Titanium Distal Femoral Nail System

For Retrograde Insertion Titanium Distal Femoral Nail System Surgical Technique

Table of Contents Introduction Titanium Distal Femoral Nail System 2 AO Principles 4 Indications 5 Clinical Cases 6 Surgical Technique Preoperative Planning 8 Opening the Distal Femur 9 Inserting the Nail 14 Locking Distally 16 Locking Proximally 20 Inserting the End Cap 22 Implant Removal 23 Product Information Implant Specifications 27 Implants 28 Instruments 32 Set List 35 MR Information The Titanium Distal Femoral Nail 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 Titanium Distal Femoral Nail System in the MR environment is unknown. Scanning a patient who has this device may result in patient injury. Image intensifier control Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 1

Titanium Distal Femoral Nail System. For retrograde insertion. Advanced solutions Nail Features Universal design for the right and left femur 1.5 m radius of curvature for anatomic fit Titanium 6% aluminum 7% niobium alloy 9 mm solid nails 10 mm 13 mm cannulated nails 9 mm and 10 mm diameters, round cross-section 11 mm, 12 mm, and 13 mm diameters, fluted cross-section Lengths: 160 mm 460 mm (20 mm increments) 4.9 mm Titanium Locking Bolts (green) Lengths: 26 mm 100 mm 4.3 mm core diameter Fully threaded Self-cutting trocar tip 3.5 mm hex drive 5.0 mm Titanium Locking Screws (green) Lengths: 26 mm 100 mm 4.3 mm core diameter Fully threaded Self-cutting trocar tip 3.5 mm hex drive 2 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Titanium Distal Femoral Nail System. For retrograde insertion. Proximal Locking Proximal locking holes accept 4.9 mm locking bolts or 5.0 mm locking screws Dynamic slot accepts 4.9 mm locking bolt or 5.0 mm locking screw Permits up to 5 mm controlled axial dynamization Distal Locking Distal locking holes accept 6.0 mm titanium locking screws 30 mm from end of nail 15 mm from end of nail 6.0 mm Titanium Locking Screws (aqua) Lengths: 30 mm 100 mm 4.8 mm core diameter Fully threaded Self-tapping 3.5 mm hex drive Titanium End Cap (aqua) 8 mm diameter Locks distal most 6.0 mm titanium locking screw in place Protects nail threads from tissue ingrowth Sits flush with the distal end of the nail Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 3

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 1 05.07.12 12:08 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, Early, active mobilization Early Early and and safe safe mobilization and rehabilitation of of the the injured part and and the the patient as as a whole. 4 3 Preservation of of blood blood supply supply 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; 1991. 2. 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; 2007. Fixation. 3rd ed. Berlin Heidelberg New York: Springer. 1991. 2 Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme. 2007. 4 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Indications The Titanium Distal Femoral Nail is indicated for the stabilization of fractures of the distal femur and/or diaphyseal fractures in which a retrograde approach is indicated. These include: supracondylar fractures, including those with intra-articular extension ipsilateral hip/ shaft fractures ipsilateral femur/ tibia fractures femoral fractures in the multiply-injured patient fractures proximal to a total knee arthroplasty fractures distal to a hip implant fractures in the morbidly obese patient pathologic fractures including those in osteoporotic bone malunions nonunions The Titanium Distal Femoral Nail may be used in either reamed or nonreamed applications. Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 5

Clinical Cases Case 1 Preoperative Preoperative Postoperative Postoperative 6 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Clinical Cases Case 2 Preoperative Postoperative Postoperative Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 7

Preoperative Planning Recommended Set 105.954 Small Battery Drive Set, with 14.4 V Battery Use the AO preoperative planner ruler for the Titanium Distal Femoral Nail to determine nail length and nail diameter. Note: There are two templates available for use: actual size and 115%, with template image magnified 15% to account for average radiograph magnification. However, variations in magnification levels are common. When selecting nail size, consider canal diameter, fracture pattern, and postoperative protocol. J5653C GP0801F Rev. 10/07 J5653C GP0801F Rev. 10/07 9 mm 10 mm 11 mm 12 mm 13 mm 160 mm 180 mm 200 mm 220 mm 240 mm 260 mm 280 mm 300 mm 320 mm 340 mm 360 mm 380 mm 400 mm 420 mm 440 mm 460 mm AO A P View Lateral View A P View Lateral View 0% Magnification DFN 9-13 mm For Titanium Distal Femoral Nails [450.XXX] For proximal locking, use the 4.9 mm Titanium Locking Bolts [459.30 459.60] or 5.0 mm Titanium Locking Screws [458.926 458.960] For distal locking, use the 6.0 mm Titanium Locking Screws [450.86 450.872] 11 mm 12 mm 13 mm 9 mm 10 mm Titanium Distal Femoral Nail Ruler For 9 mm, 10 mm, 11 mm, 12 mm, and 13 mm Nails For use only with the AO System of instruments and implants. 8 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Opening the Distal Femur 1 Position patient Position the patient supine on a radiolucent table. The knee of the injured leg should be flexed 30 40. A leg roll may be used to allow for proper reduction and stabilization of the fracture. Ensure that x-ray visualization of the entire femur is possible in both the AP and lateral views. 2 Reduce fracture Intra-articular fractures should be stabilized with interfragmentary screw fixation prior to insertion of the nail. The screws should be positioned so as not to interfere with the path of the nail. Optional instrument 394.35* Large Distractor A large distractor may also be used. *Also available Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 9

Opening the Distal Femur 3 Confirm nail length Instrument 357.111 Radiographic Ruler Position the image intensifier for an AP view of the distal femur. With a long forceps, hold the radiographic ruler along the lateral aspect of the leg, parallel to and at the same level as the femur. Adjust the ruler until the distal end is at the desired nail insertion depth. Mark the skin at that site. Move the image intensifier to the proximal femur, replace the distal end of the ruler at the skin mark, and take an AP image of the proximal femur. Verify fracture reduction. Read nail length directly from the ruler image, selecting the measurement that places the proximal end of the nail at the level of the lesser trochanter. Note: All fractures should be treated with the longest nail possible, taking into account patient anatomy or previous implant. 10 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Opening the Distal Femur 4 Identify nail entry point Instruments 292.69 3.2 mm Calibrated Guide Wire 357.127 13.0 mm Protection Sleeve 357.128 13.0 mm/3.2 mm Trocar Make a medial parapatellar incision. Retract the patellar tendon laterally. The entry point for the nail is in the intercondylar notch, just anterior and lateral to the femoral attachment of the posterior cruciate ligament. The location of the entry point in relation to the intercondylar notch varies with patient anatomy. Thread the 13.0 mm/3.2 mm trocar into the 13.0 mm protection sleeve. Insert the assembly through the incision to the bone. Hold the protection sleeve firmly and pass the 3.2 mm calibrated guide wire through the trocar. Insert the guide wire using a power drill. The guide wire should be inserted in line with the anatomic axis of the femur which is 7 9 lateral to a line perpendicular to the articular surface. AP view Lateral view Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 11

Opening the Distal Femur 5 Open canal Instrument 351.27 13.0 mm Cannulated Drill Bit Place the 13.0 mm cannulated drill bit into a cannulated drill. Pass the drill bit over the guide wire and through the protection sleeve. Advance the drill bit to the bone and drill to a depth of 50 mm. Optional instrument 351.11 Large Reverse Awl The surgeon may also use the large reverse awl to open the canal. 12 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Opening the Distal Femur Optional technique: reaming Instruments 355.006 Medullary Tube Note: Single Sterilization only. Do not use with 3.0 mm Reaming Rod with offset ball tip (351.71). 355.041* 3.0 mm Guide Rod, with smooth tip Under image intensification, reduce the fracture and insert the appropriate reaming rod into the canal to the desired nail insertion depth. Ream in 0.5 mm increments and advance the reamer with steady, moderate pressure. Note: Do not force the reamer. Partially retract the reamer often to clear debris from the medullary canal. Ream to a diameter 0.5 mm to 1.0 mm greater than nail diameter. After reaming, remove the reaming assembly. Pass the medullary tube down the reamed canal over the reaming rod. Remove the reaming rod and insert a 3.0 mm guide rod, with smooth tip, through the medullary tube. Remove the medullary tube leaving the guide rod in position for insertion of the cannulated nail. *Also available Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 13

Inserting the Nail 1 Assemble insertion instruments Instruments 321.25 Spanner Wrench 357.095 Connecting Screw 357.112 Insertion Handle 357.22 Hammer Guide 357.25 Slide Hammer Orient the insertion handle laterally and match the flats on the handle and nail. The anterior bow of the implant must be aligned with the anterior bow of the femur. Place the connecting screw into the insertion handle and thread it into the distal end of the nail. Tighten the connecting screw with the spanner wrench. Note: Do not overtighten. Slide the hammer guide through the slide hammer and attach the hammer guide to the connecting screw. Finger-tighten the assembly. Alternative technique Instrument 399.43 Hammer, 700 grams A hammer may also be used to insert the nail. The distal end of the connecting screw is the direct striking surface for the hammer. 14 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Inserting the Nail 2 Insert nail Insert the nail as far as possible by hand using a twisting motion. When using a guide wire, pass the cannulated nail (10 mm 13 mm nails) over the guide wire and into the femoral opening. Monitor nail passage across the fracture under image intensification. The insertion assembly may be used to manipulate the nail across the fracture. Use light blows of the slide hammer on the connecting screw until the distal end of the nail is inserted 5 mm 10 mm beyond the articular cartilage. Insertion depth is indicated by the grooves on the barrel of the insertion handle. Notes: Do not attach the aiming arm to the insertion handle until the nail is fully inserted. The aiming arm may loosen during nail insertion. After nail insertion, check that the connecting screw is still tight as it could have loosened during hammering. Do not attach the aiming arm for standard locking or spiral blade locking, respectively, to the insertion handle until the nail is fully inserted. Otherwise, the aiming arm may loosen during nail insertion. 10 mm 5 mm Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 15

Locking Distally 1 Assemble instruments Instruments 357.096 Aiming Arm, for 6.0 mm Titanium Locking Screws 357.097 8.0 mm/ 5.0 mm Drill Sleeve 357.098 5.0 mm Trocar 357.76 11.0 mm/ 8.0 mm Protection Sleeve Distal locking is performed using the 6.0 mm titanium locking screws. Attach the aiming arm to the insertion handle. Insert the triple trocar assembly (11.0 mm/8.0 mm protection sleeve, 8.0 mm/5.0 mm drill sleeve and 5.0 mm trocar) into the aiming arm and through a stab incision to the bone. Remove the trocar. 16 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Locking Distally 2 Drill Instrument 357.099 5.0 mm Three-Fluted Drill Bit Drill through both cortices using the 5.0 mm three-fluted drill bit, stopping the drill immediately after penetrating the far cortex. Confirm drill bit position radiographically. Ensure the drill sleeve is pressed firmly to the cortex and read locking screw length directly from the drill bit at the back of the drill sleeve. The drill bit provides a direct measurement. Note: Since drill bit position directly represents locking screw position in bone, the locking screw will be too long if the drill bit is overinserted, or if the drill sleeve is not pressed down to the cortex. Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 17

Locking Distally 2. Drill continued Alternative technique Instruments 357.097 8.0 mm/ 5.0 mm Drill Sleeve 357.113 Locking Bolt Measuring Device 357.76 11.0 mm/ 8.0 mm Protection Sleeve The locking bolt measuring device may be used through the 11.0 mm/8.0 mm protection sleeve to determine locking screw length. Remove the 8.0 mm/5.0 mm drill sleeve and pass the measuring hook through the 11.0 mm/8.0 mm protection sleeve. Read locking screw length directly from the measuring device at the back of the protection sleeve. 18 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Locking Distally 3 Insert locking screws Instrument 314.75 Hexagonal Screwdriver Insert the locking screw through the protection sleeve using the hexagonal screwdriver. Repeat the procedure for a second distal locking screw. Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 19

Locking Proximally 1 Reconfirm reduction Instrument 511.30* Radiolucent Drive Confirm reduction/ alignment of the fracture. 2 Align image Align the image intensifier with the hole in the nail closest to the fracture until a perfect circle is visible in the center of the screen. 3 Determine incision point Place a scalpel blade on the skin to determine the incision point and make a stab incision. Oblique (incorrect) Round (correct) 4 Center drill bit in locking hole Instrument 511.417* 4.0 mm Three-Fluted Drill Bit Under image intensification, insert the tip of the 4.0 mm drill bit for the radiolucent drive through the incision and place it onto the bone. Keep the drill bit oblique to the x-ray beam until the tip is centered in the locking hole. *Also available 20 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Locking Proximally 5 Drill Tilt the drive until the drill bit is in line with the beam and appears centered in the outer ring. The drill bit will nearly fill the locking hole image. Hold the drill firmly in this position and drill through both cortices. 6 Measure Instrument 357.113 Locking Bolt Measuring Device Measure for locking bolt or locking screw length using the locking bolt measuring device. Locking bolt or locking screw length is read directly from the device. 7 Insert locking bolt or locking screw Instrument 314.75 Hexagonal Screwdriver Insert the appropriate length 4.9 mm titanium locking bolt or 5.0 mm titanium locking screw, using the hexagonal screwdriver. Alternative technique Instrument 315.40 4.0 mm Three-Fluted Drill Bit Use the 4.0 mm three-fluted drill bit to perform freehand proximal locking. Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 21

Inserting the End Cap Insert end cap Instrument 314.75 Hexagonal Screwdriver The end cap locks the most distal 6.0 mm titanium locking screw in place, thereby creating a fixed angle construct. Remove the insertion instrumentation. Using the hexagonal screwdriver, align the end cap with the nail axis to prevent cross-threading. Thread the end cap into the nail until it engages the locking screw. Note: To minimize the chance of cross-threading, turn the end cap counterclockwise until the threads of the end cap align with the threads of the nail. Insert the end cap by turning clockwise until it is fully seated. 22 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Implant Removal 1 Remove locking implants and end cap Instrument 314.75 Hexagonal Screwdriver Clear tissue ingrowth from the hex of the end cap and locking implants and remove using the hexagonal screwdriver. 2 Remove nail Instruments 357.095 Connecting Screw 357.22 Hammer Guide 357.25 Slide Hammer Thread the connecting screw into the distal end of the nail. Slide the hammer guide through the slide hammer and attach it to the connecting screw. Finger-tighten the assembly. Remove the final locking screw and remove the nail. Note: Before removing the last locking screw, thread the connecting screw into the distal end of the nail. This will prevent the nail from rotating in the medullary canal. Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 23

Implant Removal Alternative Technique Extraction Hook The extraction hook is for use with cannulated nails only. For removal of broken nail Instruments 355.399 Extraction Hook, for Titanium Cannulated Nails 393.10 Universal Chuck with T-handle or 393.105 Small Universal Chuck with T-handle 1 Clear tissue from the end of the nail and remove the end cap. 2 Remove the locking bolts and/or screws with the appropriate screwdriver. 3 Insert the extraction hook into the universal chuck with T-handle. The hook should be parallel with the T-handle. This facilitates visualization of the hook position in the bone. Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. 24 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Implant Removal 4 Attach the appropriate extraction bolt or connecting screw to the nail. Remove the near nail fragment using the extraction the bolt or connecting screw. Note: The extraction hook can be used as an alternative to extraction instrumentation. 5 Ream the medullary canal 1 mm larger than the diameter to clear a path for the distant nail fragment. 6 Insert the extraction hook and explanted, near nail fragment into the medullary canal. The near nail fragment aligns the extraction hook with the cannulation of the distant nail fragment. 7 Pass the extraction hook through the cannula of the distant nail fragment. Note: Under image intensification, verify that the hook has passed through and engaged the distant end of the nail. 8 Extract both nail fragments. Note: Keep the patient s limb restrained to increase the efficiency of the extraction force. Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 25

Implant Removal For removal of an intact nail Instruments 355.399 Extraction Hook, for Titanium Cannulated Nails 393.10 Universal Chuck with T-Handle or 393.105 Small Universal Chuck with T-Handle 1 Clear tissue from the end of the nail and remove the end cap. 2 Remove the locking bolts and/or screws with the appropriate screwdriver. 3 Insert the extraction hook into the universal chuck with T-handle. The hook should be parallel with the T-handle. This facilitates visualization of the hook position in the bone. 4 Insert the extraction hook through the nail cannula. Note: Under image intensification, verify that the hook has passed through and engaged the distant end of the nail. 5 Extract the nail. Note: Keep the patient s limb restrained to increase the efficiency of the extraction force. Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. 26 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Implant Specifications Titanium Distal Femoral Nails Universal design for the right and left femur 1.5 m radius of curvature for anatomic fit Material Titanium 6% aluminum 7% niobium alloy Diameters 9 mm solid nails 10 mm 13 mm cannulated nails 9 mm 12 mm nails are 12 mm in diameter at the distal end 13 mm nails are 13 mm in diameter throughout Color Aqua 0 mm 17 mm 22 mm 37 mm 52 mm Dynamic Static Static Static Proximal locking hole orientation: two anterior-to-posterior holes; one lateral-to-medial hole Lengths 160 mm 460 mm (20 mm increments) Cross Section 9 mm and 10 mm diameters, round cross-section 11 mm, 12 mm, and 13 mm diameters, fluted cross-section Proximal Locking Proximal locking holes accept 4.9 mm locking bolts or 5.0 mm locking screws Dynamic slot accepts 4.9 mm locking bolt or 5.0 mm locking screw Permits up to 5 mm controlled axial dynamization Distal Locking Distal locking holes accept 6.0 mm titanium locking screws 30 mm from end of nail 15 mm from end of nail Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 27

Implants Titanium Solid Distal Femoral Nails (9 mm diameter) Length (mm) 450.701 160 450.714 180 450.702 200 450.715 220 450.703 240 450.716 260 450.704 280 450.705 300 450.706 320 450.707 340 450.708 360 450.709 380 450.710 400 450.711 420 450.712 440 450.713 460 Length (mm) Titanium Cannulated Distal Femoral Nails (10 mm 13 mm diameters) 10 mm dia. Length (mm) 450.781 160 450.794 180 450.782 200 450.795 220 450.783 240 450.796 260 450.784 280 450.785 300 450.786 320 450.787 340 450.788 360 450.789 380 450.790 400 450.791 420 450.792 440 450.793 460 11 mm dia. Length (mm) 450.801 160 450.814 180 450.802 200 450.815 220 450.803 240 405.816 260 450.804 280 450.805 300 450.806 320 450.807 340 450.808 360 450.809 380 450.810 400 450.811 420 450.812 440 450.813 460 12 mm dia. Length (mm) 450.821 160 450.834 180 450.822 200 450.835 220 450.823 240 450.836 260 450.824 280 450.825 300 450.826 320 450.827 340 450.828 360 450.829 380 450.830 400 450.831 420 450.832 440 450.833 460 13 mm dia. Length (mm) 450.841 160 450.854 180 450.842 200 450.855 220 450.843 240 450.856 260 450.844 280 450.845 300 450.846 320 450.847 340 450.848 360 450.849 380 450.850 400 450.851 420 450.852 440 450.853 460 28 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Implants 4.9 mm Titanium Locking Bolts (green) Titanium alloy* Lengths: 26 mm 100 mm 4.3 mm core diameter Fully threaded Self-cutting trocar tip 3.5 mm hex drive Length (mm) 459.26 26 459.28 28 459.30 30 459.32 32 459.34 34 459.36 36 459.38 38 459.40 40 459.42 42 459.44 44 459.46 46 459.48 48 459.50 50 459.52 52 Length (mm) 459.54 54 459.56 56 459.58 58 459.60 60 459.64 64 459.68 68 459.72 72 459.76 76 459.80 80 459.85 85 459.90 90 459.95 95 459.100 100 * Titanium-6% aluminum-7% niobium alloy Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 29

Implants 5.0 mm Titanium Locking Screws (green) Titanium alloy* Lengths: 26 mm 100 mm 4.3 mm core diameter Fully threaded Self-cutting trocar tip 3.5 mm hex drive Length (mm) 458.926 26 458.928 28 458.930 30 458.932 32 458.934 34 458.936 36 458.938 38 458.940 40 458.942 42 458.944 44 458.946 46 458.948 48 458.950 50 458.952 52 Length (mm) 458.954 54 458.956 56 458.958 58 458.960 60 458.964 64 458.968 68 458.972 72 458.976 76 458.980 80 458.985 85 458.990 90 458.995 95 458.999 100 * Titanium-6% aluminum-7% niobium alloy 30 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Implants 6.0 mm Titanium Locking Screws (aqua) Titanium alloy* Lengths: 30 mm 100 mm 4.8 mm core diameter Fully threaded Self-tapping 3.5 mm hex drive 450.873 30 450.874 35 450.875 40 450.861 45 450.862 50 450.863 55 450.864 60 450.865 65 Length (mm) Length (mm) 450.866 70 450.867 75 450.868 80 450.869 85 450.870 90 450.871 95 450.872 100 Titanium End Cap (aqua) Titanium alloy* 8 mm diameter Locks distal most 6.0 mm titanium locking screw in place Protects nail threads from tissue ingrowth Sits flush with the distal end of the nail 450.896 Titanium End Cap, for Titanium Distal Femoral Nail * Titanium-6% aluminum-7% niobium alloy Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 31

Instruments 292.69 3.2 mm Calibrated Guide Wire, 300 mm 314.75 Hexagonal Screwdriver 315.40 4.0 mm Three-Fluted Drill Bit, 195 mm, quick coupling 321.25 Spanner Wrench 351.11 Large Reverse Awl 351.27 13.0 mm Cannulated Drill Bit, 300 mm 357.095 Connecting Screw 32 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Instruments 357.096 Aiming Arm, for 6.0 mm Titanium Locking Screws 357.097 8.0 mm/ 5.0 mm Drill Sleeve 357.098 5.0 mm Trocar 357.099 5.0 mm Three-Fluted Drill Bit, 330 mm, 100 mm calibration, quick coupling 357.111 Radiographic Ruler 357.112 Insertion Handle Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 33

Instruments 357.113 Locking Bolt Measuring Device 357.127 13.0 mm Protection Sleeve 357.128 13.0 mm/ 3.2 Trocar 357.22 Hammer Guide, for use with Slide Hammer (357.25) 357.25 Slide Hammer, for use with Hammer Guide (357.22) 357.76 11.0 mm/ 8.0 mm Protection Sleeve 34 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

Titanium Distal Femoral Nail Insertion and Locking Set With locking bolts (105.521) With locking screws (105.523) Graphic Case and Labels 304.545 Titanium Distal Femoral Nail Insertion and Locking Set Graphic Case 305.580 Graphic Case Labels, for 4.0 mm/5.0 mm Titanium Locking Screws (in set 105.523) Instruments (in both sets) 292.69 3.2 mm Calibrated Guide Wire, 300 mm, 5 ea. 314.75 Hexagonal Screwdriver 315.40 4.0 mm Three-Fluted Drill Bit, 195 mm, quick coupling, 2 ea. 321.25 Spanner Wrench 351.11 Large Reverse Awl 351.27 13.0 mm Cannulated Drill Bit, 300 mm 357.095 Connecting Screw 357.096 Aiming Arm, for 6.0 mm Titanium Locking Screws 357.097 8.0 mm/ 5.0 mm Drill Sleeve 357.098 5.0 mm Trocar 357.099 5.0 mm Three-Fluted Drill Bit, 330 mm, 100 mm calibration, quick coupling, 2 ea. 357.111 Radiographic Ruler 357.112 Insertion Handle 357.113 Locking Bolt Measuring Device 357.127 13.0 mm Protection Sleeve 357.128 13.0 mm/ 3.2 mm Trocar 357.22 Hammer Guide 357.25 Slide Hammer 357.76 11.0 mm/ 8.0 mm Protection Sleeve Note: For additional information, please refer to package insert. Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. For detailed cleaning and sterilization instructions, please refer to www.synthes.com/cleaning-sterilization or sterilization instructions, if provided. Titanium Distal Femoral Nail System Surgical Technique DePuy Synthes 35

Titanium Distal Femoral Nail Insertion and Locking Set With locking bolts (105.521) With locking screws (105.523) Implants (in both sets) 6.0 mm Titanium Locking Screws, 2 ea. Length (mm) 450.873 30 450.874 35 450.875 40 450.861 45 450.862 50 450.863 55 450.864 60 450.865 65 450.896 Titanium End Cap, 2 ea. Implants (in set 105.521) 4.9 mm Titanium Locking Bolts, 2 ea. Length (mm) 459.26 26 459.28 28 459.30 30 459.32 32 459.34 34 459.36 36 459.38 38 459.40 40 459.42 42 Implants (in set 105.523) 5.0 mm Titanium Locking Screws, 2 ea. Length (mm) 458.926 26 458.928 28 458.930 30 458.932 32 458.934 34 458.936 36 458.938 38 458.940 40 458.942 42 Length (mm) 450.866 70 450.867 75 450.868 80 450.869 85 450.870 90 450.871 95 450.872 100 Length (mm) 459.44 44 459.46 46 459.48 48 459.50 50 459.52 52 459.54 54 459.56 56 459.58 58 459.60 60 458.944 44 458.946 46 458.948 48 458.950 50 458.952 52 458.954 54 458.956 56 458.958 58 458.960 60 Length (mm) Also Available Sets 105.954 Small Battery Drive Set, with 14.4 V Battery 150.060 Flexible Reamer Set, for IM Nails Also Available Instruments 314.11 Holding Sleeve for Hexagonal Screwdriver (314.75) 351.71S 3.0 mm Reaming Rod, with offset ball tip, 950 mm, sterile 351.76S 3.0 mm Reaming Rod, with straight ball tip, 950 mm, sterile 355.006 Medullary Tube 355.041 3.0 mm Guide Rod, with smooth tip, 950 mm, sterile 393.10 Universal Chuck with T-Handle 394.35 Large Distractor 399.43 Hammer, 700 grams 511.30 Radiolucent Drive 511.417 4.0 mm Three-Fluted Drill Bit, brad point, 150 mm, for use with radiolucent drive Also Available Implants 450.701 9 mm Titanium Solid Distal Femoral Nails, 450.716 160 mm 460 mm (20 mm increments) 450.781 10 mm Titanium Solid Distal Femoral Nails, 450.796 160 mm 460 mm (20 mm increments) 450.801 11 mm Titanium Solid Distal Femoral Nails, 450.816 160 mm 460 mm (20 mm increments) 450.821 12 mm Titanium Solid Distal Femoral Nails, 450.836 160 mm 460 mm (20 mm increments) 450.841 13 mm Titanium Solid Distal Femoral Nails, 450.856 160 mm 460 mm (20 mm increments) 458.964 5.0 mm Titanium Locking Screws, 458.999 64 mm 80 mm (4 mm increments), 85 mm 100 mm (5 mm increments) 459.64 4.9 mm Titanium Locking Bolts, 459.100 64 mm 80 mm (4 mm increments), 85 mm 100 mm (5 mm increments) Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. 36 DePuy Synthes Titanium Distal Femoral Nail System Surgical Technique

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 19380 Synthes USA, LLC 1101 Synthes Avenue Monument, CO 80132 To order (USA): 800-523-0322 To order (Canada): 855-946-8999 Note: For recognized manufacturer, refer to the product label. www.depuysynthes.com DePuy Synthes 1997 2017. All rights reserved. DSUS/TRM/0916/1032 2/17 DV