TRAUMATOLOGY Trochanter 1
References Prof. Dr. András Sárváry Head of Department Fővárosi Önkormányzat Péterfy Sándor úti Kórház Rendelőintézet és Baleseti Központ Budapest The following surgical description contains general outlines for intramedullary nailings performed on the femur with SpectruM Trochanter system. However, the operating surgeon shall adapt the content to the patient, fracture type and all other relevant factors that may have influence on the outcome of the surgery. Therefore, Sanatmetal Ltd. strongly recommends participation on workshops and trainings prior to the initial operation.
Contents 1. Introduction 4 4. Implant list 16-19 1.1 The implant 4 4.1 SpectruM Trochanter nail, short 16 1.2 The instrumentarium 4 4.2 SpectruM Trochanter nail, long 17-18 1.3 Indications 4 4.3 Trochanter spiral 19 2. Implant sizes 5 4.4 4.5 Support screw Closing cap 19 19 3. Surgical description 6-15 4.6 Locking screw 19 3.1 3.2 3.3 3.4 Patient positioning Incision Preparation of the intramedullary Reaming 6 6 6 6 5. 5.1 5.2 Instrument list Filled up tray Instruments 20-23 20 21-23 3.5 Assembly of the targeting arm and the 7 implant, determinig nail length (long nail) 3.6 Introduction of the nail 7-8 3.7 Guide wire insertion I. 8 3.8 Guide wire insertion II. 8 3.9 Measuring the length of the trochanter 9 screw 3.10 Proximal locking I. 9 3.11 Proximal locking II. 9 3.12 Proximal locking III. 10 3.13 Supporting screw insertion 10 3.14 Distal locking I. (short nail) 11 3.15 Distal locking II. (short nail) 11 3.16 Distal locking I. (long nail) 12 3.17 Distal locking II. (long nail) 12 3.18 Distal locking III. (long nail) 13 3.19 Removal of the targeting arm 13 3.20 End cap insertion 13 3.21 Implant removal 14
1 Introduction The SpectruM Trochanter implant and instrument system combines the advantages of the previously distributed and successfully applied systems furthermore the advantages of the radiolucent targeting arm. The system based on a well-considered development process, where the main aims were the simplicity and the striving for the minimal time duration of the operation. 1.1 The implant 1.2 The instrument set Cannulated nail Short nail trochanter fractrures Long, anatomic nail combined fractures 125, 130, 135 angled nails Dynamic locking possibility Usable with Trochanter Spiral as well The supporting screw is protected against loosening Sliding assured by support screw Asymmetric slots on the screw shaft limited blacksliding Special thread profile for easier screw insertion Raw materials:, Titanium alloy Special distal hole for the distal targeting device Different length end caps Radiolucent targeting arm Universal targeting arm (125, 130, 135 ) Canullated technique reposition keeping during operation Optimal targeting arm shape for more comfortable insertion point Colour coded instrument set for obvious surgical steps Instrument are protected against fall out 1.3 Indications Intertrochanteric fractures Pertrochanteric fractures Pseudarthrosis Subtrochanteric fractures (long nail) Pertrochanteric and diaphysis fractures (long nail) Pathological fracture trochanter and diaphysis (long nail) 4
Implant range 2 2.1 SpectruM Trochaner nail Short Long (left, right) CCD (angle) 125 125 130 130 135 135 Proximal diameter (mm) 16 16 Distal diameter (mm) 10 10 11 11 12 12 180 280 200 295 220 310 240 325 340 355 370 385 400 415 430 445 460 2.2 Tochanter screw Ø10.5 mm 75 80 85 90 95 100 105 110 115 120 125 130 135 140 Raw material Anodised Titanium 2.3 Locking screw Ø4.8 mm 25-100 Raw material Anodised Titanium Raw material Anodised Titanium 2.5 Closing cap 2.4 Support screw 0-25 Raw material Anodised Titanium Raw material Anodised Titanium The support screw and the nail are in the same package. 5
3 Surgical description 3.1 Patient positioning In supine position on extension surgical table. 3.2 Incision Between the greater trochanter and the wing of the iliac bone. The proper place depends on the quantity of the soft tissues. 3.3 Preparation of the intramedullary Drill in the Kirschner wire (Ø3.2 mm, NOT threaded) through the tip of the greater trochanter under image intensifier control. Drive the awl to the wire and open the intramedullary canal. Remove the Kirschner wire. 3.4 Reaming Introduce the 4/3x900 mm olive tip guide rod through the awl to the intramedullary canal with the T-handle. Remove the awl. Place the soft tissue protector to the trochanter tip through the guide rod and ream the proximal place of the nail with the cannulated conical reamer. While using the soft tissue protector and the conical reamer the position of the awl made gap can be slightly modified. Remove the conical reamer and the soft tissue protector. Ream the intramedullary canal if needed, then remove the reamer. In case of problems remove the reamer head with the olive tip guide rod. 6
3.5 Assembly of the targeting arm the implant, determining nail length (long nail) In case of long nails measure the length of the guide wire part outside of the femur with a measuring rod. Subtract this value from the 900 mm length of the olive tip guide wire. The result is the required nail length. To make measurement easier the 500 mm is marked on the guide wire. Assemble the chosen Spectrum Trochanter nail onto the targeting arm with the fixing screw. Tighten the screw with the 8 mm screwdriver. Attention Always check the assembly before insertion. Place the soft tissue protector into the red slot. Push the stepped drill through the tissue protector. In case of optimal assembly the sleeve drives the drill to the proper hole. 3.6 Introduction of the nail Insert the nail into the intramedullary canal with rotating movements. The proximal end of the nail is indicated by the Kirschner wire led through the targeting arm as per the image. There are 3 slots on the metal part of the targeting arm connecting to the nail. This can help the identification of the nail tip under image intensifier. The nail tip is located 5 mms away from the most distal slot. Determine the rotational position of the nail with a Kirschner wire under image intensifier as seen on the image. Check the optimal sinking of the nail with the indicator. Place the indicator into the targeting arm to the corresponding angulation slots in such a way that its sleeves for Kirschner wires shall facet he anterior. Place a Kirschner wire into the distal of the two sleeves and under image intensifier check the depth of the nail. In optimal case the Kirschner wire s centerline is about 8 mm from the Adam arch. 7
3 Surgical description If the nail insertion is blocked, and the surgeon decide that the guide wire is removable, after removal of the guide wire, connect the 8 mm screwdriver to the connecting screw and guide the nail to its final position with light mallet blows. In case the guide wire is irremovable, remove the nail, ream again the intramedullary canal, and introduce the nail again into the canal. Remove the olive tip guide rod. Important Do not hit the targeting arm. 3.7 Guide wire insertion I. Push the red marked soft tissue protector (assembled with the drill sleeve) to the appropriate angulation hole (125, 130, 135 ) on the targeting arm and hit the bone surface. 3.8 Guide wire insertion II. Through the red sleeve open the cortical with a 3.2 mm spiral drill (1). Drill the 3.2 mm Kirschner wire to 5 mm far from the subchondralis surface through the distal hole of the red sleeve under image intensifier control (2). Repeat the process in the proximal holes (3,4). 1 2 3 4 8
3.9 Measuring the length of the trochanter screw Remove the 3.2 mm sleeve and push the length gauge to the Kirschner wire. Read the necessary screw length at the end of the Kirschner wire. Inbetween values should be rounded up. 3.10 Proximal locking I. Set the bumper of the stepped drill to the value of the previous step (the value is shown in the window) then drill through the Kirschner wire. Remove the stepped drill. 3.11 Proximal locking II. Assemble the chosen trochanter screw with the threaded retaining stem to the screw insertion device and fix with a hand (in case it can be secured by a 3.5 mm screwdriver). The compression nut on the insertion device is set into upper position. 9
3 Surgical description 3.12 Proximal locking III. The trochanter screw is driven in through the soft tissue protector that the end of the screw should be 5-8mm far from the subchondralis surface. Check the position under an image intensifier. After performing this operation the T-wrench of the screw insertion device should be perpendicular or parallel with the targeting arm. This way the supporting screw will slide to the slot on the trochanter screw shaft. Turn the compression nut on the retaining stem to the direction of the arrow to achieve necessary compression. (On occasion wrench can be used.) Remove the reposition maintaining Kirschner wire in the proximal hole. 3.13 Supporting screw insertion Put the supporting screw to the 3.5 mm flexible screwdriver and drive it into the nail. Loosen up the support screw with a quarter turn so that the sliding effect may prevail. Move the T-handle with slight rotating movements to check the stability against rotation of the supporting screw. Dismount the screw insertion device and remove the Kirschner wire and the red sleeve. In case of long nail continue with 3.16 step. 10
3.14 Distal locking I. (short nail) Place the assembled green soft tissue protector (for dynamic hole - sign ) and the sleeve into the green marked distal targeting arm. Then drill with a 4.2 mm spiral drill. In case of only static locking use the soft tissue protector and drill sleeve (only for static holes - sign) into the chosen S marked hole of the targeting arm. D S S 3.15 Distal locking II. (short nail) Remove the drill sleeve, the length of the screw should be measured through the green soft tissue protector, push the measurer up to the bone surface. The value shown at the soft tissue protector directly determines the necessary length of the interlocking screw. Important Continue with 3.18 step. Alternative length gauging method: put the drill stop on the drillbit, just above the spiral part. Perform drilling. Read the necessary screw length at bottom side of the stop. The selected screw should be driven in with a 3.5 mm screwdriver through the soft tissue protector. 11
3 Surgical description 3.16 Distal locking I. (long nail) Check the position of the hole under an image intensifier and make skin incision on the given place. Put the free-hand target device onto the bone and find the accurate place of the locking hole with the help of the image intensifier. Drill the closer corticalis with a 6 mm spiral drill through the soft tissue protector. Make drilling carefully. As soon as the drill passes through the corticalis and reaches the nail stop the movement. Remove the free-hand target device. 3.17 Distal locking II. (long nail) Put the distal targeting device into the hole on the bone (the double hole should face to distal direction) then click it into the special slot on the nail (1). After skin incision put the tissue protector and the drill sleeve into the chosen hole of the distal targeting device, push them to the bone surface and perform drilling (2). Hold the distal targeting device continuously on the bone surface during drilling. Remove the drill sleeve. 1 Measure the required screw length through the soft tissue protector, push the measurer up to the bone surface (3). Alternative length gauging method: put the drill stop on the drillbit, just above the spiral part. Perform drilling. Read the necessary screw length at bottom side of the stop. 2 Drive the screw in (4). 3 D Special S 4 12
3.18 Distal locking III. (long nail) Remove the manual aiming device and put back the free hand targeting device and the drill sleeve on the special hole. Drill through the ventral wall of the cortical with the 4.2 mm drillbit through the soft tissue protector and drill sleeve. After length measurement introduce the screw. Mind that the screw will hold only in the farther cortical. Do not tighten with excessive force to prevent sinking the screw head. Warning Do not use the scaled drillbit for length gauging! 3.19 Removal of the targeting arm Loosen the connecting screw with the 8 mm screwdriver and dismantle the targeting arm from the nail. 3.20 End cap insertion Drive in the proper size end cap with the 3.5 mm screwdriver or the 3.5 mm adapter assembled to the flexible shaft or the 3.5 mm flexible screwdriver. 13
3 Surgical description 3.21 Implant removal Remove the distal 4.8 mm locking screws with the 3.5 mm screwdriver. After opening up the nail end take the end cap out with the 3.5 mm screwdriver. Loosen the supporting screw with the 3.5 mm screwdriver or the 3.5 mm adapter assembled to the flexible shaft. Connect the nail impactor dowel to the end of the Spectrum trochanter nail. Open the soft tissues and assemble the impactor with T-handle with the threaded stem to the end of the trochanter screw. Take the trochanter screw out. Hit the nail out of the bone with the forked hammer. 14
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4 Implant list 4.1 SpectruM Trochanter nail, short CCD=125 Distal diameter Anodised Titanium 10 11 12 10 11 12 180 258510218 258511218 258512218 398510218 398511218 398512218 200 258510220 258511220 258512220 398510220 398511220 398512220 220 258510125 258511125 258512125 398510125 398511125 398512125 240 258510224 258511224 258512224 398510224 398511224 398512224 CCD=130 Distal diameter Anodised Titanium 10 11 12 10 11 12 180 258510318 258511318 258512318 398510318 398511318 398512318 200 258510320 258511320 258512320 398510320 398511320 398512320 220 258510130 258511130 258512130 398510130 398511130 398512130 240 258510324 258511324 258512324 398510324 398511324 398512324 CCD=135 Distal diameter Anodised Titanium 10 11 12 10 11 12 180 258510418 258511418 258512418 398510418 398511418 398512418 200 258510420 258511420 258512420 398510420 398511420 398512420 220 258510135 258511135 258512135 398510135 398511135 398512135 240 258510424 258511424 258512424 398510424 398511424 398512424 16
4.2 SpectruM Trochanter nail, long CCD=125 Distal diameter 10 10 11 11 12 12 Left Right Left Right Left Right 280 258620280 258720280 258621280 258721280 258622280 258722280 295 258620295 258720295 258621295 258721295 258622295 258722295 310 258620310 258720310 258621310 258721310 258622310 258722310 325 258620325 258720325 258621325 258721325 258622325 258722325 340 258620340 258720340 258621340 258721340 258622340 258722340 355 258620355 258720355 258621355 258721355 258622355 258722355 370 258620370 258720370 258621370 258721370 258622370 258722370 385 258620385 258720385 258621385 258721385 258622385 258722385 400 258620400 258720400 258621400 258721400 258622400 258722400 415 258620415 258720415 258621415 258721415 258622415 258722415 430 258620430 258720430 258621430 258721430 258622430 258722430 445 258620445 258720445 258621445 258721445 258622445 258722445 460 258620460 258720460 258621460 258721460 258622460 258722460 CCD=130 Distal diameter 10 10 11 11 12 12 Left Right Left Right Left Right 280 258630280 258730280 258631280 258731280 258632280 258732280 295 258630295 258730295 258631295 258731295 258632295 258732295 310 258630310 258730310 258631310 258731310 258632310 258732310 325 258630325 258730325 258631325 258731325 258632325 258732325 340 258630340 258730340 258631340 258731340 258632340 258732340 355 258630355 258730355 258631355 258731355 258632355 258732355 370 258630370 258730370 258631370 258731370 258632370 258732370 385 258630385 258730385 258631385 258731385 258632385 258732385 400 258630400 258730400 258631400 258731400 258632400 258732400 415 258630415 258730415 258631415 258731415 258632415 258732415 430 258630430 258730430 258631430 258731430 258632430 258732430 445 258630445 258730445 258631445 258731445 258632445 258732445 460 258630460 258730460 258631460 258731460 258632460 258732460 CCD=135 Distal diameter 10 10 11 11 12 12 Left Right Left Right Left Right 280 258610280 258710280 258611280 258711280 258612280 258712280 295 258610295 258710295 258611295 258711295 258612295 258712295 310 258610310 258710310 258611310 258711310 258612310 258712310 325 258610325 258710325 258611325 258711325 258612325 258712325 340 258610340 258710340 258611340 258711340 258612340 258712340 355 258610355 258710355 258611355 258711355 258612355 258712355 370 258610370 258710370 258611370 258711370 258612370 258712370 385 258610385 258710385 258611385 258711385 258612385 258712385 400 258610400 258710400 258611400 258711400 258612400 258712400 415 258610415 258710415 258611415 258711415 258612415 258712415 430 258610430 258710430 258611430 258711430 258612430 258712430 445 258610445 258710445 258611445 258711445 258612445 258712445 460 258610460 258710460 258611460 258711460 258612460 258712460 17
4 Implant list CCD=125 Anodised Titanium Distal diameter 10 10 11 11 12 12 Left Right Left Right Left Right 280 398620280 398720280 398621280 398721280 398622280 398722280 295 398620295 398720295 398621295 398721295 398622295 398722295 310 398620310 398720310 398621310 398721310 398622310 398722310 325 398620325 398720325 398621325 398721325 398622325 398722325 340 398620340 398720340 398621340 398721340 398622340 398722340 355 398620355 398720355 398621355 398721355 398622355 398722355 370 398620370 398720370 398621370 398721370 398622370 398722370 385 398620385 398720385 398621385 398721385 398622385 398722385 400 398620400 398720400 398621400 398721400 398622400 398722400 415 398620415 398720415 398621415 398721415 398622415 398722415 430 398620430 398720430 398621430 398721430 398622430 398722430 445 398620445 398720445 398621445 398721445 398622445 398722445 460 398620460 398720460 398621460 398721460 398622460 398722460 CCD=130 Anodised Titanium Distal diameter 10 10 11 11 12 12 Left Right Left Right Left Right 280 398630280 398730280 398631280 398731280 398632280 398732280 295 398630295 398730295 398631295 398731295 398632295 398732295 310 398630310 398730310 398631310 398731310 398632310 398732310 325 398630325 398730325 398631325 398731325 398632325 398732325 340 398630340 398730340 398631340 398731340 398632340 398732340 355 398630355 398730355 398631355 398731355 398632355 398732355 370 398630370 398730370 398631370 398731370 398632370 398732370 385 398630385 398730385 398631385 398731385 398632385 398732385 400 398630400 398730400 398631400 398731400 398632400 398732400 415 398630415 398730415 398631415 398731415 398632415 398732415 430 398630430 398730430 398631430 398731430 398632430 398732430 445 398630445 398730445 398631445 398731445 398632445 398732445 460 398630460 398730460 398631460 398731460 398632460 398732460 Anodised Titanium CCD=135 Distal diameter 10 10 11 11 12 12 Left Right Left Right Left Right 280 398610280 398710280 398611280 398711280 398612280 398712280 295 398610295 398710295 398611295 398711295 398612295 398712295 310 398610310 398710310 398611310 398711310 398612310 398712310 325 398610325 398710325 398611325 398711325 398612325 398712325 340 398610340 398710340 398611340 398711340 398612340 398712340 355 398610355 398710355 398611355 398711355 398612355 398712355 370 398610370 398710370 398611370 398711370 398612370 398712370 385 398610385 398710385 398611385 398711385 398612385 398712385 400 398610400 398710400 398611400 398711400 398612400 398712400 415 398610415 398710415 398611415 398711415 398612415 398712415 430 398610430 398710430 398611430 398711430 398612430 398712430 445 398610445 398710445 398611445 398711445 398612445 398712445 460 398610460 398710460 398611460 398711460 398612460 398712460 18
4.3 Trochanter screw Ø10.5 mm 4.6 Locking screw Ø4.8 mm 4.4 Support screw 4.5 Closing cap Anodised Titanium 75 258315075 398315075 80 258315080 398315080 85 258315085 398315085 90 258315090 398315090 95 258315095 398315095 100 258315100 398315100 105 258315105 398315105 110 258315110 398315110 115 258315115 398315115 120 258315120 398315120 125 258315125 398315125 130 258315130 398315130 135 258315135 398315135 140 258315140 398315140 Anodised Titanium 254450001 394450001 Anodised Titanium 0 258400001 398400001 5 258400002 398400002 10 258400003 398400003 15 258400004 398400004 20 258400005 398400005 25 258400006 398400006 Anodised Titanium 25 932148025 364048025 26 932148026 364048026 28 932148028 364048028 30 932148030 364048030 32 932148032 364048032 34 932148034 364048034 35 932148035 364048035 36 932148036 364048036 38 932148038 364048038 40 932148040 364048040 42 932148042 364048042 44 932148044 364048044 45 932148045 364048045 46 932148046 364048046 48 932148048 364048048 50 932148050 364048050 52 932148052 364048052 54 932148054 364048054 55 932148055 364048055 56 932148056 364048056 58 932148058 364048058 60 932148060 364048060 62 932148062 364048062 64 932148064 364048064 65 932148065 364048065 66 932148066 364048066 68 932148068 364048068 70 932148070 364048070 72 932148072 364048072 75 932148075 364048075 76 932148076 364048076 80 932148080 364048080 85 932148085 364048085 90 932148090 364048090 95 932148095 364048095 100 932148100 364048100 19
5 Instrument list 5.1 Filled-up tray Surgical description Description Size Quantity Cat. no. Linear gauge for locking screws 1 254900020 T-wrench with compression nut 1 254900021 Threaded Retaining Stem 1 254900022 Depth gauge for locking screws 4.8 mm 1 258900016 Stepped drill 10.5/6.7 can. 3.2 mm 1 254915009 Target device SpectruM Trochanter 1 258900001 Awl 1 258900002 Free-hand target device SpectruM Trochanter 1 258900003 Nail Extractor Dowel 1 258900004 Flexible shaft 1 258900005 T-handle 1 258900008 Distal targeting device SpectruM Trochanter 1 258900009 Spiral drill 4.2x250 mm 1 258900010 Spiral drill 4.2x280 mm 1 258900011 Conical reamer 16 mm 1 258900012 Soft tissue protector 16 mm 1 258900013 Measuring rod 500 mm 1 939999072 Spiral drill with quick-conn. end 3.2x310 mm 1 939532310 Kirschner wire 3.2x375 mm 1 256732375 Threaded kirschner wire 3.2x375x10 mm 2 256737532 Fork Hammer 1 210510030 Screwdriver 3.5 mm 1 210510002 Spiral drill 6 mm 1 257930008 Guide Rod with olive Tip 4/3x900 mm 1 210904004 Screwdriver 8 mm 1 210510021 Wrench 1 251910008 Drill stop 4.2 mm 2 210510242 Indicator (optional 1 258900014 Double wire (optional) 1 258900015 Tray (empty) SpectruM Trochanter Filled-up tray (SpectruM Trochanter) 258800001 258800000 20
5.2 Instruments Linear gauge for locking screws 254900020 T-wrench with compression nut 254900021 Threaded Retaining Stem 254900022 Linear gauge for locking screws (4.8 mm) 258900016 Stepped drill (10.5/6.7 can. 3.2 mm) 254915009 Target device SpectruM Trochanter 258900001 Awl 258900002 Free-hand target device SpectruM Trochanter 258900003 Nail Extractor Dowel 258900004 21
5 Instrument list Flexible shaft 258900005 T-handle 258900008 Distal targeting device-sm Trochanter 258900009 Spiral drill (4.2x250 mm) 258900010 Spiral drill (4.2x280 mm) 258900011 Conical reamer (16 mm) 258900012 Soft tissue protector (16 mm) 258900013 Measuring rod (500 mm) 939999072 Spiral drill with quick-connecting end (3.2x310 mm) 939532310 22
Kirschner wire (3.2x375 mm) 256732375 Threaded kirschner wire (3.2x375x10 mm) 256737532 Fork Hammer 210510030 Screwdriver (3.5 mm) 210510002 Spiral drill (6 mm) Guide Rod with Olive Tip (4/3x900 mm) 257930008 210904004 Screwdriver (8 mm) 210510021 Wrench 251910008 Drill stop (4.2 mm) 210510242 Indicator (optional) 258900014 Double wire (optional) 258900015 23
Product family TRAUMATOLOGY 1.1. Intramedullary nails 1.1.1. Humerus nails 1.1.2. Ulna-radius nails 1.1.3. Trochanter nails 1.1.4. Femur nails 1.1.5. Tibia nails 1.1.6. Fibula nails 1.1.7. Sanat PIN 1.2. Plates 1.3. Screws 1.4. Fixateur externe 1.5. Other ORTHOPEADICS DENTAL SPINE Contact address: 5, Faiskola st. 3300 Eger, Hungary e-mail: metal@sanatmetal.hu phone: +36 36 512 900 fax: +36 36 512 932 www.sanatmetal.com TRAUMA REV_C 16/09/2014