DARCO. LPS Plate SURGICAL TECHNIQUE

Transcription

1 DARCO LPS Plate SURGICAL TECHNIQUE

2 Contents Preface 3 Chapter 1 4 Chapter Appendix Design Rationale Preoperative Planning Surgical Technique Surgical Approach Joint Preparation Surgical Fixation Closure and Post-op Protocol Ordering Information DARCO Implants DARCO Instruments Proper surgical procedures and techniques are the responsibility of the medical professional. The following guidelines are furnished for information purposes only as techniques used by the describing physicians. Each surgeon must evaluate the appropriateness of the procedures based on his or her personal medical training and experience. Prior to use of the system, the surgeon should refer to the product package insert for complete warnings, precautions, indications, contraindications and adverse effects. Package inserts are also available by contacting Wright Medical Technology, Inc.

3 Design Rationale Peface The DARCO LPS Locked Plate offers an innovative, stable method of fixation for fusion of the 1st tarsometatarsal (TMT) joint. Advantages of Lapidus Procedure with DARCO LPS Locked Plate»» Extremely stable locked-screw fixation.»» Incremented step-off design permits accurate plantarization of the metatarsal to counter 1st ray shortening.»» Low profile, anatomically contoured plate minimizes soft tissue irritation due to hardware prominence.»» Pre-determined locked screw positions eliminate screw collision, potentially shortening operative time. DARCO LPS Plate 3

4 Preoperative Planning Surgical Technique as described by Christopher F. Hyer, DPM; Greg Berlet, MD; Thomas Lee, MD; and Ernst Orthner, MD chapter 1 In addition to standard small-joint instrumentation, the following items should be planned for in the operating room:»» intra-operative flouroscopy»» powered handpiece with k-wire driver, jacobs chuck and sagittal saw»» straight and curved osteotomes of varying widths»» straight and curved bone curettes»» bone graft substitute, as indicated by procedure, such as Wright Medical ALLOMATRIX DR Bone Graft Substitute. If the surgeon desires a porous block graft, Wright Medical CANCELLO-PURE Wedges are appropriate. 4 Chapter 1 Preoperative Planning

5 Surgical Technique chapter 2 Surgical Approach Plan a dorso-medial approach to the proximal 1st TMT, just medial to the EHL tendon. The approach should extend 2-3 cm on either side of the TMT. Figure 1 Create the skin incision taking care to identify and protect any overlying neurovascular structures. Deepen the incision through the fascial layers to the dorsal capsule of the TMT; use blunt dissection to release the EHL off the TMT and retract the tendon laterally. Figure 2 Confirm the location of the 1st TMT joint either directly or using flouroscopy; a 22g needle or k-wire may be used to mark the joint. Figure 3 Perform a capsulotomy at the superior aspect of the 1st TMT to expose the entire joint. Care should be taken to ensure complete exposure of the plantar and lateral aspects of this joint, which is quite deep. Figure 4 A pin-based distractor can be used for easier joint debridement. Figure 1 Figure 2 Figure 3 Figure 4 Chapter 2 Surgical Technique 5

6 Joint Preparation Take down the cartilage of the 1st TMT joint using a ¼ inch curved osteotome and bone curettes. Remove the cartilage thoroughly until dense subchondral bone is completely exposed on both sides of the joint. Figure 5 Thoroughly perforate the subchondral plates with a small diameter drill or k-wire until rich cancellous bone is exposed. Figure 6 The ¼ inch osteotome is then used to perform a fish scaling technique to further prepare the joint surfaces. At the surgeon s discretion, the intermetatarsal joint between the 1st and 2nd bases may be similarly prepared. This is done to allow some lateralization of the 1st metatarsal (MT) base and create an additional fusion surface for added stability. ALLOMATRIX DR Bone Graft is used to thoroughly grout the fusion sites, filling any voids or incongruities. Figure 7 Figure 5 Figure 6 Figure 7 6 Chapter 2 Surgical Technique

7 Surgical Fixation Three separate fixation elements are used to facilitate proper correction and fixation of the TMT joint:»» A 3.5 or 4.0mm cannulated compression screw, directed from the base of the 1st MT into the cuneiform. The screw applies compression across the TMT joint prior to fixation of the locked LPS plate.»» The LPS plate itself, which determines plantarization of the MT base and provides definitive fixation.»» A provisional k-wire, placed distally between the 1st and 2nd MT. This wire may be used to close and adjust the intermetatarsal angle. Compression Screw Wire Drive the wire for the cannulated screw through the center of the TMT joint, out the medial plantar aspect of the MT, and out through the skin. Figure 8 Advance the wire until countersunk in the joint; it will be retrograded back into the cuneiform in a later step. Provisional Plate Placement If the 1st ray has any shortening, translate the base of the MT plantarly to compensate. Select the LPS plate that has the corresponding amount of stepoff. Place the plate dorsally over the TMT joint and provisionally fix with 2 k-wires; make sure that the distal k-wire is placed at the most distal extent of the compression slot. Figure 9 (In the case of Metatarsus Primus Varus, the plate may also be placed dorso-medially, which would translate the MT base both plantarly and laterally). Intermetatarsal Angle Adjustment Correct widening of the 1st intermetatarsal angle by using a k-wire distally between the 1st and 2nd metatarsals. Figure 10 Verify correction flouroscopically. Figure 8 Figure 9 Figure 10 Chapter 2 Surgical Technique 7

8 Cannulated Screw Placement Holding the great toe in dorsiflexion, retrograde the screw k-wire proximally from the MT into the cuneiform under flouroscopic guidance until in contact with the lateral/proximal cortex. Figure 11 Percutaneously place cannulated compression screw per normal protocol. Figure 12 Plate Fixation Recheck the positioning of the Darco LPS plate using fluoroscopy and adjust if needed. Thread the Locking Drill Guide (P/N DC4169) into one of the proximal screw holes; it is imperative to use the Locking Guide for locking screw application. Use the 2.5mm Drill (P/N DC5620) to drill through the guide. Figure 13 Bicortical fixation may be considered in the case of osteoporotic bone, but is generally not required with locked plating systems. Measure using the Depth Gauge (P/N DC4263-2) Figure 14 and advance the appropriate screw until flush with the plate. Figure 15 Figure 11 In the event that a locking screw interferes with the cannulated compression screw, the drill may be redirected freehand within the screwhole and a nonlocking screw used in that location. Use caution going far off the normal drilling axis, as this may result in unwanted screw head prominence. Each of the 4 screws are inserted in the same fashion. If subtle contouring of the plate is required, both Locking Drill Guides can be used as in-situ benders. This method allows the plate to perfectly fit the anatomy while protecting the locking threads within the plate. Figure 12 Figure 13 Figure 14 Figure 15 8 Chapter 2 Surgical Technique

9 Closure and Post-op Protocol The incision is closed in layers per the surgeon s technique. A well-padded post-operative splint is recommended for the first days as the incision heals. Post-operative care and time to weightbearing is the responsibility of the surgeon. Chapter 2 Surgical Technique 9

10 Ordering Information Appendix Kit List Part No. Description Quantity DMRSKITA DMRSKIT1 Implant Kit Instrument Kit Locked Screws DC mm x 3.5mm 5 DC mm x 3.5mm 5 DC mm x 3.5mm 5 DC mm x 3.5mm 5 DC mm x 3.5mm 5 DC mm x 3.5mm 5 DC mm x 3.5mm 5 DC mm x 3.5mm 5 DC mm x 3.5mm 5 DC mm x 3.5mm 5 DC mm x 3.5mm 5 Non-Locked Screws DC mm x 3.5mm 2 DC mm x 3.5mm 2 DC mm x 3.5mm 2 DC mm x 3.5mm 2 DC mm x 3.5mm 2 DC mm x 3.5mm 2 DC mm x 3.5mm 2 DC mm x 3.5mm 2 DC mm x 3.5mm 2 DC mm x 3.5mm 2 DC mm x 3.5mm 2 Instruments and accessories DC 35 Box System tray assembly 1 DC Bending forceps 1 DC 4157 Bending iron 1 DC 4169 Drill guide 2 DC Depth gauge 1 DC 4197 Forceps 1 DC 4261 Screwdriver, hexagonal, cannulated 1 DC 5136 Drill bit, 2.5mm 2 DC 5620 Cannulated drill bit 2.5mm 1 NO K-wire mm 6 DC 4584 Screw holding and bending iron 1 10 DARCO LPS Plate

11 Part No. Description Placement in Trays LPS (Lapidus Plating System) DC mm step DC mm step DC mm step DC mm step DC mm step DC mm step DC mm step PIA (Poly Interpositioning Arthrodesis) DC mm spacer DC mm spacer DC mm spacer DC mm spacer DC mm spacer UPS 3.5 (Universal Plating System) DC mm DC mm DC mm DC mm DC mm RPS (Rearfoot Plating System) DC mm, 6 holes DC mm, 8 holes DC mm, 14 holes AFP (Arthrodesis Flat Plate) DC mm DC mm DC mm DPS (Displacement Plating System) DC mm step DC mm step DC mm step CPS (Calcaneus Plating System) DC S: 54mm DC M: 64mm DC L: 74mm L M S DARCO LPS Plate 11

12 Additional Products For Bone Voids, Use Allomatrix DR Peri-articular graft 86DR cc For Bone Grafting, Use CANCELLO-PURE Wedge For Ligament Reinforcement, Use Graftjacket Matrix Maximum Force Regenerative Tissue Matrix X07 4x7cm Non-meshed Wright Medical Technology, Inc Airline Road Arlington, TN phone toll-free Wright Medical EMEA Krijgsman DM Amstelveen The Netherlands phone Trademarks and Registered marks of Wright Medical Technology, Inc. DARCO is a licensed trademark of Wright Medical Technology, Inc. Patents pending Wright Medical Technology, Inc. All Rights Reserved. SO