4.5 mm LCP Condylar Plate Aiming Instruments

Transcription

1 Part of the LCP Periarticular Aiming Instrument System (Large) 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

2 Table of Contents Introduction 4.5 mm LCP Condylar Plate Aiming Instruments mm LCP Condylar Plate 3 AO Principles 4 Indications 5 Surgical Technique Preoperative Planning 6 Preparation 7 Attach Insertion Handle 8 Make Incision 10 Reduce Articular Surface 11 Insert Plate 12 Determine Plate Position 13 Insert Cannulated Screws 14 Secure Aiming Arm to Plate 17 Use Pull Reduction Device (optional) 23 Insert 4.5 mm Cortex Screws 25 Insert 4.0 mm or 5.0 mm Locking Screws 28 Remove Aiming Arm and Insertion Handle 31 Product Information MR Information The 4.5 mm LCP Condylar Plate System has not been evaluated for safety and compatibility in the MR environment. It has not been tested for heating, migration or image artifact in the MR environment. The safety of the 4.5 mm LCP Condylar Plate System in the MR environment is unknown. Scanning a patient who has this device may result in patient injury. Implants 32 Instruments 34 Set Lists 39 Image intensifier control 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 1

3 4.5 mm LCP Condylar Plate Aiming Instruments The aiming arms for the 4.5 mm LCP Condylar Plates facilitate percutaneous, submuscular insertion of the plate. The LCP Periarticular Aiming Instrument System, Large, provides common instrumentation throughout the system, including: Screwdrivers Threaded drill sleeves Drill bits Locking/ neutral guides Compression sleeves Cannulated connecting posts Trocars Features Aiming for all three positions of the Combi hole: Locking Compression Neutral Instruments snap into aiming arms for quick assembly and removal Multiple options for connecting plates and insertion handles accommodate surgeon preferences Color coding provides easier system familiarity 2 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

4 4.5 mm LCP Condylar Plate The DePuy Synthes 4.5 mm LCP Condylar Plate is part of the LCP Periarticular Plating System, which merges locking screw technology with conventional plating techniques. The LCP Periarticular Plating System is capable of addressing complex fractures of the distal femur with the 4.5 mm LCP Condylar Plates, complex fractures of the proximal femur with the 4.5 mm LCP Proximal Femur Plates and the 4.5 mm LCP Proximal Femur Hook Plates, and complex fractures of the proximal tibia with the 4.5 mm LCP Proximal Tibia Plates and 4.5 mm LCP Medial Proximal Tibia Plates. The Locking Compression Plate (LCP) has Combi holes in the plate shaft that combine a dynamic compression unit (DCU) hole with a locking screw hole. The Combi hole provides the flexibility of axial compression and locking capability throughout the length of the plate shaft. Note: For information on fixation principles using conventional and locked plating techniques, please refer to the DePuy Synthes Large Fragment Locking Compression Plate (LCP) Technique Guide. The 4.5 mm LCP Condylar Plate System has many similarities to traditional plate fixation methods, with a few important improvements. The technical innovation of locking screws provides the ability to create a fixed-angle construct while using familiar AO plating techniques. Locking capability is important for a fixed-angle construct in osteopenic bone or multifragment fractures where screw purchase is compromised. These screws do not rely on plate-to-bone compression to resist patient load, but function similarly to multiple, small angled blade plates. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 3

5 AO Principles AO PRINCIPLES In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation. 1,2 In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation 1, 2. 4_Priciples_03.pdf :08 Anatomic Anatomic reduction reduction Fracture Fracture reduction reduction and and fixation fixation to to restore restore anatomical anatomical relationships. relationships. 1 2 Stable Stable fixation fixation Fracture Fracture fixation fixation providing providing absolute absolute or relative or relative stability, stability, as required as by the required patient, by the the injury, patient, and the the injury, personality and the personality of the fracture. of the fracture. Early, active mobilization Early Early and and safe safe mobilization and rehabilitation of of the injured part and and the the patient as as a whole. 4 3 Preservation Preservation of of blood blood supply supply Preservation Preservation of of the the blood blood supply supply to to soft soft tissues tissues and and bone bone by by gentle reduction gentle reduction techniques techniques and and careful careful handling. handling. 1. Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation. 3rd ed. Berlin, Heidelberg, New York: Springer-Verlag; Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 1 Müller ME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal 2nd ed. Stuttgart, New York: Thieme; Fixation. 3rd ed. Berlin Heidelberg New York: Springer Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 42nd ed. DePuy Stuttgart, Synthes New York: 4.5 Thieme. mm LCP Condylar Plate Aiming Instruments Surgical Technique

6 Indications The Synthes 4.5 mm LCP Condylar Plates are intended for buttressing of multifragment distal femur fractures, including: Supracondylar fractures Intra-articular and extra-articular condylar fractures Malunions and nonunions of the distal femur Periprosthetic fractures Osteotomies of the femur Osteopenic bone 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 5

7 Preoperative Planning Use a preoperative planner template for the 4.5 mm LCP Condylar Plate. Note: Straight condylar plate templates are available in two sizes: actual size and 115%. Precaution: Plate bending is not recommended as this may weaken the plate and the plate-screw interface and can compromise the targeting function of an aiming arm, if in use. However, there may be cases in which plate bending is clinically necessary. In such cases, the plate should only be bent to fit proximal femur anatomy and only bend the plate incrementally and between screw holes using the plate bending press ( ), and never bend back-and-forth. Insert at least one screw distal to the bend. 6 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

8 Preparation 1 Preparation Required sets Periarticular LCP Plating System, with 5.0 mm Locking Screws or Periarticular LCP Plating System, with 4.0 mm Locking Screws mm LCP Condylar Plate Implant Set or mm LCP Curved Condylar Plate Implant Set Optional sets mm/ 7.3 mm Combined Cannulated Screw Instrument and Implant Set Periarticular Reduction Forceps Set Large Distractor Complete a preoperative radiographic assessment and prepare the preoperative plan. Position the patient supine on a radiolucent table. Viewing the distal femur under fluoroscopy in both the lateral and AP views is necessary. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 7

9 Attach Insertion Handle 2 Attach insertion handle Instruments Periarticular Insertion Handle, for 4.5 mm LCP Condylar Plate, right or Periarticular Insertion Handle, for 4.5 mm LCP Condylar Plate, left mm Wire Guide with Shoulder Cannulated Connecting Post for 2.5 mm wires Nut for Cannulated Connecting Post, for 2.5 mm wires mm Hexagonal Key mm Percutaneous Wire Guide Thread a nut onto a cannulated connecting post until the hex stops flush against the head of the post. Choose an appropriate insertion handle (left or right). Insert an assembled cannulated connecting post with nut through a 5 mm plate head hole in the insertion handle and thread into the corresponding 5 mm locking hole in the distal plate head. Finger-tighten the cannulated connecting post into the plate. In the same manner, thread at least one additional connecting post with nut into the plate. Place as many assemblies into the plate as necessary for wire guides. Note: Two connecting posts with nuts must remain threaded into the plate head to maintain the insertion handle/aiming arm connection for subsequent aiming of screws in the shaft. 8 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

10 Attach Insertion Handle Notes: It is not necessary to thread the connecting post assemblies into the plate in any particular order. However, it is recommended that one of the connecting post assemblies is placed through the most proximal hole of the insertion handle, corresponding with the first Combi hole in the plate shaft. A 4.0 mm hexagonal key may be used to facilitate insertion and removal of the connecting post from the most proximal position. The hole immediately distal to the insertion handle will not accept a connecting post and nut due to its proximity to the handle. A 2.5 mm percutaneous wire guide is used in this hole. Turn each of the nuts down their cannulated connecting post and finger-tighten to firmly clamp the insertion handle to the plate. Thread the 2.5 mm wire guide with shoulder through the central head hole of the periarticular insertion handle and into the central 7.3 mm locking head hole on the plate. Optional instruments Solid Hexagonal Screwdriver Cannulated Hexagonal Screwdriver A hexagonal screwdriver can be used to facilitate insertion and removal of connecting posts. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 9

11 Make Incision 3 Make incision Lateral incision A lateral incision is recommended when a simple articular (AO classification 33-C1) or extra-articular fracture (AO classification 32- or 33-A) is present. The skin incision starts at Gurdy s tubercle and extends about 80 mm in a proximal direction. Precaution: The incision can be extended if necessary to improve visualization of the articular surface or lateral metaphysis and diaphysis. It may not always be appropriate to use limited incisions and closed reduction techniques. Lateral parapatellar incision In the presence of a complex intra-articular fracture (AO classifications 33-C2 or C3), perform a lateral parapatellar approach. Perform an arthrotomy to expose the joint for reduction. Evert the patella and extend the incision for adequate exposure of the joint for reduction and anatomic fixation. Lateral Lateral parapatellar 11 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

12 Reduce Articular Surface 4 Reduce articular surface Instruments Countersink Condylar Plate Guide, right Condylar Plate Guide, left Reduce and temporarily secure the articular fragments with pointed reduction forceps and/or Kirschner wires. If a posterior Hoffa fragment is present, it must be reduced and provisionally stabilized with Kirschner wires inserted from anterior to posterior. Secure the condyles with appropriately placed bone screws. The condylar plate guide, or the plate itself, may be held laterally on the condyle to select an area where the screw(s) will not interfere with plate placement. For fixation of a posterior articular fragment (Hoffa fracture), place 3.5 mm cortex screws or 4.0 mm cancellous bone screws from anterior to posterior and countersink the screw heads so they lie below the level of the articular cartilage. It may occasionally be necessary to reposition one of these screws to avoid impingement on screws placed through the plate considered essential for fixation. Precaution: Kirschner wires are single use items, do not re-use. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 11

13 Insert Plate 5 Insert plate Using the insertion handle assembly, insert the plate submuscularly distal-to-proximal. Slide the plate proximally until the plate head is oriented properly on the lateral condyle. 11 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

14 Determine Plate Position 6 Determine plate position Place a Kirschner wire across the femoral condyles at the level of the knee to indicate the joint axis. Place a second Kirschner wire across the patellofemoral joint on the trochlear surface. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 11

15 Insert Cannulated Screws 7 Insert 7.3 mm and 5.0 mm cannulated screws in plate head Instruments Cannulated Connecting Post for 2.5 mm wires mm Drill Tip Guide Wire, 300 mm Cannulated Hexagonal Screwdriver Cannulated Hexagonal Screwdriver Shaft Cannulated Screw Measuring Device Lag screw external to the plate Figure Percutaneous Direct Measuring Device mm Percutaneous Wire Guide Notes: Although screws may be inserted in any order, it is usually advantageous to start with the central 7.3 mm screw. Before proceeding, confirm plate head placement. Use clinical examination and radiographic imaging to confirm that the plate is properly oriented on the condyle under the lateral image. Because the shaft of the femur is frequently out of alignment with the distal fragment, proper plate placement can be determined by orienting the distal plate shape to that of the condyle. Placement of the plate on the condyle at this point will determine final flexion/extension reduction. The plate should be oriented so that the shape mimics the condyle anteriorly and posteriorly (Figure 1). Figure 2 Secure the plate position on the lateral femoral condyle with at least three guide wires before inserting the first screw. Precaution: Take into consideration that the most posterior distal screw hole Ø5.0 may be positioned distal to Blumensaat s line, requiring unicondylar screw (Figures 2 and 3). Figure 3 11 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

16 Insert Cannulated Screws Precaution: Take into consideration that the most posterior distal 5.0 mm screw hole may be positioned distal to Blumensaat s line, requiring a unicondylar screw (Figures 2 and 3). Note: If the plate shifts during screw insertion, the guide wires must be removed and reinserted for the screws to lock to the plate properly. Advance a guide wire through a cannulated connecting post until it reaches the medial wall of the femoral condyle. Measure for screw length using the cannulated screw measuring device. For proper screw length measurement, the cannulated screw measuring device must contact the end of the wire guide or connecting post. This will place the tip of the screw at the tip of the guide wire. Notes: If it is desired to place a cannulated locking screw in the hole immediately distal to the insertion handle, a 2.5 mm percutaneous wire guide can be used. Measure for screw length using the percutaneous direct measuring device. The self-drilling, self-tapping flutes of the 7.3 mm and 5.0 mm cannulated screws make predrilling and pretapping unnecessary in most cases. In dense bone, the lateral cortex can be predrilled, if necessary. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 11

17 Insert Cannulated Screws 7 Insert 7.3 mm and 5.0 mm cannulated screws in plate head continued Optional instruments mm Cannulated Drill Bit, for use with 7.3 mm Screws mm Cannulated Drill Bit, for use with 5.0 mm Screws Torque Limiting Attachment, 4 Nm Using the cannulated hexagonal screwdriver, remove a cannulated connecting post assembly and insert the appropriate length screw over the guide wire and into the bone. Locking screws may be inserted using power equipment and the 4 Nm torque limiting attachment. However, final tightening should be done by hand. Precaution: Two connecting posts with nuts must remain threaded into the plate head to maintain the insertion handle/aiming arm connection for subsequent aiming of screws in the shaft. Warning: If the 4 Nm torque limiting attachment is unavailable, do not tighten the screws to the plate under power. Perform final tightening by hand. Note: If required, lag screw reduction of a fragment must be accomplished before inserting locking screws into the fragment. Lag screw reduction can be accomplished using the 5.0 mm or 7.3 mm partially threaded conical screws. Conical screws may be replaced with locking screws after reduction is complete. 11 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

18 Secure Aiming Arm to Plate 8 Secure aiming arm to plate Instruments Periarticular Insertion Handle, for 4.5 mm LCP Condylar Plates, right Periarticular Aiming Arm, for 4.5 mm LCP Curved Condylar Plate, right Periarticular Insertion Handle, for 4.5 mm LCP Condylar Plates, left Periarticular Aiming Arm, for 4.5 mm LCP Curved Condylar Plate, left Periarticular Aiming Arm, for 4.5 mm LCP Condylar Plate, 18 holes, straight Periarticular Aiming Arm, for 4.5 mm LCP Condylar Plate, 8 holes, straight Locking/ Neutral Guide, self-retaining, large Trocar with Handle, for use with Attach the appropriate aiming arm onto the insertion handle for LCP Condylar Plates. Finger-tighten the connection bolt to secure the aiming arm to the insertion handle. Locate the hole in the aiming arm that corresponds with the most proximal Combi hole in the plate. The aiming arm is numbered to facilitate locating the most proximal hole in the plate. Make a small skin incision at this location. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 11

19 Secure Aiming Arm to Plate 8 Secure aiming arm to plate continued Optional instrument Scalpel Handle, for Periarticular Aiming Instrument Set, large Attach a blade to the scalpel holding end of the handle. The scalpel handle will pass through the aiming arm holes and assist in performing a minimally invasive and accurate incision. (The scalpel, with a #10 blade, will only travel through the aiming arm as far as the top edge of the plate.) (for CGI cover is ) Remove the scalpel from the aiming arm. Precaution: Remove the scalpel blade prior to storage in the graphic case. 11 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

20 Secure Aiming Arm to Plate Insert the trocar with handle into a locking/neutral guide and align the self-retaining features until the trocar snaps into place within the locking/neutral guide. Orient the arrow on the locking/neutral guide in the direction of the LOCKING arrow on the aiming arm, and then use the assembled trocar and locking/neutral guide to push down to the plate through the incision. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 11

21 Secure Aiming Arm to Plate 8 Secure aiming arm to plate continued Push the assembly completely down, aligning the self-retaining features, until it snaps into the aiming arm. Remove the trocar with handle by depressing its release mechanism and pulling it away from the locking/neutral guide. 22 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

22 Secure Aiming Arm to Plate Instruments Handle for Percutaneous Threaded Drill Guides mm Drill Tip Guide Wire, 300 mm mm Percutaneous Wire Guide Thread the handle into the wire guide. Insert the handle and wire guide assembly through the locking/neutral guide, and securely thread it to the plate. Turn the handle counterclockwise to disengage and remove it from the guide. Precaution: Be sure to securely tighten the wire guide to the plate to achieve a stable construct between the aiming arm and the plate. Insert a 2.5 mm drill tip guide wire into the bone through the percutaneous wire guide. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 22

23 Secure Aiming Arm to Plate 8 Secure aiming arm to plate continued Alternative instruments mm Percutaneous Threaded Drill Guide mm Percutaneous Threaded Drill Guide mm Percutaneous Drill Bit mm Percutaneous Drill Bit Using the appropriate diameter drill bit, drill through the drill guide to the far cortex, leaving the drill bit in place to stabilize the proximal portion of the plate on the bone DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

24 Use Pull Reduction Device (optional) 9 Use pull reduction device (optional) Instruments Locking/ Neutral Guide Pull Reduction Device, for 4.3 mm Percutaneous Drill Guide Combination Wrench mm Percutaneous Threaded Drill Guide Additional correction can be completed prior to placement of screws in both main fracture fragments. The pull reduction device with quick coupling is placed through the guide and plate holes to pull or push bone fragments in relation to the plate. This instrument can be used for: Minor varus-valgus adjustment (approximately 2 4 ) Translational adjustments Stabilization of plate-bone orientation during insertion of the first screws Alignment of segmental fragments Predrilling dense or thick cortical bone before placing a 5.0 mm locking screw Note: The pull reduction device for 4.3 mm percutaneous drill guide must be used with a 4.3 mm percutaneous drill guide and a locking/ neutral guide. Thread the nut for pull reduction device over the drill tip of the pull reduction device. When the pull reduction device has been attached to a power tool (quick coupling), insert it through a 4.3 mm percutaneous threaded drill guide that has already been threaded to the plate. With the nut in its highest position possible, begin power insertion of the pull reduction device. Stop insertion before the end of the threaded portion meets the plate surface. Precaution: Attempting to advance beyond this point may cause threads to strip in bone. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 22

25 Use Pull Reduction Device (optional) 9 Use pull reduction device (optional) continued Remove the power tool and begin tightening the nut toward the drill guide while monitoring progress under radiographic imaging. Stop when the desired reduction is achieved. The pull reduction device is 4.3 mm in diameter and calibrated for screw length measurement to allow later placement of a 5.0 mm locking screw in the same hole. Optional instrument * Stopper for LCP Periarticular Aiming Arms, large Mark each screw location in the aiming arm using a stopper for reference as screw insertion proceeds. * Also available 22 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

26 Insert 4.5 mm Cortex Screws 10 Insert 4.5 mm cortex screws Instruments Star/ HexDrive Screwdriver, T25/ 3.5 mm hex Star/HexDrive Screwdriver Shaft, T25/3.5 mm hex Locking/ Neutral Guide, self-retaining, large Trocar with Handle, for use with Neutral Drill Guide, for 4.5 mm Cortex Screws Compression Drill Guide, for 4.5 mm Cortex Screws mm Percutaneous Drill Bit, calibrated Choose an aiming arm hole through which to make an appropriate incision. Create an incision. As described on page 19, assemble a trocar with handle and locking/ neutral guide. Orient the arrow on the locking/neutral guide in the direction of the CORTEX arrow on the aiming arm, and then use the assembled trocar guide to stab down to the plate through the chosen aiming arm hole with corresponding incision. Push the assembly completely down until it snaps into the self-retaining feature of the aiming arm. Remove the trocar by depressing its release mechanism and pulling it away from the locking/neutral guide. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 22

27 Insert 4.5 mm Cortex Screws 10 Insert 4.5 mm cortex screws continued Choose an appropriate drill guide, neutral or compression, and insert it into the locking/neutral guide while aligning the self-retaining features until it snaps into place. Note: When using the compression guide, orient the guide s directional arrow toward the CORTEX arrow on the aiming arm. Use the 3.2 mm percutaneous drill bit to drill and determine screw length from the drill bit calibration aligned with the top of the drill guide. Remove the drill bit. 22 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

28 Insert 4.5 mm Cortex Screws Alternative instrument Percutaneous Direct Measuring Device Place the percutaneous direct measuring device over the drill bit and against the end of the drill guide. Determine screw length from the end of the drill bit. Remove the drill guide and insert a screw using a Star/ HexDrive screwdriver. Repeat this process to insert as many 4.5 mm cortex screws as necessary into the plate shaft. Optional instrument * Stopper for LCP Periarticular Aiming Arms, large Mark each screw location in the aiming arm using a stopper for reference as screw insertion proceeds. Precaution: All of the 4.5 mm cortex screws must be inserted before insertion of locking screws. * Also available 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 22

29 Insert 4.0 mm or 5.0 mm Locking Screws 11 Insert 4.0 mm or 5.0 mm locking screws Instruments Star/ HexDrive Screwdriver, T25/ 3.5 mm hex Star/HexDrive Screwdriver Shaft, T25/ 3.5 mm hex Locking/ Neutral Guide, self-retaining, large Trocar with Handle, for use with Handle for Percutaneous Threaded Drill Guides mm Hexagonal Key mm Percutaneous Threaded Drill Guide mm Percutaneous Threaded Drill Guide mm Percutaneous Drill Bit, calibrated mm Percutaneous Drill Bit, calibrated Torque Limiting Attachment, 4 Nm Choose an aiming arm hole through which to make an appropriate incision. Create an incision. As described on page 19, assemble a trocar with handle and locking/ neutral guide. Orient the arrow on the locking/neutral guide in the direction of the LOCKING arrow on the aiming arm, and then use the assembled trocar guide to stab down to the plate through the chosen aiming arm hole with corresponding incision. Push the assembly completely down until it snaps into the self-retaining feature of the aiming arm. Remove the trocar by depressing its release mechanism and pulling it away from the locking/ neutral guide. 22 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

30 Insert 4.0 mm or 5.0 mm Locking Screws Thread the handle into an appropriate percutaneous drill guide. For 4.0 mm locking screws, use the 3.2 mm percutaneous threaded drill guide For 5.0 mm locking screws, use the 4.3 mm percutaneous threaded drill guide Insert the handle and drill guide assembly through the locking/neutral guide, and thread it into the plate. Turn the handle counterclockwise to disengage and remove it from the drill guide. Drill using the appropriate percutaneous drill bit. Determine screw length from the drill bit calibration aligned with the top of the drill guide. Remove the drill bit. Alternative instrument Percutaneous Direct Measuring Device Place the percutaneous direct measuring device over the drill bit and against the end of the drill guide. Determine screw length from the end of the drill bit. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 22

31 Insert 4.0 mm or 5.0 mm Locking Screws 11 Insert 4.0 mm or 5.0 mm locking screws continued Remove the drill guide. Notes: Use the tip of the handle for percutaneous threaded drill guides as a pin wrench to loosen the drill guides from the plate. The 4.0 mm hexagonal key can also be used. Insert a screw using the Star/HexDrive screwdriver or screwdriver shaft. Option: Mark each screw location in the guide using a stopper for reference as screw insertion proceeds. Insert as many 4.0 mm or 5.0 mm locking screws as necessary into the plate shaft. 33 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

32 Remove Aiming Arm and Insertion Handle 12 Remove aiming arm and insertion handle Remove all locking/ neutral guides. Turn the connecting bolt on the aiming arm counterclockwise to loosen and remove the aiming arm from the insertion handle. As desired, insert 2.5 mm guide wires and measure for remaining screws in the plate head where connecting points were maintained. Remove the connecting post assemblies from the plate head and insert the remaining screws. Remove the insertion handle and any remaining guide wires. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 33

33 Screws Used with the 4.5 mm LCP Condylar Plates 7.3 mm Cannulated Locking Screw Creates a locked, fixed-angle screw/ plate construct Threaded conical head Fully threaded shaft Self-drilling, self-tapping tip 7.3 mm Cannulated Conical Screw Compresses the plate to the lateral femoral condyle Smooth conical head Fully threaded shaft Self-drilling, self-tapping tip 7.3 mm Cannulated Conical Screw, partially threaded Compresses the plate to the lateral femoral condyle and provides interfragmentary compression Smooth conical head Partially threaded shaft Self-drilling, self-tapping tip 5.0 mm Locking Screw Creates a locked, fixed-angle screw/ plate construct Threaded conical head Fully threaded shaft Self-tapping tip 5.0 mm Cannulated Locking Screw Creates a locked, fixed-angle screw/ plate construct Threaded conical head Fully threaded shaft Self-drilling, self-tapping tip 5.0 mm Cannulated Conical Screw Compresses the plate to the lateral femoral condyle and provides interfragmentary compression Smooth conical head Partially threaded shaft Self-drilling, self-tapping tip Screws are available in implant-quality 316L stainless steel 33 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

34 Screws Used with the 4.5 mm LCP Condylar Plates 5.0 mm Screw Nut Offers additional fixation and compression options for complex fractures Self-cutting, serrated tip Inserted from the medial aspect of the distal femur Internal threads mate with the 5.0 mm cannulated conical screws 4.5 mm Cortex Screw Compresses the plate to the bone or creates axial compression May be used in the DCU portion of the Combi holes in the plate shaft 4.0 mm Locking Screw Creates a locked, fixed-angle screw/ plate construct Threaded conical head Fully threaded shaft Self-tapping tip 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 33

35 Selected Instruments from LCP Periarticular Aiming Instrument Set, Large ( ) Star/HexDrive Screwdriver Shaft, T25, 3.5 mm Hexagonal, self-retaining, 165 mm Periarticular Insertion Handle, for 4.5 mm LCP Condylar Plates, right Periarticular Aiming Arm, for 4.5 mm LCP Curved Condylar Plates, right Periarticular Insertion Handle, for 4.5 mm LCP Condylar Plates, left Periarticular Aiming Arm, for 4.5 mm LCP Curved Condylar Plates, left Periarticular Aiming Arm, for 4.5 mm LCP Condylar Plates, 18 holes, straight 33 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

36 Selected Instruments from LCP Periarticular Aiming Instrument Set, Large ( ) Periarticular Aiming Arm, for 4.5 mm LCP Condylar Plates, 8 holes, straight Locking/ Neutral Guide, large, self-retaining Trocar with Handle, for use with Scalpel Handle, large (blade not included) Neutral Drill Guide, for 4.5 mm Cortex Screws Compression Drill Guide, for 4.5 mm Cortex Screws 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 33

37 Selected Instruments from LCP Periarticular Aiming Instrument Set, Large ( ) mm Wire Guide with Shoulder, for 7.3 mm Cannulated Locking and 7.3 mm Conical Screws Cannulated Connecting Post for 2.5 mm wires for Periarticular Insertion Handles Nut for Cannulated Connecting Post, for 2.5 mm wires Handle for Percutaneous Threaded Drill Guides Pull Reduction Device, for 4.3 mm Percutaneous Threaded Drill Guide mm Drill Tip Guide Wire, 300 mm mm Percutaneous Threaded Drill Guide 33 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

38 Selected Instruments from LCP Periarticular Aiming Instrument Set, Large ( ) mm Percutaneous Threaded Drill Guide Percutaneous Direct Measuring Device mm Percutaneous Drill Bit, quick coupling, 300 mm, calibrated mm Percutaneous Drill Bit, quick coupling, 300 mm, calibrated mm Percutaneous Wire Guide 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 33

39 Selected Instruments from Periarticular LCP Plating System ( ) Star/HexDrive Screwdriver, T25, 3.5 mm hexagonal, self-retaining mm Cannulated Drill Bit, quick coupling, 200 mm (short flute) mm Cannulated Drill Bit, quick coupling, 200 mm (long flute) Countersink, for 4.5 mm and 6.5 mm Screws Solid Hexagonal Screwdriver, 4.0 mm width across flats Cannulated Hexagonal Screwdriver, 4.0 mm width across flats Cannulated Screw Measuring Device 33 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

40 LCP Periarticular Aiming Instrument Set, Large, with 4.5 mm LCP Proximal Tibia and 4.5 mm LCP Condylar Plate Components ( ) Graphic Case Graphic Case for Periarticular Aiming Instruments Set, large Instruments Star/HexDrive Screwdriver Shaft, T25, 3.5 mm Hexagonal, self-retaining, quick coupling, 165 mm Periarticular Aiming Arm, for 4.5 mm LCP Proximal Tibia Plates, right Periarticular Insertion Handle, for 4.5 mm LCP Proximal Tibia Plates, right Oblique Aiming Guide for Periarticular Aiming Arm, for 4.5 mm LCP Proximal Tibia Plates, right Periarticular Aiming Arm, for 4.5 mm LCP Proximal Tibia Plates, left Periarticular Insertion Handle, for 4.5 mm LCP Proximal Tibia Plates, left Oblique Aiming Guide for Periarticular Aiming Arm, for 4.5 mm LCP Proximal Tibia Plates, left Periarticular Insertion Handle, for 4.5 mm LCP Condylar Plates, right Periarticular Aiming Arm, for 4.5 mm LCP Curved Condylar Plates, right Periarticular Insertion Handle, for 4.5 mm LCP Condylar Plates, left Periarticular Aiming Arm, for 4.5 mm LCP Curved Condylar Plates, left Periarticular Aiming Arm, for 4.5 mm LCP Condylar Plates, 18 holes, straight Periarticular Aiming Arm, for 4.5 mm LCP Condylar Plates, 8 holes, straight Locking/Neutral Guide for LCP Periarticular Aiming Instrument System, self-retaining, large, 6 ea Trocar with Handle, for use with Scalpel Handle, for use with LCP Periarticular Aiming Instrument Set, large Neutral Drill Guide, for 4.5 mm Cortex Screws for LCP Periarticular Aiming Instruments Compression Drill Guide, for 4.5 mm Cortex Screws for LCP Periarticular Aiming Instruments Note: For additional information, please refer to package insert. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 33

41 LCP Periarticular Aiming Instrument Set, Large, with 4.5 mm LCP Proximal Tibia and 4.5 mm LCP Condylar Plate Components ( ) Instruments continued mm Wire Guide with Shoulder, for 7.3 mm Cannulated Locking and 7.3 mm Conical Screws, 2 ea Cannulated Connecting Post for 2.5 mm wires, for Periarticular Insertion Handles, 8 ea Nut for Cannulated Connecting Post, for 2.5 mm wires, 9 ea Handle for Percutaneous Threaded Drill Guides, 2 ea Pull Reduction Device, for 4.3 mm Percutaneous Drill Guide, 2 ea mm Drill Tip Guide Wire, 300 mm, 8 ea Interlocking Bolt, 151 mm, for Periarticular Insertion Handle, for 4.5 mm LCP Proximal Tibia Plates mm Hexagonal Key StarDrive Screwdriver Shaft, T25, self-retaining, quick coupling mm Cleaning Stylet Combination Wrench, 11 mm width across flats mm Percutaneous Threaded Drill Guide, 4 ea mm Percutaneous Threaded Drill Guide, 4 ea Percutaneous Direct Measuring Device mm Percutaneous Drill Bit, quick coupling, 300 mm, calibrated, 2 ea mm Percutaneous Drill Bit, quick coupling, 300 mm, calibrated, 2 ea mm Percutaneous Wire Guide, for 5.0 mm Locking Screws, 2 ea. Required Set Periarticular Plating System, with 5.0 mm or Locking Screws Periarticular Plating System, with 4.0 mm Locking Screws Recommended Additional Sets mm Cannulated Screw Instrument and Implant Set Basic Percutaneous Instrument Set mm/7.3 mm Combined Cannulated Screw Instrument and Implant Set Periarticular LCP Plating System Instrument and Screw Set Small Fragment Instrument and Implant Set LC-DCP Periarticular Reduction Forceps Set Large Fragment LCP Instrument and Implant Set Large Distractor Set Also Available Stopper for LCP Periarticular Aiming Arms, large Stopper Rack 44 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

42 4.5 mm LCP Condylar Plate Implant Set ( ) Graphic Case Graphic Case for 4.5 mm LCP Curved and Straight Condylar Plates Instruments Condylar Plate Guide, right Condylar Plate Guide, left Implants 4.5 mm LCP Condylar Plates Holes Length (mm) right left right left right left right left right left right left right left For detailed cleaning and sterilization instructions, please refer to or sterilization instructions, if provided. Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 44

43 4.5 mm LCP Curved Condylar Plate Implant Set ( ) Graphic Case Graphic Case for 4.5 mm LCP Curved and Straight Condylar Plates Instruments Condylar Plate Guide, right Condylar Plate Guide, left Implants 4.5 mm LCP Condylar Plates Holes Length (mm) right left right left 4.5 mm LCP Curved Condylar Plates Holes Length (mm) right left right left right left right left right left Also Available 4.5 mm LCP Curved Condylar Plates, sterile Holes Length (mm) S right S left S right S left Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. 44 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

44 Periarticular LCP Plating System, with 5.0 mm Locking Screws ( ) Graphic Cases and Screw Racks Locking Periarticular Plating System Graphic Case Screw Rack, for 4.5 mm cortex screws Screw Rack, for 5.0 mm locking screws, with T25 StarDrive Recess Screw Rack, for 5.0 mm and 7.3 mm cannulated locking screws and 7.3 mm conical screws Screw Rack, for 5.0 mm cannulated conical screws Locking Periarticular Plating System Instrument Tray Instruments mm Non-Colored Threaded Guide Wire, 230 mm, spade point, 10 ea Star/HexDrive Screwdriver, T25, 3.5 mm Hexagonal, self-retaining Star/HexDrive Screwdriver Shaft, T25, 3.5 mm hexagonal, self-retaining, 165 mm mm Drill Tip Guide Wire, 200 mm, 10 ea mm Drill Bit, quick coupling, 145 mm mm Drill Bit, quick coupling, 180 mm, for 5.0 mm Locking Screws mm Drill Bit, quick coupling, 145 mm mm Cannulated Drill Bit, quick coupling, 200 mm (short flute) mm Cannulated Drill Bit, quick coupling, 200 mm (long flute) Countersink, for 4.5 mm and 6.5 mm screws T-Handle, with quick coupling Push-Pull Reduction Device, for use with 4.5 mm LCP plates, 2 ea Tap for 4.5 mm Screws mm Threaded Drill Guide, 4 ea mm/ 3.2 mm Insert Drill Sleeve Solid Hexagonal Screwdriver, 4.0 mm width across flats Cannulated Hexagonal Screwdriver, 4.0 mm width across flats Holding Sleeve Cannulated Hexagonal Screwdriver Shaft, 4.0 mm width across flats 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 44

45 Periarticular LCP Plating System, with 5.0 mm Locking Screws ( ) Instruments continued Depth Gauge, for 4.5 mm and 6.5 mm screws mm Cleaning Brush mm Cleaning Stylet Cannulated Screw Measuring Device Articulated Tension Device Combination Wrench, 11 mm width across flats mm Universal Drill Guide mm Wire Guide, for 5.0 mm screws, 5 ea mm Wire Guide, for 7.3 mm screws, 2 ea mm Drill Guide, for 4.0 mm screws, 2 ea Large Quick Coupling Handle, for AO Reaming Coupler Connection Torque Limiting Attachment, 4 Nm, for AO Reaming Coupler Implants 4.5 mm Cortex Screws, self-tapping Length Length (mm) Qty. (mm) Qty mm Locking Screws, self-tapping, with T25 StarDrive Recess Length Length (mm) Qty. (mm) Qty mm Cannulated Locking Screws Length Length (mm) Qty. (mm) Qty mm Periprosthetic Locking Screws, self-tapping, with T25 StarDrive Recess Length (mm) Qty Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. 44 DePuy Synthes 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique

46 Periarticular LCP Plating System, with 5.0 mm Locking Screws ( ) Implants continued 5.0 mm Cannulated Conical Screws Length Length (mm) Qty. (mm) Qty mm Cannulated Locking Screws Length Length (mm) Qty. (mm) Qty Also Available Periarticular LCP Plating System with 4.0 mm Locking Screws Periarticular LCP Plating System Instrument and Screw Set Large Fragment LCP Screw Set 5.0 mm Periprosthetic Locking Screws, self-tapping, with T25 StarDrive Recess mm mm Tap for 6.5 mm Cancellous Bone Screws mm/ 3.2 mm Double Drill Sleeve Handle, quick coupling, for ComPact Air Drive Connection Large Quick Coupling Torque Limiting Attachment, 4 Nm Screw Rack for 4.0 mm Locking Screws Screw Rack for 6.5 mm Cancellous Bone Screws 7.3 mm Cannulated Conical Screws (1 ea.) Length (mm) Length (mm) mm Cannulated Conical Screws, partially threaded (1 ea.) Length (mm) Length (mm) mm Screw Nut, 2 ea. 4.5 mm LCP Condylar Plate Aiming Instruments Surgical Technique DePuy Synthes 44

47 Limited Warranty and Disclaimer: DePuy Synthes products are sold with a limited warranty to the original purchaser against defects in workmanship and materials. Any other express or implied warranties, including warranties of merchantability or fitness, are hereby disclaimed. Please also refer to the package insert(s) or other labeling associated with the devices identified in this surgical technique for additional information. CAUTION: Federal Law restricts these devices to sale by or on the order of a physician. Some devices listed in this surgical technique may not have been licensed in accordance with Canadian law and may not be for sale in Canada. Please contact your sales consultant for items approved for sale in Canada. Not all products may currently be available in all markets. Manufactured or distributed by: Synthes USA Products, LLC 1302 Wrights Lane East West Chester, PA Synthes USA, LLC 1101 Synthes Avenue Monument, CO To order (USA): To order (Canada): Note: For recognized manufacturer, refer to the product label. DePuy Synthes All rights reserved. DSUS/TRM/1016/1143 7/17 DV