Dual-Opening USS. For deformity correction.

Dual-Opening USS. For deformity correction. Technique Guide Instruments and implants approved by the AO Foundation

Table of Contents Introduction Dual-Opening USS 2 AO Principles 4 Indications 5 Preoperative Planning 6 Surgical Technique Hook Placement 7 Pedicle Preparation 10 Screw Insertion 13 Rod Contouring 15 Construct Assembly 18 Distraction and Compression 23 Final Construct Tightening 25 Transconnector Attachment 27 Transverse Bar Attachment (optional) 28 Anterior Approach 29 Product Information Implants 30 Instruments 32 Set List 39 Image intensifier control Synthes

Dual-Opening USS. For deformity correction. Goals of Scoliosis Surgery Correct sagittal and coronal alignment Restore balance in the spine Prevent further progression of deformity Fuse the fewest number of vertebral segments Protect the spinal cord The Dual-Opening USS is designed to achieve the goals of scoliosis surgery. The system is based upon: Independent anchorage of hooks and/or screws to the spine and independent rod positioning Simple connection between the implant and the rod Segmental correction and stabilization Preoperative Postoperative 2 Synthes Dual-Opening USS Technique Guide

Features and Benefits Low-profile system Dual-opening (side), top-tightening Reduces inventory Simplifies intraoperative procedure Technique adaptable Designed to correct scoliosis either by segmental translation or global derotation Versatile linkage mechanism Allows addition or removal of anchor points to an assembled construct Synthes 3

AO Principles In 1958, the AO formulated four basic principles, 1 which have become the guidelines for internal fixation. They are: Anatomic reduction Stable internal fixation Preservation of blood supply Early, active mobilization The fundamental aims of fracture treatment in the limbs and fusion of the spine are the same. A specific goal in the spine is returning as much function as possible to the injured neural elements. 2 AO Principles as Applied to the Spine 3 Anatomic alignment Restoration of normal spinal alignment to improve the biomechanics of the spine. Stable internal fixation Stabilization of the spinal segment to promote bony fusion. Preservation of blood supply Creation of an optimal environment for fusion. Early, active mobilization Minimization of damage to the spinal vasculature, dura, and neural elements, which may contribute to pain reduction and improved function for the patient. 1. M.E. Müller, M. Allgöwer, R. Schneider, H. Willenegger: Manual of Internal Fixation, 3rd Edition. Berlin; Springer-Verlag. 1991. 2. Ibid. 3. M. Aebi, J.S. Thalgott, J.K. Webb. AO ASIF Principles in Spine Surgery. Berlin; Springer-Verlag. 1998. 4 Synthes Dual-Opening USS Technique Guide

Indications The Synthes USS are non-cervical spinal fixation devices intended for posterior pedicle screw fixation (T1-S2/ilium), posterior hook fixation (T1-L5), or anterolateral fixation (T8-L5). Pedicle screw fixation is limited to skeletally mature patients with the exception of the Small Stature USS, which includes small stature and pediatric patients. These devices are indicated as an adjunct to fusion for all of the following indications: degenerative disc disease (defined as discogenic back pain with degeneration of the disc confirmed by history and radiographic studies), spondylolisthesis, trauma (i.e., fracture or dislocation), deformities or curvatures (i.e., scoliosis, kyphosis, and/or lordosis, Scheuermann s Disease), tumor, stenosis, and failed previous fusion (pseudoarthrosis). When treating patients with Degenerative Disc Disease (DDD), transverse bars are not cleared for use as part of the posterior pedicle screw construct. Synthes USS 6.0 mm Rod Systems: USS Side-Opening, USS Dual- Opening, USS VAS variable axis components, USS Fracture, Click X, Click X Monoaxial, Pangea, Pangea Monoaxial, USS Polyaxial, USS Iliosacral, ClampFix 5.5 mm Rod System: Matrix 5.0 mm Rod System: USS Small Stature CerviFix 3.5 mm Rod Systems: CerviFix, Axon, Synapse 4.0 mm Rod System: Synapse Please refer to product insert GPOOO1 for complete system description, indications, contraindications, precautions and warnings. When used with the 3.5/6.0 mm parallel connectors, the Synthes USS 6.0 mm rod systems can be linked to the CerviFix 3.5 mm systems. In addition, when used with 3.5/5.0 mm parallel connectors, the Synthes Small Stature USS can be linked to the CerviFix 3.5 mm systems. When used with the 5.0/6.0 mm parallel connectors, the Synthes Small Stature USS can be linked to the Synthes USS 6.0 mm rod systems. When used with the 3.5/6.0 mm and 4.0/6.0 mm tapered rods, the Synthes USS 6.0 mm rod systems can be linked to the CerviFix 3.5 mm and 4.0 mm systems, respectively. When used with the 3.5/5.5 mm and 4.0/5.5 mm tapered rods, Matrix can be linked to the CerviFix 3.5 mm and 4.0 mm systems, respectively. When used with the 5.5/6.0 mm tapered rods, the Synthes USS 6.0 mm rod systems can be linked to the Matrix System. In addition, Synthes USS 6.0 mm rod systems can be in terchanged with all USS 6.0 mm rods and transconnectors except Synthes 6.0 mm cobalt-chromium-molybdenum alloy and titanium grade 3 rods, which can only be used with Pangea. Synthes 5

Preoperative Planning Preoperative planning is critical in the preparation for spinal surgery. Dual-Opening USS Preoperative Planner A radiographic evaluation (AP and lateral standing, and AP and lateral bending) should be completed for proper diagnosis prior to surgical intervention. Additional evaluation, such as CT scans, may be required. Posterior View Dual-Opening Hooks * Lamina Hooks Tall Body Lamina Hooks Side-opening Front-opening Side-opening Front-opening x99.287 Small x99.270 x99.271 Small x99.286 Medium x99.288 x99.289 Medium x99.272 x99.273 Large x99.290 x99.291 Large x99.274 x99.275 A preoperative planner may be used to plan the hook and screw layout. Thoracic Lamina Hooks x99.276, Side-opening x99.277, Front-opening Angled Lamina Hooks x99.284, Side-opening x99.285, Front-opening Pedicle Hooks x99.278, Side-opening x99.279, Front-opening Right Left Transverse Process Hooks, Right x99.280, Side-opening x99.282, Front-opening Transverse Process Hooks, Left x99.281, Side-opening x99.283, Front-opening Dual-Opening Screws * 4.2 mm Screws Length x99.201 25 mm x99.202 28 mm x99.203 30 mm x99.204 32 mm x99.205 35 mm x99.206 38 mm x99.207 40 mm 7.0 mm Screws Length x99.230 30 mm x99.231 35 mm x99.232 40 mm x99.233 45 mm x99.234 50 mm x99.235 55 mm x99.236 60 mm x99.237 65 mm 5.2 mm Screws Length x99.210 25 mm x99.211 30 mm x99.212 35 mm x99.213 40 mm x99.214 45 mm x99.215 50 mm x99.216 55 mm 8.0 mm Screws Length x99.240 30 mm x99.241 35 mm x99.242 40 mm x99.243 45 mm x99.244 50 mm x99.245 55 mm x99.246 60 mm x99.247 65 mm x99.248 70 mm x99.249 75 mm x99.250 80 mm 6.2 mm Screws Length x99.220 30 mm x99.221 35 mm x99.222 40 mm x99.223 45 mm x99.224 50 mm x99.225 55 mm x99.226 60 mm x99.227 65 mm 9.0 mm Screws Length x99.260 35 mm x99.261 40 mm x99.262 45 mm x99.263 50 mm x99.264 55 mm x99.265 60 mm x99.266 65 mm x99.267 70 mm x99.268 75 mm x99.269 80 mm * Implants are available in both Stainless Steel and Titanium. Replace X with a 2 for Stainless Steel or 4 for Titanium. Illustrations not shown actual size. SYNTHES Spine 2002 Original Instruments and Implants of the Association for the Study of Internal Fixation AO/ASIF SYNTHES and ASIF are registered trademarks of SYNTHES (USA) and SYNTHES AG Chur. Printed in U.S.A GP1549A J3852A 6/02 6 Synthes Dual-Opening USS Technique Guide

Hook Placement 1a Prepare lamina for lamina hook Instrument 388.521 Lamina Finder, for dual-opening hooks Use the lamina finder to separate the ligamentum flavum from the underside of the lamina to ensure good bony contact with the lamina hook. 1b Prepare pedicle for pedicle hook Instrument 388.511 Pedicle Finder, for dual-opening hooks Using the pedicle finder, open the facet capsule and locate the pedicle. Remove a small piece of the inferior articular process to ensure proper seating of the pedicle hook (up-going only). Synthes 7

Hook Placement 2 Place hook Instruments 388.612 Hook/ Screw Holder, with 4.0 mm hex ( Hex Stick ) 388.622 Handle, for Hook/Screw Holder with 4.0 mm hex 388.631 Hook Positioner, for dual-opening implants Insert the hook/screw holder ( Hex Stick ) into the appropriate hook and secure with the coupling screw. Snap the Hex Stick into the handle by depressing the button on the handle. Place the hook in the desired location. The hook positioner may also be used to facilitate placement of the hook. After the hook is properly seated, remove the handle. The Hex Stick can remain attached to the hook. 8 Synthes Dual-Opening USS Technique Guide

3 Place remaining hooks Repeat Steps 1 and 2 to place hooks at each hook site, as determined in the preoperative plan. Optional technique for hook placement Instrument 388.523 Hook Holding Forceps, for dual-opening implants Attach the appropriate hook to the hook holding forceps and place the hook in the desired location. The hook positioner may be used to facilitate placement of the hook. After the hook is properly seated, remove the hook holding forceps and repeat hook placement at each hook site as determined in the preoperative plan. Synthes 9

Pedicle Preparation 1 Identify pedicles The point of entry for each thoracic pedicle is at the intersection of a line through the transverse process and a line through the inferolateral edge of the facet joint. The entry point for each lumbar pedicle is at the intersection of a horizontal line bisecting the transverse process and a vertical line drawn along the lateral border of the superior articular process. 10 Synthes Dual-Opening USS Technique Guide

2 Prepare pedicle Instruments 388.539 Pedicle Probe, for 7.0 mm, 8.0 mm, and 9.0 mm screws or 388.54 Pedicle Probe, for 5.2 mm and 6.2 mm screws or 388.544 Pedicle Probe, for 4.2 mm screws 388.545 Straight Ball Tip Probe or 388.546 Curved Ball Tip Probe 388.55 Awl, for 5.2 mm 9.0 mm screws or 388.551 Awl, for 4.2 mm screws Use the awl to perforate the posterior cortex of the pedicle (Figure 1). Figure 1 Figure 2 Open the pedicle canal using the appropriate pedicle probe (Figure 2). Displace the soft cancellous bone by advancing the probe into the pedicle canal. Use radiographic imaging to check position and orientation. Care should be taken to not perforate the walls of the pedicle. Palpate the walls of the pedicle using a ball tip probe. Synthes 11

Pedicle Preparation 3 Select proper screw length Instruments 388.608 Pedicle Marker, beaded 388.609 Pedicle Marker, long beaded Place the ball tip probe into the pedicle canal to determine proper screw length. This instrument has depth markings at 25 mm, 30 mm, 40 mm, 50 mm, 60 mm, and 70 mm. Position all screws approximately 50 80% into the vertebral body. 4 Pedicle markers may be used during radiographic imaging to confirm position and orientation. 4. Müller, op cit. p. 668. 12 Synthes Dual-Opening USS Technique Guide

Screw Insertion Screw insertion Instruments 388.612 Hook /Screw Holder, with 4.0 mm hex ( Hex Stick ) 388.622 Handle, for Hook/Screw Holder with 4.0 mm hex Insert the Hex Stick into the appropriate dual-opening screw and secure with the coupling screw. Snap the Hex Stick into the handle by depressing the button on the handle. Insert the dual-opening screw into the prepared pedicle. After the screw has been inserted, remove the handle by depressing the button, leaving the Hex Stick in place, if desired. Synthes 13

Screw Insertion Optional methods of screw insertion Instruments 388.335 4.0 mm Hex Screwdriver 388.337 4.0 mm Hexagonal Screwdriver Shaft 388.38 Holding Sleeve, for Screwdriver for side-opening implant 388.653 Ratchet Handle, with 5.0 mm drive The 4.0 mm hexagonal screwdriver may also be used for screw insertion. The ratchet handle, or handle for the hook/screw holder with 4.0 hex, used with the 4.0 mm hexagonal screwdriver shaft offers an alternative method for screw insertion. The holding sleeve may be used with either the screwdriver or the screwdriver shaft to retain the screw during initial insertion into the pedicle. 14 Synthes Dual-Opening USS Technique Guide

Rod Contouring 1 Determine rod contour Instruments 388.902 Coated Rod Template for 6.0 mm Rod, 150 mm or 388.905 Coated Rod Template for 6.0 mm Rod, 500 mm Once the screws and hooks have been placed and their positions confirmed radiographically, determine the contour of the rod by using the appropriate 6.0 mm coated rod template. Synthes 15

Rod Contouring 2 Cut rod to length (if necessary) Instruments 388.750 Table Top Rod Cutter and Bender 388.751 Handheld Rod Cutter, for 4.0 mm, 5.0 mm and 6.0 mm rods Adjust the rod length using the optional table top rod cutter or the handheld rod cutter. All rod cutting should take place outside the operative field. 16 Synthes Dual-Opening USS Technique Guide

3 Contour rod Instruments 388.961 Rod Bender or 329.052 Bending Iron, right, for 6.0 mm rods and 329.053 Bending Iron, left, for 6.0 mm rods Contour the rod to match the rod template using the rod bender or the bending irons. Alternatively, the table top rod cutter and bender may be used to contour the rod. Synthes 17

Construct Assembly 1 Align rod to hooks and screws Instruments 388.449 Rod Holding Forceps, for dual-opening implants 388.94 Rod Pusher, for 6.0 mm rods Position the rod parallel to the side opening of the screws and hooks using the rod holding forceps. Introduce the rod into the side-opening screw or hook, using the rod pusher. 18 Synthes Dual-Opening USS Technique Guide

2 Apply collars and nuts Instruments 388.159 Socket Wrench with Straight Handle, 11 mm, for 12-Point Nut 388.162 Holding Sleeve, for Straight Handle Socket Wrench Assemble holding sleeve to the straight handled socket wrench. Load a collar and nut into the assembly by placing the wrench on top of the nut and collar, which have been stacked onto the loading posts in the graphic case. Advance the holding sleeve to engage the collar. Note: The collar can be loaded in only one direction. Place the instrument over the head of the implant and seat both the collar and the nut. Tighten the nut using the socket wrench. Synthes 19

Alternative Methods for Construct Assembly Option 1 Using the collar positioner with the Hex Stick Instruments 388.151 Collar Positioner, for dual-opening implants 388.612 Hook/ Screw Holder, with 4.0 mm hex ( Hex Stick ) 388.755 Collar Impactor Load a collar for 6.0 mm rods into the collar positioner. Note: The collar can be loaded in only one direction. With the Hex Stick inserted in the hook or screw, place the loaded collar over the head of the implant to seat the collar. If light impaction of the collar is necessary for final seating, remove the collar positioner and use the collar impactor with a small mallet. Place a 12-point nut over the construct and tighten, using the socket wrench. Option 2 Using the Persuader with the Hex Stick 1 Load collar Instrument Collar 388.509 Rod Introduction Pliers ( Persuader ), for dual-opening implants Load a collar onto the barrel of the rod introduction pliers ( Persuader ). Note: The collar can be loaded on the Persuader in only one direction. 20 Synthes Dual-Opening USS Technique Guide

2 Engage rod Instruments 388.410 Distraction Forceps, curved 388.615 Distraction Clip, side, for Hook/ Screw Holder Position the barrel of the Persuader over the Hex Stick and slide it down to the implant. Engage the rod with the jaws opposite the barrel of the Persuader and squeeze the handle to insert the rod into the hook or screw. If biplanar reduction of the rod is necessary, use the distraction clip and the distraction forceps with the Persuader to guide the rod into the hook or screw opening. Place the distraction clip over the Hex Stick. Use the distraction forceps against the distraction clip while squeezing the Persuader until the rod is seated into the hook or screw. Synthes 21

Alternative Methods for Construct Assembly 3 Seat collar Instruments 388.158 Socket Wrench with L-Handle, 11 mm, for 12-Point Nut or 388.159 Socket Wrench with Straight Handle, 11 mm, for 12-Point Nut 388.631 Hook Positioner, for dual-opening implants Use the hook positioner to tap the collar retaining sleeve and seat the collar onto the implant assembly. Once the collar is pushed down over the implant, remove the distraction clip (if necessary) and the Persuader. Place a 12-point nut over the construct and tighten with the socket wrench. 22 Synthes Dual-Opening USS Technique Guide

Distraction and Compression If necessary, grasp the rod with the rod holding forceps and slowly rotate the rod in the proper direction. Make sure all nuts are loose before rotating the rod. 1 Determine point of fixation Instruments 388.449 Rod Holding Forceps, for dual-opening implants 298.911/ USS Half Ring (stainless steel or titanium) 498.911 Use the rod holding forceps or half ring as a point of fixation, if necessary, against which to distract or compress. 2 If distraction is required Instruments 388.159 Socket Wrench with Straight Handle, 11 mm, for 12-Point Nut 388.410 Distraction Forceps, curved Use the distraction forceps for 6.0 mm rods. Make sure all nuts are loose before distracting against the point of fixation. Once in the desired position, tighten the nuts using a socket wrench. Synthes 23

Distraction and Compression 3 If compression is required Instruments 388.159 Socket Wrench with Straight Handle, 11 mm, for 12-Point Nut 388.422 Compression Forceps Use the compression forceps. Make sure all nuts are loose before compressing against the point of fixation. Once in the desired position, tighten the nuts using a socket wrench. 24 Synthes Dual-Opening USS Technique Guide

Final Construct Tightening The torque indicator wrench and socket adapter for torque indicator wrench can be used for final construct tightening. The torque indicator wrench and socket adapter are used with the 4.0 mm hexagonal screwdriver shaft and ratchet handle, which are used to apply countertorque. Option 1 Applying countertorque using the 4.0 mm hexagonal screwdriver Instruments 388.134 Torque Indicator Wrench 388.160 Adapter, 12 points, for Wrench with Torque Indicator 388.337 4.0 mm Hexagonal Screwdriver Shaft 388.653 Ratchet Handle Place the torque indicator wrench and adapter over the 12-point nut. Insert the 4.0 mm hexagonal screwdriver shaft with ratchet handle through the torque indicator wrench and adapter and into the hexagonal socket of the hook or screw. Hold the ratchet handle stationary and turn the torque indicator wrench clockwise to secure the nut. The torque indicator wrench deflects to indicate the desired torque. Recommended tightening is from 10 Nm to 12 Nm. The torque indicator wrench is calibrated to 12 Nm. The 4.0 mm hexagonal screwdriver can also be used to provide countertorque with the torque indicator wrench. Synthes 25

Final Construct Tightening Option 2 Applying countertorque using the 5 mm socket wrench and Hex Stick Instruments 388.145 Socket Wrench with T-handle, 5 mm hex 388.158 Socket Wrench with L-Handle, 11 mm, for 12-Point Nut 388.612 Hook/ Screw Holder, with 4.0 mm hex ( Hex Stick ) Place the L-handle socket wrench over the Hex Stick and engage the 12-point nut. Insert the 5 mm T-handle socket wrench through the L-handle socket wrench to engage the 5 mm hex on the Hex Stick. Hold the T-handle wrench stationary and turn the L-handle socket wrench clockwise to secure the nut. 26 Synthes Dual-Opening USS Technique Guide

Transconnector Attachment The low profile transconnector is used as a construct stabilizer to reduce rotation. 1 Measure distance between rods Instrument 388.865 Measuring Template, for Low Profile Transconnectors for 6.0 mm Rods Use the measuring template to measure the distance between the two rods. 2 Secure transconnector to rods Instrument 314.070 Small Hexagonal Screwdriver Loosen all setscrews and place a low profile transconnector of the appropriate length onto the rods. Use the small hexagonal screwdriver to secure the transconnector to the rods by tightening the setscrews on each end. Note: For transconnectors with stargrind, tighten the stargrind setscrew to lock the angle between the rods. When using an adjustable length transconnector, adjust the distance between the rods, if desired, by compressing or distracting; then tighten the center setscrew on the rotating shaft using the small hexagonal screwdriver. Note: If any part of the construct requires further adjustment, all transconnector setscrews must be loosened. After final adjustment, retighten the setscrews. Synthes 27

Transverse Bar Attachment (optional) The transverse bar acts as an extension to the hook or screw in situations where the rod contour or patient anatomy prevents direct hook/ screw-to-rod connection. The bar lengths are 15 mm, 20 mm, and 25 mm. Placement of transverse bar Instruments 314.070 Small Hexagonal Screwdriver 388.94 Rod Pusher, for 6.0 mm rods Place the opening of the transverse bar over the 6.0 mm rod. Loosely attach the transverse bar to the rod by tightening the setscrew with the small hexagonal screwdriver. Introduce the transverse bar into the front-opening hook or screw. Use the rod pusher if necessary. Use a collar with grooves and a 12-point nut to secure the bar to the hook or screw. Secure the bar to the rod by tightening the setscrew firmly. 28 Synthes Dual-Opening USS Technique Guide

Anterior Approach Staples (5.0 mm, 6.0 mm, and 7.0 mm) and washers can be used to provide secure anchorage for anterolateral constructs. Insert staple Instruments 385.807 Staple Impactor 388.755 Collar Impactor For the 5.0 mm staple, use the collar impactor to seat the staple. For the 6.0 mm and 7.0 mm staples, use the staple impactor to position the staple on the anterolateral aspect of the thoracolumbar spine, to accommodate optimal screw placement. Drive the tips through the cortical bone and seat the staple using the impactor and a small mallet. Final construct Insert the screws through the staples or washers. Use the other implants (rod, collars, and nuts) to complete the construct. Synthes 29

Implants Hooks Dual-opening design allows rod attachment from either side of the hook Multiple hook profiles for use around the lamina, pedicle or transverse process Specialized lamina hooks for thoracic and lumbar applications Low-profile design to minimize soft tissue interference Pedicle hook Lamina hook Angled lamina hook Thoracic lamina hook Transverse process hook 11.5 mm Hard Rods 6.0 mm diameter 150 mm 500 mm lengths, in 50 mm increments Collars and Nuts Screws and hooks are secured to a 6.0 mm rod by collars and nuts Collars capture the rod, yet permit longitudinal adjustments along the rod before tightening Collars with grooves are available for use with transverse bars 12-point nuts secure the construct Collar 12-point nut Collar with grooves Screws Dual-opening design simplifies intraoperative rod-to-screw assembly Dual-core thread design Constant outer diameter optimizes pull-out strength Core diameter transitions to provide cancellous and cortical bone-specific threads Rounded tip promotes safe screw insertion Self-tapping tip Double-lead thread for easy insertion Available in 4.2 mm, 5.2 mm, 6.2 mm, 7.0 mm, 8.0 mm, and 9.0 mm diameters, and thread lengths from 25 mm to 80 mm 30 Synthes Dual-Opening USS Technique Guide

Low Profile Transconnectors Used as a construct stabilizer to reduce rotation Preassembled for ease of placement Available in four fixed lengths (15 mm, 18 mm, 21 mm, and 24 mm) and five adjustable lengths (25.5 mm 83 mm) Adjustable length Fixed length Center shaft allows 45 rotation about the horizontal axis Stargrind Transverse Bars Provide a lateral extension from the 6.0 mm rod to the hook or screw Used with screws and front-opening hooks Available in lengths of 15 mm, 20 mm and 25 mm Eliminate the need for severe rod contours which might otherwise be required for direct hook/screw-to-rod connection Parallel Connectors The 6.0 mm/6.0 mm Parallel Connector is available for extending Dual-Opening USS constructs The 5.0 mm/ 6.0 mm Parallel Connector allows attachment to Small Stature USS constructs The 3.5 mm/6.0 mm Parallel Connector permits attachment of the Dual-Opening USS to the CerviFix System (available in titanium only) 6.0 mm/6.0 mm 5.0 mm/6.0 mm 3.5 mm/6.0 mm Staples and Washers Provide secure anchorage for anterolateral constructs in the thoracolumbar spine Three sizes of staples for use with 5.2 mm, 6.2 mm and 7.0 mm screws Synthes 31

Instruments Taps for Dual Core Screws 311.601 4.2 mm 311.602 5.2 mm 311.603 6.2 mm 311.604 7.0 mm 311.605 8.0 mm 311.606 9.0 mm Cannulated Taps for Dual Core Screws 311.611 4.2 mm 311.612 5.2 mm 311.613 6.2 mm 311.614 7.0 mm 311.615 8.0 mm 311.616 9.0 mm 314.070 Small Hexagonal Screwdriver Bending Irons, for 6.0 mm rods, 329.052 right 329.053 left 385.807 Staple Impactor, for 6.0 mm 8.0 mm staples 32 Synthes Dual-Opening USS Technique Guide

388.134 Torque Indicator Wrench 388.145 Socket Wrench with T-Handle, 5 mm hex 388.151 Collar Positioner, for dual-opening implants 388.158 Socket Wrench with L-Handle, for 12-point nut 388.159 Socket Wrench, for 12-point nut 388.160 Adapter, 12-points, for Wrench with Torque Indicator Synthes 33

Instruments 388.162 Holding Sleeve, for Straight Handle Socket Wrench 388.274 Universal Spinal System Tap Handle 388.335 4.0 mm Hexagonal Screwdriver 388.337 4.0 mm Hexagonal Screwdriver Shaft 388.363 USS Holding Sleeve, for Pre-Assembled Transconnector Clamp 388.38 Holding Sleeve, for Screwdriver for side-opening implants 34 Synthes Dual-Opening USS Technique Guide

388.410 Distraction Forceps, curved, for 6.0 mm rods 388.422 Compression Forceps, for 6.0 mm rods 388.449 Rod Holding Forceps, for 6.0 mm rods 388.509 Rod Introduction Pliers, for dual-opening implants ( Persuader ) Synthes 35

Instruments 388.511 Pedicle Finder, for dual-opening hooks 388.521 Lamina Finder, for dual-opening hooks 388.523 Hook Holding Forceps, for dual-opening implants Pedicle Probes 388.539 For 7.0 mm, 8.0 mm, and 9.0 mm screws 388.54 For 5.2 mm and 6.2 mm screws 388.544 For 4.2 mm screws Ball Tip Probes 388.545 Straight 388.546 Curved Awl 388.55 For 5.2 mm 9.0 mm screws 388.551 For 4.2 mm screws 36 Synthes Dual-Opening USS Technique Guide

Pedicle Markers 388.608 beaded 388.609 long beaded 388.612 Hook/Screw Holder, with 4.0 mm hex ( Hex Stick ) 388.615 Distraction Clip, side, for hook/ screw holder 388.622 Handle, for hook/ screw holder with 4.0 mm hex 388.631 Hook Positioner, for dual-opening implants 388.653 Ratchet Handle Synthes 37

Instruments 388.755 Collar Impactor 388.865 Measuring Template, for Low Profile Transconnector for 6.0 mm Rods Coated Rod Templates for 6.0 mm Rod 388.902 150 mm 388.905 500 mm 388.94 Rod Pusher, for 6.0 mm rods 388.961 Rod Bender, with bend radius adjustment 38 Synthes Dual-Opening USS Technique Guide

Dual-Opening USS Instrument and Implant Sets Stainless Steel (105.127) and Titanium (145.127) Graphic Case 690.043 Graphic Case for Dual-Opening USS Rod Instrument Set Instruments 314.070 Small Hexagonal Screwdriver 329.052 Bending Iron, right, for 6.0 mm rods 329.053 Bending Iron, left, for 6.0 mm rods 385.807 Staple Impactor, for 6.0 mm 8.0 mm staples 388.134 Torque Indicator Wrench 388.145 Socket Wrench with T-Handle, 5 mm hex 388.151 Collar Positioner, for dual-opening implants, 2 ea. 388.158 Socket Wrench with L-Handle, 11 mm, for 12-Point Nut 388.159 Socket Wrench with Straight Handle, 11 mm, for 12-Point Nut, 2 ea. 388.160 Adapter, 12-points, for Wrench with Torque Indicator 388.162 Holding Sleeve, for Straight Handle Socket Wrench, 2 ea. 388.363 USS Holding Sleeve, for Pre-Assembled Transconnector Clamp 388.410 Distraction Forceps, curved 388.422 Compression Forceps 388.449 Rod Holding Forceps, for dual-opening implants, 2 ea. 388.509 Rod Introduction Pliers ( Persuader ), for dual-opening implants, 2 ea. 388.615 Distraction Clip, side, for Hook/ Screw Holder, 2 ea. 388.755 Collar Impactor 388.865 Measuring Template, for Low Profile Transconnectors for 6.0 mm Rods 388.902 Coated Rod Template for 6.0 mm Rod, 150 mm, 2 ea. 388.905 Coated Rod Template for 6.0 mm Rod, 500 mm, 2 ea. 388.94 Rod Pusher, for 6.0 mm rods 388.961 Rod Bender 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 39

Dual-Opening USS Instrument and Implant Sets Stainless Steel (105.127) and Titanium (145.127) Graphic Case 690.044 Graphic Case for Dual-Opening USS Hook and Screw Instrument Set Instruments Tap for Dual Core Screws 311.601 4.2 mm 311.602 5.2 mm 311.603 6.2 mm 311.604 7.0 mm 311.605 8.0 mm 311.606 9.0 mm Cannulated Tap for Dual Core Screws 311.611 4.2 mm 311.612 5.2 mm 311.613 6.2 mm 311.614 7.0 mm 311.615 8.0 mm 311.616 9.0 mm 388.274 Universal Spinal System Tap Handle 388.335 4.0 mm Hex Screwdriver 388.337 4.0 mm Hex Screwdriver Shaft 388.38 Holding Sleeve, for Screwdriver for side-opening implants 388.511 Pedicle Finder, for dual-opening hooks 388.521 Lamina Finder, for dual-opening hooks 388.523 Hook Holding Forceps, for dual-opening implants, 2 ea. Pedicle Probes 388.539 For 7.0 mm, 8.0 mm, and 9.0 mm screws 388.54 For 5.2 mm and 6.2 mm screws 388.544 For 4.2 mm screws 388.545 Straight Ball Tip Probe 388.546 Curved Ball Tip Probe 388.608 Pedicle Marker, beaded, 5 ea. 388.609 Pedicle Marker, long beaded, 5 ea. 388.612 Hook/ Screw Holder, with 4.0 mm hex ( Hex Stick ), 16 ea. 388.622 Handle, for Hook/Screw Holder with 4.0 mm hex, 2 ea. 388.631 Hook Positioner, for dual-opening implants 388.653 Ratchet Handle, with 5.0 mm drive Awl 388.55 For 5.2 mm 9.0 mm screws 388.551 For 4.2 mm screws 40 Synthes Dual-Opening USS Technique Guide

Graphic Case 690.045 Graphic Case for Dual-Opening USS Hook and Rod Implant Set Implants Small Lamina Hooks, dual-opening Stainless Steel Titanium Description Qty. 299.270 499.270 side 8 299.271 499.271 frontal 2 Medium Lamina Hooks, dual-opening Stainless Steel Titanium Description Qty. 299.272 499.272 side 8 299.273 499.273 frontal 2 Large Lamina Hooks, dual-opening Stainless Steel Titanium Description Qty. 299.274 499.274 side 8 299.275 499.275 frontal 2 Thoracic Lamina Hooks, dual-opening Stainless Steel Titanium Description Qty. 299.276 499.276 side 4 299.277 499.277 frontal 2 Pedicle Hooks, dual-opening Stainless Steel Titanium Description Qty. 299.278 499.278 side 10 299.279 499.279 frontal 2 Transverse Process Hooks, dual-opening Stainless Steel Titanium Description Qty. 299.280 499.280 side, right 4 299.281 499.281 side, left 4 299.282 499.282 frontal, right 2 299.283 499.283 frontal, left 2 Synthes 41

Dual-Opening USS Instrument and Implant Sets Stainless Steel (105.127) and Titanium (145.127) Implants continued Angled Lamina Hook, dual-opening Stainless Steel Titanium Description Qty. 299.284 499.284 side 4 299.285 499.285 frontal 2 Small Tall Body Lamina Hooks, dual-opening Stainless Steel Titanium Description Qty. 299.286 499.286 side 2 299.287 499.287 frontal 2 Medium Tall Body Lamina Hooks, dual-opening Stainless Steel Titanium Description Qty. 299.288 499.288 side 2 299.289 499.289 frontal 2 Large Tall Body Lamina Hooks, dual-opening Stainless Steel Titanium Description Qty. 299.290 499.290 side 2 299.291 499.291 frontal 2 6.0 mm Hard Rods Stainless Steel Titanium Length (mm) Qty. 298.106 498.106 150 2 298.108 498.108 200 2 298.110 498.110 250 2 298.112 498.112 300 4 298.114 498.114 350 4 298.116 498.116 400 2 298.118 498.118 450 2 298.119 498.119 500 2 12-Point Nut Stainless Steel Titanium Length (mm) Qty. 299.294 499.294 11 30 Low Profile Transconnectors, for 6.0 mm rods Stainless Steel Titanium Length (mm) Qty. 297.791 497.791 15 2 297.792 497.792 18 2 297.793 497.793 21 3 297.794 497.794 24 3 297.795 497.795 25.5 30.5 4 297.796 497.796 31.5 34.0 3 297.797 497.797 35.0 41.0 3 297.798 497.798 42.0 55.0 2 297.799 497.799 56.0 83.0 2 Parallel Connectors, 2 ea. Stainless Steel Titanium Length (mm) 498.960 3.5/6.0 298.160 498.160 6.0/6.0 298.162 498.162 5.0/6.0 6.0 mm Transverse Bars, 2 ea. Stainless Steel Titanium Length (mm) 299.295 499.295 15 299.296 499.296 20 299.297 499.297 25 Collars for 6.0 mm Rods Stainless Steel Titanium Description Qty. 299.292 499.292 25 299.293 499.293 With Grooves 4 42 Synthes Dual-Opening USS Technique Guide

Graphic Case 690.046 Graphic Case for Dual-Opening USS Screw Implant Set Implants Dual-Opening Screws Dia. Thread Stainless Steel Titanium (mm) Length (mm) Qty. 299.210 499.210 5.2 25 4 299.211 499.211 5.2 30 6 299.212 499.212 5.2 35 6 299.213 499.213 5.2 40 4 299.214 499.214 5.2 45 4 299.215 499.215 5.2 50 4 299.216 499.216 5.2 55 4 299.220 499.220 6.2 30 4 299.221 499.221 6.2 35 6 299.222 499.222 6.2 40 8 299.223 499.223 6.2 45 8 299.224 499.224 6.2 50 6 299.225 499.225 6.2 55 4 299.226 499.226 6.2 60 4 299.227 499.227 6.2 65 4 299.230 499.230 7.0 30 4 299.231 499.231 7.0 35 6 299.232 499.232 7.0 40 8 299.233 499.233 7.0 45 8 299.234 499.234 7.0 50 6 299.235 499.235 7.0 55 4 299.236 499.236 7.0 60 4 299.237 499.237 7.0 65 4 299.240 499.240 8.0 30 2 299.241 499.241 8.0 35 4 299.242 499.242 8.0 40 4 299.243 499.243 8.0 45 4 299.244 499.244 8.0 50 4 299.245 499.245 8.0 55 2 299.246 499.246 8.0 60 2 299.247 499.247 8.0 65 2 299.248 499.248 8.0 70 2 299.249 499.249 8.0 75 2 299.250 499.250 8.0 80 2 Washers, 4 ea. Stainless Steel Titanium For Screw Dia. Outer Dia. 298.035 498.035 5.0 16 298.036 498.036 6.0 16 298.037 498.037 7.0 16 298.038 498.038 8.0 16 298.045 498.045 5.0 18 298.046 498.046 6.0 18 298.047 498.047 7.0 18 298.048 498.048 8.0 18 Staples, 4 ea. Stainless Steel Titanium 298.301 498.301 for 5.2 mm screws 298.302 498.302 for 6.2 mm screws 298.303 498.303 for 7.0 mm screws Synthes 43

Also Available 105.128 Dual-Opening USS Implant Set 105.129 Dual-Opening USS Instrument Set 145.128 Dual-Opening USS Titanium Implant Set 03.602.042 12 Nm Torque Limiting Wrench 388.652 Ratchet T-Handle, 6 mm hex coupling 388.750 Table Top Rod Cutter and Bender 388.751 Handheld Rod Cutter, for 4.0 mm, 5.0 mm and 6.0 mm rods USS Preassembled Transconnector Clamp Stainless Steel Titanium 298.813 498.813 USS Half Ring, for 6.0 mm rods Stainless Steel Titanium 298.911 498.911 Low Profile Transconnectors, for 6.0 mm rods Stainless Steel Titanium Length (mm) 02.620.203 04.620.203 33 36.5 02.620.204 04.620.204 38.5 48 02.620.205 04.620.205 49 69 Dual-Opening Screws* Stainless Steel Titanium Thread Dia. Length (mm) 299.201 499.201 4.2 25 299.202 499.202 4.2 28 299.203 499.203 4.2 30 299.204 499.204 4.2 32 299.205 499.205 4.2 35 299.206 499.206 4.2 38 299.207 499.207 4.2 40 299.260 499.260 9.0 35 299.261 499.261 9.0 40 299.262 499.262 9.0 45 299.263 499.263 9.0 50 299.264 499.264 9.0 55 299.265 499.265 9.0 60 299.266 499.266 9.0 65 299.267 499.267 9.0 70 299.268 499.268 9.0 75 299.269 499.269 9.0 80 * May be stored in Graphic Case 690.046 44 Synthes Dual-Opening USS Technique Guide

Synthes Spine 1302 Wrights Lane East West Chester, PA 19380 Telephone: (610) 719-5000 To order: (800) 523-0322 Fax: (610) 251-9056 Synthes (Canada) Ltd. 2566 Meadowpine Boulevard Mississauga, Ontario L5N 6P9 Telephone: (905) 567-0440 To order: (800) 668-1119 Fax: (905) 567-3185 www.synthes.com 2002 Synthes, Inc. or its affiliates. All rights reserved. CerviFix and Synthes are trademarks of Synthes, Inc. or its affiliates. Printed in U.S.A. 5/11 J3985-G