customer. 47

50 48 Notes

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52 Manufacturer Smith & Nephew Orthopaedics AG For further information please contact Erlenstrasse 4a our local sales office Rotkreuz Switzerland Trademark of Smith & Nephew Lit. No e Ed. 06/08 EU 200 Ex. 05/