Hybrid Fixator Proximal Tibia Frame. Using rings with clamps. Technique Guide Part of the External Fixation System
Hybrid Fixator Proximal Tibia Frame Technique Overview 1 Insert wires 2 Attach wires to ring using adjustable wire/pin clamps 7 2 1 3 Wrench-tighten clamp-locking nuts 4 Tighten wire-locking nuts Wrench-tighten the wire-locking nut on the far side of the ring (A). Finger-tighten on the side to be tensioned (B). 3 9 5 Tension wires Typically, wires are tensioned to 100 kg. Tighten wire-locking nuts (B) and remove tensioner. To obtain maximum wire tension, it is recommended after tensioning the second wire, to retension both wires in the same sequence to obtain the best frame stability. An alternative method would be to use two tensioners simultaneously. 8 6 11 6 Insert Schanz screw into proximal fragment Insert through wire/ pin clamp. Note: A third wire can be inserted if the fracture pattern does not permit Schanz screw placement. 4, 5 B A Synthes Hybrid Fixator Proximal Tibia Frame Technique Guide
7 Trim, bend and cap wires Leave 3 cm 4 cm in case retensioning becomes necessary. 10 8 Construct anterior half-frame 9 Connect ring to half-frame with ring-to-rod clamp 10 Reduce extra-articular component of fracture Use ring and anterior rod as handles to manipulate fracture. Tighten ring-to-rod clamp. 11 Add second rod Connect ring-to-rod clamp and large combination clamp. Add carbon fiber rod. Note: Operating instructions for the Wire Tensioner (393.742) can be found in Wire Tensioners for Hybrid Fixator Synthes
Recommended Components for Hybrid Fixator Product Item Quantity Number Needed 294.785* 5.0 mm Self-Drilling 3 Schanz Screw, 175 mm 292.38 Spade-Point Reduction Wire 2 292.41 (or Spade-Point Wire) 390.005* Large Combination Clamp 3 393.436 Ring-to-Rod Clamp 2 393.464 Adjustable Wire/ Pin Clamp 5 Notes: Additional components are required for optional frame configurations. Additionally available lengths of stainless steel self-drilling Schanz screws, stainless steel non self-drilling Schanz screws and titanium self-drilling Schanz screws may also be used. * Although some components are MR Conditional, the standard hybrid frame is not safe to be utilized in an MR environment. Synthes Hybrid Fixator Proximal Tibia Frame Technique Guide
Product Item Quantity Number Needed 393.7xx 3/4 Ring (size chosen should 1 allow two finger breadths of soft tissue clearance) 394.8x* 11.0 mm Carbon Fiber Rod 2 392.18 Protective Cap, for 1.8 mm and 4 2.0 mm wires 394.97 Protective Cap, for 11.0 mm rods 4 394.99x Protective Cap, for Fixation Pins 3 Synthes
Hybrid Fixator Proximal Tibia Frame When to use The hybrid frame is used for the stabilization of complex proximal tibial fractures, particularly those involving the joint. Wire positioning Proper wire positioning follows these basic guidelines: Use a minimum of two wires with a separating angle of at least 60. 1 Ideally, the wires should intersect at the center of the bone. Wires may be positioned at different levels using the Adjustable Wire/ Pin Clamp. An adequate incision should be made at wire and Schanz screw insertion points to avoid skin tenting and soft tissue irritation. Wires should be straight for the same reason. An additional Schanz screw or third wire is placed in the proximal fragment for stability. If a Schanz screw is used, it should be placed below the ring and angled proximally to maximize thread purchase in the bone. Position wires within the zone for safe pin placement (note the location of the peroneal nerve). Place wires distal to the capsular attachment of the knee joint. The capsular attachment is approximately 14 mm below the plateau surface. 2,3 When wires are placed near the proximal tibiofibular joint, the safe distance from the knee joint must be carefully evaluated because a torn septum may render this area intra-articular. 4 This is of special concern when a wire is placed through the fibular head, as in Figure 3 which illustrates alternative wire placement. Generally, wires should be placed distal to cannulated screws. A C Figure 1 Typical wire positions with insertion sequence, as noted on diagram: A. Posterolateral to anteromedial tibia B. Posteromedial to anterolateral tibia C. Optional third wire, lateral to medial 14 mm Figure 2 Level of cross section in Figures 1 and 3 B Most proximal level of wire level of wire Level of cross section in Figures 1 and 3 C 1. F.J. Kummer. Biomechanics of the Ilizarov External Fixator. Clinical Orthopaedics and Related Research. 1992;280. 11 14. A B 2. T.A. DeCoster, M.K. Crawford and M.A. Steven Kraut. Safe Extracapsular Placement of Proximal Tibia Transfixion Pins. Journal of Orthopaedic Trauma. 1999;13;4. 236 240. 3. J.S. Reid, M.A. Vanslyke, M.J.R. Moulton, and T.A. Mann. Safe Placement of Proximal Tibial Transfixation Wires with Respect to Intracapsular Penetration. Journal of Orthopaedic Trauma. 2001;15;1. 10 17. 4. Ibid. 5. J. Geller, P. Tornetta III, D. Tiburzi, F. Kummer, and K. Koval. Tension Wire Position for Hybrid External Fixation of the Proximal Tibia. Journal of Orthopaedic Trauma. 2000;14;7. 502 504. Figure 3 Alternative wire position, recommended for smaller fragments: Both wires A and B can be inserted from a more posterior point, with A traversing the fibular head. Insertion of wire C remains in the coronal plane. Wires A and B exit more anteriorly than in typical configuration (Figure 1) and all three wires create a triangle about the geographic center of the proximal tibia. This configuration increases bending stiffness in the AP plane and thus better resists displacement forces. 5 Synthes Hybrid Fixator Proximal Tibia Frame Technique Guide
Basic principles Restore the articular surface. Screw fixation must be used to provide interfragmentary compression after anatomic reduction of the articular surface. Bone graft may be necessary for any metaphyseal defect. Opposing spade-point reduction wires may be used. 6,7 They prevent frame movement and are helpful in the reduction of small fragments. When using spade-point reduction wires, insert the wire until the olive contacts the bone surface (Figure 4). Washers can be used in osteopenic bone. To increase frame stability, the proximal pin on the anterior rod should be 2 cm distal to the fracture, and the second pin should be as far distal as possible. To accommodate pins placed in differing planes, modular frame technique, using more than one carbon fiber rod, can be used in place of the anterior frame. (See the Basic Modular Frame Technique Guide.) A second carbon fiber rod must be placed either laterally or medially for optimal stability. If desired, a third rod can be added on the opposite side. Preoperative planning of clamp and ring placement should take into consideration future x-ray visibility of both the joint line and the fracture site. To achieve fine distraction, Open Compressors (393.76) can be used as illustrated (Figure 5). For more information, consult the Open Compressor Technique Guide. Figure 4 Figure 5 6. G.L. Orbay, V.H. Frankel and F.J. Kummer. The Effect of Wire Configuration in the Stability of the Ilizarov External Fixator. Clinical Orthopaedics and Related Research. 1992;279. 299 302. 7. Kummer. op cit.. Synthes
Using the Adjustable Wire/ Pin Clamp (393.464) 1 Hold clamp in hand as with a syringe. 15 mm Wire-locking nut 2 Pull vise plates apart with thumb and fingers. Clamp-locking nut The wire/pin connection provides up to 15 mm of excursion for versatile wire or pin placement. 3 Hook top vise plate over ring and release. Synthes Hybrid Fixator Proximal Tibia Frame Technique Guide
Optional Frame Configurations Frame with anterior, medial and lateral carbon fiber rods. Large multi-pin clamp frame with anterior and medial carbon fiber rods. Additional reading Stamer, D., R. Schenk, B. Staggers, K. Aurori, B. Aurori, and F.F. Behrens. Bicondylar Tibial Plateau Fractures Treated with a Hybrid Ring External Fixator: a Preliminary Study. Journal of Orthopaedic Trauma. 1994;8,6. 455 461. Weiner, L., M. Kelley, E. Yang, J. Steuer, N. Watnick, M. Evans, and M. Bergman. The Use of Combination Internal Fixation and Hybrid External Fixation in Severe Proximal Tibia Fractures. Journal of Orthopaedic Trauma. 1995;9,3. 244 250. Synthes
Hybrid Fixator Universal Set (115.940) Graphic Case 304.340 Hybrid Fixator Set Graphic Case Implants 219.98 Washer, 7.0 mm, 6 ea. 292.38 1.8 mm Spade-Point Wire, 350 mm, 6 ea. 292.39 1.8 mm Spade-Point Reduction Wire, 400 mm, 4 ea. 292.40 2.0 mm Spade-Point Wire, 350 mm, 6 ea. 292.41 2.0 mm Spade-Point Reduction Wire, 400 mm, 4 ea. 294.785 5.0 mm Self-Drilling Schanz Screw, 175 mm, 6 ea. Instruments 310.37 3.5 mm Drill Bit, quick coupling,195 mm, 2 ea. 321.20 Ratchet Wrench, 11 mm width across flats 391.962 Bending/Cutting Pliers 393.10 Universal Chuck with T-Handle 393.103 Drive Adaptor with quick coupling, for 5.0 mm Schanz Screws 393.742 Wire Tensioner 393.743 Backup Wire Tensioner 393.745 Split Tissue Protection Sleeve, for wires up to 2.5 mm 393.746 Split Tissue Protection Sleeve, for wires and pins up to 5.0 mm 394.182 3.5 mm Trocar, 118 mm (long) 395.913 5.0 mm/3.5 mm Drill Sleeve, 107 mm (long) Fixation Material 390.005 Large Combination Clamp, 6 ea. 392.18 Protective Caps, for 1.8 mm and 2.0 wires, 1 pkg. of 10 393.436 Ring-to-Rod Clamp, 4 ea. 393.464 Adjustable Wire/Pin Clamp, 10 ea. 393.722 3/4 Ring, 205 mm ID 393.732 3/4 Ring, 115 mm ID 393.734 3/4 Ring, 140 mm ID, 2 ea. 393.736 3/4 Ring, 165 mm ID, 2 ea. 394.85 11.0 mm Carbon Fiber Rod, 300 mm, 2 ea. 394.86 11.0 mm Carbon Fiber Rod, 350 mm, 2 ea. 394.97 Protective Caps, for 11.0 mm Rods, 1 pkg. of 10 394.993 Protective Caps, for 5.0 mm Fixation Pins, 1 pkg. of 10 Note: For additional information, please refer to package insert. For detailed cleaning and sterilization instructions, please refer to http://us.synthes.com/medical+community/cleaning+and+sterilization.htm or to the below listed inserts, which will be included in the shipping container: Processing Synthes Reusable Medical Devices Instruments, Instrument Trays and Graphic Cases DJ1305 Processing Non-sterile Synthes Implants DJ1304 Synthes Hybrid Fixator Proximal Tibia Frame Technique Guide
Also Available Sets 105.135 4.0 mm Cannulated Screw Instrument and Implant Set 105.185 7.3 mm Cannulated Screw Instrument and Implant Set 105.957 Power Drive Set 115.720 Large External Fixator Set, with Self-Drilling Schanz Screws 115.740 Large External Fixator Set, with Titanium Self-Drilling Schanz Screws 150.16 ComPact Air Drive II Set Implants Schanz Screws 294.43.48 4.0 mm, spade point, 60 mm 150 mm 294.52.57 5.0 mm, blunted trocar point, 100 mm 250 mm 294.71.76 4.5 mm, blunted trocar point, 100 mm 200 mm Fixation Material 390.002 Large Multi-Pin Clamp, 6 position 390.003 Rod Attachment, for Large Multi-Pin Clamp 390.008 Large Open Adjustable Clamp 393.721 Full Ring, 205 mm ID 393.731 Full Ring, 115 mm ID 393.735 Full Ring, 165 mm ID 393.737 1/4 Ring, 165 mm ID Protective Caps 394.991 For 4.0 mm Fixation Pins, 10/pkg. 394.992 For 4.5 mm Fixation Pins, 10/pkg. 394.994 For 6.0 mm Fixation Pins, 10/pkg. Self-Drilling Schanz Screws 294.774.779 4.0 mm, 60 mm 175 mm 294.782.788 5.0 mm, 100 mm 250 mm 294.792.798 6.0 mm, 100 mm 250 mm Titanium Self-Drilling Schanz Screws 494.774.779 4.0 mm, 60 mm 175 mm 494.782.788 5.0 mm, 100 mm 250 mm 494.792.798 6.0 mm, 100 mm 250 mm Instruments Drive Adaptors with quick coupling 393.101 For 4.0 mm Schanz Screws 393.102 For 4.5 mm Schanz Screws 393.104 For 6.0 mm Schanz Screws 393.105 Small Universal Chuck with T-Handle Synthes
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