LCP Pediatric Condylar Plate 90, 3.5 and 5.0. For distal femur osteotomies. Surgical Technique This publication is not intended for distribution in the USA.
Image intensifier control Warning This description alone does not provide sufficient background for direct use of DePuy Synthes products. Instruction by a surgeon experienced in handling these products is highly recommended. Processing, Reprocessing, Care and Maintenance For general guidelines, function control and dismantling of multi-part instruments, as well as processing guidelines for implants, please contact your local sales representative or refer to: http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance For general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, as well as processing of Synthes non-sterile implants, please consult the Important Information leaflet (SE_023827) or refer to: http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance
Table of Contents Introduction LCP Pediatric Condylar Plate System 2 AO Principles 4 Indications 5 Clinical Cases 6 Surgical Technique Preoperative Planning 8 Patient Positioning and Approach 10 Guide Wire Insertion 11 Osteotomy 17 Distal Fixation 19 Reduction 27 Proximal Fixation 28 Medialization 34 Product Information Implants 38 Instruments 43 LCP Pediatric Plate System Module Overview 55 Bibliography 56 MRI Information 57 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 1
LCP Pediatric Condylar Plate 90, 3.5 and 5.0. For distal femur osteotomies. LCP Pediatric Condylar Plate System LCP Pediatric Condylar Plates are specifically designed locking compression plates for osteotomies of the distal femur in children and adolescents. The LCP features incorporated are fixed angle locking screws in the metaphysis and combi holes for the diaphysis that allow a choice of locked or cortical screws. LCP Pediatric Condylar Plates 3.5 and 5.0 have a universal design for the left and right femur. Osteotomies for correction in every plane can be stabilized with these plates. The LCP Pediatric Condylar Plate belongs to the family of LCP Pediatric Hip Plates and requires that instrumentation for its use. 2 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Features and Benefits The LCP Pediatric Condylar Plate offers several advantages: Angular stability Reduces the risk of primary and secondary loss of correction. The angular stability eliminates the need for additional immobilization in the majority of cases. Easy and safe surgical technique Initial plate positioning with Kirschner wires allows easy adjustment with less bone damage. Medialization Medialization of the shaft can be achieved using the plate as an internal fixator, preventing golf club deformity of the distal femur. Anatomic design This plate fits the distal femur proximal to the growth plate allowing easy positioning. Low profile Plate design and locking construct minimize muscle disruption and reduce soft-tissue irritation. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 3
AO Principles Stable fixation The fixation of the LCP plate with angular stable screws reduces the risk of intra- and postoperative loss of correction in osteotomies. Preservation of blood supply The structure and nature of the pediatric periosteum allow blood supply to be maintained even if the periosteum is elevated. Early mobilization The use of LCP implants allows early and active mobilization, including cast-free postoperative management (3.5/5.0 system) in younger and handicapped children where appropriate. 4 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Indications This surgical technique focuses on the LCP Pediatric Condylar Plate 90, 3.5 and 5.0 for deformity correction in the distal femur in all planes with or without additional rotation correc tion. The LCP Pediatric Condylar Plate is intended for use in pediatric patients up to adolescence and for small-stature adult patients. Specific indications include: Fixed flexion contracture of knee in neurological conditions Deformity correction in the distal femur Rotational malalignment of the femur (if distal correction preferred) Supracondylar fractures of the femur Important: Make sure to choose the appropriate plate for the patient s age, size and bone quality. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 5
Clinical Cases Case 1 * Preoperative, AP 10 years old male with spastic diplegia. Preoperative, lateral Fracture of the inferior pole of the patella as a sign of high stress caused by fixed flexion contracture of 30. Postoperative, AP and lateral Anatomical position of the plate in AP view following supracondylar extending osteotomy with 30 of extension and 15 of external rotation shown in lateral view. This procedure was combined with patellar tendon shortening. Case 2 * Preoperative, AP and lateral 8 year old girl with arthrogryposis multiplex congenita and bilateral severe, fixed knee flexion deformity. Postoperative, AP and lateral Eight weeks after bilateral supracondylar 25 extension osteotomy with complete consolidation. 6 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Case 3 * Preoperative, AP and lateral 17 years old male with spastic diplegia and fixed flexion contracture of 25. Postoperative, AP and lateral Six weeks after bilateral supracondylar extension osteotomy of 25 and 20 of external rotation stable correction is shown. Postoperative, AP and lateral Complete consolidation after one year. * Images provide with permission from Prof. Dr Reinald Brunner and Dr Erich Rutz, MD Children s University Hospital of Basel, UKBB, Switzerland LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 7
Surgical Technique Preoperative Planning Preoperative planning of osteotomies of the distal femur is somewhat different from that for hip osteotomies. The principles, however, are identical: 1 Decide what corrections in what planes are required. This may be achieved by a combination of clinical examination, x-rays (for example long leg views for alignment), CT scans (to assess femoral torsion) or frequently through examination under anesthesia 2 Decide how the implant should be placed to achieve the correction e.g. bone wedges to be excised, opening wedges to be created (unusual in the distal femur due to the neurovascular structures), shortening of the femur required to relax for soft tissues (common in neurological disease with contracture) Note: The condylar plate is contoured such that distal screws will be at 90 to the midline of the shaft if the plate is fitted on the surface of the bone. Generally, the distal screws should be parallel to the growth plate in the coronal plane, although care must be taken to establish that there is no deformity of the distal fragment that would negate this assumption. 8 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Plate type This technique guide focuses on the LCP Pediatric Condylar Plates 3.5 and 5.0 and describes the options of axial corrections in the distal femur. The pictures represent the LCP Pediatric Condylar Plate 3.5 (corresponding to implant Art. No. 02.108.410). The surgical technique involves the use of screw holes where applicable. Please see the designation of each hole as indicated. The surgical technique described is based on a 30 extension and 30 external rotation osteotomy. 1 2 3 C A D B A, B, C: Distal locking screws D: Positioning Kirschner wire 1, 2 and 3: Locking or cortical screws LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 9
Patient Positioning and Approach 1 Positioning and preparation of the patient The operation is performed with the patient supine on a radiolucent table. The whole leg is prepared up to the inguinal region. Note: In difficult cases it may be advisable to prepare both legs to allow a visual check of both legs. 2 Approach A standard lateral approach to the distal femur reflecting the vastus lateralis anteriorly should be used. The level of the incision should be determined under image intensifier control. Tip: The use of a sterile tourniquet may facilitate the approach. 11 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Guide Wire Insertion 1 Localize the frontal plane of the distal femur Instrument 292.200 Kirschner Wire B 2.0 mm with trocar tip, length 150 mm, Stainless Steel After subperiosteal preparation of the distal femur, place a Kirschner wire extra-periosteally over the front of the femur 1 cm above the physis or by rotating the leg under image intensifier control until the patella is perfectly anterior and in the midline. Check the alignment of the Kirschner wire in the frontal plane. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 11
Guide Wire Insertion 2 Insert positioning Kirschner wire in hole D 1 Instruments for 3.5 mm plate 03.108.001 Aiming Block for Screws B 3.5 mm, for LCP Pediatric Hip Plates 03.108.006 Positioner for Aiming Block 292.790 Kirschner Wire B 2.0 mm with threaded tip, length 150/15 mm, Stainless Steel Instruments for 5.0 mm plate 03.108.002 Aiming Block for Screws B 5.0 mm, for LCP Pediatric Hip Plates 03.108.006 Positioner for Aiming Block 292.790 Kirschner Wire B 2.0 mm with threaded tip, length 150/15 mm, Stainless Steel Assemble the positioner and the aiming block accordingly (1). Localize distal femoral growth plate under image intensifier control. 2 The insertion point for the positioning Kirschner wire depends on the age and size of the patient. For the 3.5 mm plate insertion is 1.0 2.0 cm and the 5.0 mm plate 1.5 2.5 cm above the distal physis. Note: In extension osteotomy the insertion point will need to be more proximal and more posterior as the plane of the two distal screws will not be parallel to the physis in the sagittal view (2). 11 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Using the positioner/aiming block assembly to determine the angle for correction in the coronal (frontal) plane may prove difficult. This is because the cortex of the distal femur is at an angle to the line of the shaft due to the supracondylar flare. In the coronal (frontal) plane, the positioning wire is therefore inserted parallel to the physis and the positioner/ aiming block assembly is used to determine the angle of correction in the sagittal plane. 3 Insert the positioning Kirschner wire in the appropriate hole in the aiming block (hole D) so that it is parallel to the anterior surface orientation Kirschner wire and such that when the block is rotated for the correction in the sagittal plane there will be space for the main Kirschner wires that correspond to the screws (3; 4). When the positioning Kirschner wire is correctly positioned, remove the anterior orientation Kirschner wire. 4 30 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 11
Guide Wire Insertion 3 Insert Kirschner guide wires for distal screws Instruments for 3.5 mm plate 03.108.001 Aiming Block for Screws B 3.5 mm, for LCP Pediatric Hip Plates 03.108.005 Kirschner Wire B 2.8 mm with spade point tip 03.108.006 Positioner for Aiming Block 03.108.040 Adapter for Kirschner Wires B 2.8 mm, for LCP Pediatric Hip Plates 3.5/5.0 314.070 Screwdriver, hexagonal, small, B 2.5 mm, with Groove 333.080 Positioning Plate, triangular, length 45 mm, 100 /60 /20 333.070 Positioning Plate, triangular, length 45 mm, 80 /70 /30 333.060 Positioning Plate, triangular, length 45 mm, 90 /50 /40 Instruments for 5.0 mm plate 03.108.002 Aiming Block for Screws B 5.0 mm, for LCP Pediatric Hip Plates 03.108.005 Kirschner Wire B 2.8 mm with spade point tip 03.108.006 Positioner for Aiming Block 03.108.040 Adapter for Kirschner Wires B 2.8 mm, for LCP Pediatric Hip Plates 3.5/5.0 314.070 Screwdriver, hexagonal, small, B 2.5 mm, with Groove 333.080 Positioning Plate, triangular, length 45 mm, 100 /60 /20 333.070 Positioning Plate, triangular, length 45 mm, 80 /70 /30 333.060 Positioning Plate, triangular, length 45 mm, 90 /50 /40 11 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Rotate the aiming block and positioner into the correct position for the sagittal plane correction. This can be done by calculation but is more commonly achieved by placing the positioner in line with the tibia in the position of maximum achievable extension. 1 Insert the 2.8 mm Kirschner guide wires for plate holes A and B through the aiming block (1). LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 11
Guide Wire Insertion To prevent any interference with other wires, adjust the Kirschner wire adapter before inserting the Kirschner guide wire for hole B. (Insertion of wire for hole B shown in red in picture 2). 2 11 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Osteotomy Instrument 03.108.008 Positioner for Osteotomy 1 Level of the osteotomy The osteotomy needs to be at least 15 mm proximal to the aiming block for the 3.5 mm plate and 20 mm for the 5.0 mm plate. Make a mark with an oscillating saw (1). Important: Prior to cutting, the bone wires should be inserted to allow assessment and control of rotation. In the distal fragment the initial positioning wire is adequate. In the proximal fragment, a bicortical wire should be inserted such that it does not interfere with the osteotomy. It is helpful to calculate the rotational correction before inserting this wire so that after the osteotomy is fixed the wire lies parallel to the positioning wire in the distal fragment (2). If no rotational correction is planned, then clearly marking the femur with the saw may adequately control rotation. 2 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 11
Osteotomy The first cut of the osteotomy should be parallel to the Kirschner wires and sufficiently proximal to allow the third screw in hole C to gain adequate purchase (3). If considerable sagittal plane correction is planned then that must be taken into account. If the positioner for osteotomy is laid against the wires, this gives the minimum distance that will allow insertion of the screw in hole C. 3 4 Note: The cut is best made freehand under image intensifier control, keeping the blade parallel to the Kirschner wires in both planes. Opening wedge osteotomy can be used in deformity correction. It is generally not recommended when treating contracture in neurological conditions. A second cut to the osteotomy is therefore recommended in this situation and this should be made in the proximal fragment at a right angle to the line of the shaft in all planes (5). The size of the wedge is determined by preoperative planning and depending on the clinical situation. The resulting wedge is removed (6). Note: Before completing the distal cut, it is recommend to make the proximal cut to half the diameter of the bone (4). This guarantees optimal fit of both fragments after reduction. Note: Frequently some shortening is required, in which case the fragment of bone excised will be trapezoidal rather than wedge shaped. 5 6 11 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Distal Fixation 1 Position plate 1 Instruments for 3.5 mm plate 03.108.008 Positioner for Osteotomy 03.108.009 LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate Instruments for 5.0 mm plate 03.108.004 Reduction Sleeve 4.3/2.8 03.108.008 Positioner for Osteotomy 03.108.010 LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm, for LCP Pediatric Hip Plate Insert the drill sleeves into plate holes A and B until they are completely gripped by the thread. Slide the plate over the Kirschner guide wires and the positioning Kirschner wire (1;2). Note for 5.0 mm plate: An additional reduction sleeve must be inserted in each LCP drill sleeve before sliding the plate over the wires. 2 Note: Fixation in the distal fragment must always be done with locking screws. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 11
Distal Fixation 2 Determine screw length and insert distal femoral locking screws A and B 1 Instruments for 3.5 mm plate 03.108.003 Direct Measuring Device for Kirschner Wires B 2.8 mm, length 200 mm 03.108.008 Positioner for Osteotomy Instruments for 5.0 mm plate 03.108.003 Direct Measuring Device for Kirschner Wires B 2.8 mm, length 200 mm 03.108.004 Reduction Sleeve 4.3/2.8 03.108.008 Positioner for Osteotomy 310.430 LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling Determine the screw length by measuring the insertion depth of the Kirschner guide wire with the direct measuring device for Kirschner guide wires. Slide the appropriate end of the measuring device over the Kirschner wire against the LCP drill sleeve and determine the proper screw length (1). Remove the Kirschner wire and the LCP drill sleeve in hole A. If necessary, use the wrench at one end of the positioner for osteotomy (2). 2 Insert the screw in hole A (see step 3 for insertion options). 22 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Note for 5.0 mm plate: Remove the reduction sleeve and then measure the Kirschner wire length over the drill sleeve. Enlarge the hole from 2.8 to 4.3 mm with the LCP drill bit. Then remove the drill sleeve and insert the screw as above. Important: It is recommended to use a power tool to insert the self-tapping screw. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 22
Distal Fixation 3 Distal fixation Instruments for 3.5 mm plate 511.770 Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive 314.030 Screwdriver Shaft, hexagonal, small, B 2.5 mm 314.116 Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling 397.705 Handle for Torque Limiter Nos. 511.770 and 511.771 Instruments for 5.0 mm plate 511.771 Torque Limiter, 4 Nm, for Compact Air Drive and Power Drive 314.152 Screwdriver Shaft 3.5, hexagonal, self-holding 314.119 Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling 397.705 Handle for Torque Limiter Nos. 511.770 and 511.771 22 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Two options are available: Option A Manual insertion To insert the locking screw manually, attach the torque limiter handle corresponding to the plate size to the torque limiter and insert a screwdriver shaft. Insert the locking screw, and lock it in the plate. The optimum torque is reached after one click. 1 Option B Insertion with a power tool To insert the locking screw using a power tool, pick up the locking screw and insert it into the plate hole until the screw head is slightly above the plate. Do not fully tighten the screw with the power tool. Uncouple the power tool, fit the handle and tighten the screw manually. The optimum torque is reached after one click using the corresponding torque limiter. Insert the screw in hole B in the same way as in hole A (1;2). Note: Do not remove the positioning wire until the end of the proximal fixation. 2 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 22
Distal Fixation 4 Insert locking screw in hole C Instruments for 3.5 mm plate 310.284 LCP Drill Bit B 2.8 mm with Stop, length 165 mm, 2-flute, for Quick Coupling 03.108.009 LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate 319.010 Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm 511.770 Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive 314.030 Screwdriver Shaft, hexagonal, small, B 2.5 mm 314.116 Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling 397.705 Handle for Torque Limiter Nos. 511.770 and 511.771 Instruments for 5.0 mm plate 310.430 LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling 03.108.010 LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm, for LCP Pediatric Hip Plate 319.100 Depth Gauge for Screws B 4.5 to 6.5 mm, measuring range up to 110 mm 511.771 Torque Limiter, 4 Nm, for Compact Air Drive and Power Drive 314.152 Screwdriver Shaft 3.5, hexagonal, self-holding 314.164 Screwdriver Stardrive 4.5/5.0, T25, with Groove, length 240 mm 397.705 Handle for Torque Limiter Nos. 511.770 and 511.771 22 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Mount the LCP drill sleeve onto hole C and drill the hole with the LCP drill bit through both cortices. Either read off the screw length from the calibrated drill or determine the screw length with the depth gauge (1). 1 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 22
Distal Fixation Insert the screw in hole C (2;3). 2 3 22 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Reduction Instruments 399.121 Bone Holding Forceps, self-centering, soft lock, length 239 mm 1 399.124 Reduction Forceps, toothed, soft lock, length 250 mm Reduce the plate onto the femoral shaft and check the alignment on the image intensifier (1;2). Decide whether medialization will be required. Check visually that the plate is parallel to the shaft in the sagittal plane. 2 Important: After reduction, the initial positioning wire in the distal fragment lies parallel to the bicortical wire in the proximal part to achieve correct axial alignment (3). Note: If medialization is required, follow the steps as described on pages 34 37. 3 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 22
Proximal Fixation Since this is an LCP plate, either locking or cortical screws can be used. After a locking screw has been inserted into in the proximal fragment it is not permissible to insert a cortical screw; locking screws can however be inserted after cortical screws. Option A: Proximal fixation with locking screws Insert screws in holes 1, 2 and 3. Instruments for 3.5 mm plate 314.030 Screwdriver Shaft, hexagonal, small, B 2.5 mm 314.116 Screwdriver Shaft Stardrive, 3.5, T15, self-holding, for AO/ASIF Quick Coupling 319.010 Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm 511.770 Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive 397.705 Handle for Torque Limiter Nos. 511.770 and 511.771 03.108.009 LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate 310.284 LCP Drill Bit B 2.8 mm with Stop, length 165 mm, 2-flute, for Quick Coupling Instruments for 5.0 mm plate 314.152 Screwdriver Shaft 3.5, hexagonal, self-holding 314.119 Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling 319.100 Depth Gauge for Screws B 4.5 to 6.5 mm, measuring range up to 110 mm 03.108.010 LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm, for LCP Pediatric Hip Plate 310.430 LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling 511.771 Torque Limiter, 4 mm, for Compact Air Drive and Power Drive 397.705 Handle for Torque Limiter Nos. 511.770 and 511.771 22 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Drill the screw hole 3 over the LCP drill sleeve using an appropriate drill bit. Either read off the screw length from the calibrated drill or determine the screw length with the depth gauge (1;2). 1 2 Insert screw in hole 3 (3). 3 LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 22
Proximal Fixation Repeat this step for screw insertion in holes 1 and 2 (4). Then remove the initial positioning wire in the distal fragment and the bicortical positioning wire in the proximal part. 4 33 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Option B: Proximal fixation with cortical screws Insert screws in holes 1, 2 and 3. Instruments for 3.5 mm plate 310.250 Drill Bit B 2.5 mm, length 110/85 mm, 2-flute, for Quick Coupling 314.070 Screwdriver, hexagonal, small, B 2.5 mm, with Groove 314.030 Screwdriver Shaft, hexagonal, small, B 2.5 mm 314.041 Screwdriver Stardrive 3.5, T15, with Groove, length 200 mm 314.116 Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling 319.010 Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm 312.280 Double Drill Guide 3.5/2.5 323.360 Universal Drill Guide 3.5 Instruments for 5.0 mm plate 310.310 Drill Bit B 3.2 mm, length 145/120 mm, 2-flute, for Quick Coupling 314.270 Screwdriver, hexagonal, large, B 3.5 mm, with Groove, length 245 mm 314.152 Screwdriver Shaft 3.5, hexagonal, self-holding 314.164 Screwdriver Stardrive 4.5/5.0, T25, with Groove, length 240 mm 314.119 Screwdriver Shaft Stardrive 4.5 /5.0, T25, self-holding, for AO/ASIF Quick Coupling 312.460 Double Drill Guide 4.5/3.2 319.100 Depth Gauge for Screws B 4.5 to 6.5 mm, measuring range up to 110 mm 323.460 Universal Drill Guide 4.5 /3.2, for neutral and load position LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 33
Proximal Fixation If cortical screw fixation is selected, this is generally because compression at the osteotomy site is desired. Using the spring-loaded drill guide without pressing the guide down on the plate, place the drill hole as proximally as possible in the combi-hole to achieve compression when the screw is tightened (1). 1 33 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Choose the appropriate size drill bit. Measure the screw length with the depth gauge and place a self-tapping cortex screw in hole 1. 2 Repeat this step for screw insertion in holes 2 and 3. Then remove the initial positioning wire in the distal fragment and the bicortical positioning wire in the proximal part. (2) LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 33
Medialization Note: In order to facilitate medialization, locking screws must be used throughout. Instruments for 3.5 mm plate 314.030 Screwdriver Shaft, hexagonal, small, B 2.5 mm 314.116 Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling 319.010 Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm 511.770 Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive 03.108.007 Instrument for medialization 03.108.009 LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate 310.284 LCP Drill Bit B 2.8 mm with Stop, length 165 mm, 2-flute, for Quick Coupling 397.705 Handle for Torque Limiter Nos. 511.770 and 511.771 399.124 Reduction Forceps, toothed, soft lock, length 250 mm 399.098 Reduction Forceps, toothed, soft lock, length 194 mm Instruments for 5.0 mm plate 314.152 Screwdriver Shaft 3.5, hexagonal, self-holding 314.119 Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling 319.100 Depth Gauge for Screws B 4.5 to 6.5 mm, measuring range up to 110 mm 511.771 Torque Limiter, 4 Nm, for Compact Air Drive and Power Drive 03.108.007 Instrument for medialization 03.108.010 LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm, for LCP Pediatric Hip Plate 310.430 LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling 397.705 Handle for Torque Limiter Nos. 511.770 and 511.771 399.124 Reduction Forceps, toothed, soft lock, length 250 mm 399.098 Reduction Forceps, toothed, soft lock, length 194 mm 33 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Attach the medialization instruments to holes 1 and 3. Turn the knob on the bars until the required amount is protruding. Then screw an LCP drill sleeve into LCP hole 2. Reduce the plate to the shaft of the femur until complete contact of the bars of the medialization device with the bone is achieved and hold it with the reduction forceps (1). 1 Drill the screw hole and remove the drill sleeve. Determine the screw length with the depth gauge and insert a locking screw (2). 2 Check the position throughout under image intensifier guidance to ensure satisfactory reduction and medialization. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 33
Medialization After the screw in hole 2 is securely fixed, remove the instrument for medialization in hole 1 and insert a drill sleeve. Predrill the screw hole and remove the drill sleeve. Determine the screw length with the depth gauge and insert a locking screw. Repeat step two for hole 3 (3). 3 Note: Tighten the screws manually with the torque limiter. 33 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Additional medialization (if required) If the mechanical axis is not in line, additional medialization is required. 1. Remove screws in holes 1 and 3 2. Loosen screw in hole 2 if already inserted. It may be necessary to use a longer screw 3. Place positioning plates (triangles) over holes 1 and 3 to prevent protrusion of the bar into the pre-existing holes. 4. Further adjust the knob on both medialization instruments in holes 1 and 3 to the new correction level. 5. Tighten screw in hole 2. 6. Add screws 1 and 3. Note: Should the correction not turn out as planned, further correction may be achieved by re-positioning locking screws in the proximal fragment to correct unintended deviation. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 33
Product Information Implants Product range of LCP Pediatric Plates The product range consists of different plate sizes: LCP Pediatric Hip Plates 2.7 LCP Pediatric Hip Plates 3.5 and 5.0 LCP Pediatric Condylar Plates 3.5 and 5.0 Available sterile or unsterile packed For proximal femur Plates for varus osteotomies (2.7, 3.5 and 5.0) The plates are available with screw angles of 100 or 110, 130 and 2 (2.7) or 3 (3.5 / 5.0) distal fixation screws. Plates for valgization osteotomies (3.5 and 5.0) The plates are available with a screw angle of 140 and 3 distal fixation screws. Plates for fractures and rotation osteotomies (3.5 and 5.0) The plates are available with a screw angle of 130 and 3, 5, 7 or 9 distal fixation screws. For distal femur Plates for fractures and deformities (3.5 and 5.0) The plates are available with a screw angle of 90 and 3, 5 or 7 distal fixation screws. Overview of available technique guides: LCP Pediatric Hip Plate 3.5 and 5.0 for varus osteotomies (Art. No.036.001.073) LCP Pediatric Hip Plate 2.7 for varus osteotomies (Art. No.036.001.060) LCP Pediatric Hip Plate 3.5 and 5.0 for fracture treatment and rotation correction (Leaflet) (Art. No. 036.001.063) LCP Pediatric Hip Plate Straight Valgus 3.5 and 5.0 for valgus osteotomies (Art. No. 036.001.057) LCP Pediatric Condylar Plate 3.5 and 5.0 for distal femoral osteotomies (Art. No. 036.001.065) 33 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
For proximal femur Plates for varus osteotomies 02.108.300 LCP Pediatric Hip Plate 2.7, 100, width 12 mm, length 46 mm 02.108.301 LCP Pediatric Hip Plate 2.7, 110, width 12 mm, length 46 mm 02.108.310 LCP Pediatric Hip Plate 3.5, 100, width 19 mm, length 73 mm 02.108.320 LCP Pediatric Hip Plate 5.0, 100, width 23 mm, length 90 mm 02.108.311 LCP Pediatric Hip Plate 3.5, 110, width 19 mm, length 73 mm 02.108.321 LCP Pediatric Hip Plate 5.0, 110, width 23 mm, length 90 mm Plate for valgization osteotomy 02.108.316 LCP Pediatric Hip Plate 3.5, 140, straight, width 19 mm, length 70 mm 02.108.326 LCP Pediatric Hip Plate 5.0, 140, straight, width 23 mm, length 90 mm LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 39
Implants Plates for fractures and derotation osteotomies 02.108.303 LCP Pediatric Hip Plate 2.7, 130, width 12 mm, length 46 mm 02.108.330 LCP Pediatric Hip Plate 3.5, 130, width 19 mm, length 62 mm 02.108.340 LCP Pediatric Hip Plate 5.0, 130, width 23 mm, length 79 mm 02.108.331 LCP Pediatric Hip Plate 3.5, 130, width 19 mm, length 88 mm 02.108.341 LCP Pediatric Hip Plate 5.0, 130, width 23 mm, length 111 mm 02.108.332 LCP Pediatric Hip Plate 3.5, 130, width 19 mm, length 114 mm 02.108.342 LCP Pediatric Hip Plate 5.0, 130, width 23 mm, length 143 mm 02.108.333 LCP Pediatric Hip Plate 3.5, 130, width 19 mm, length 140 mm 02.108.343 LCP Pediatric Hip Plate 5.0, 130, width 23 mm, length 175 mm 40 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
For distal femur Plates for supracondylar fractures and deformities 02.108.410 LCP Pediatric Condylar Plate 3.5, 90, shaft 3 holes 02.108.420 LCP Pediatric Condylar Plate 5.0, 90, shaft 3 holes 02.108.411 LCP Pediatric Condylar Plate 3.5, 90, shaft 5 holes 02.108.421 LCP Pediatric Condylar Plate 5.0, 90, shaft 5 holes 02.108.412 LCP Pediatric Condylar Plate 3.5, 90, shaft 7 holes 02.108.422 LCP Pediatric Condylar Plate 5.0, 90, shaft 7 holes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 41
Implants Screw overview Cortex screws, self-tapping, stainless steel 202.866 Cortex Screws Stardrive B 2.7 mm, 202.969 lengths 6 60 mm 204.816 Cortex Screws B 3.5 mm, 204.860 lengths 16 60 mm 02.200.016 Cortex Screws Stardrive B 3.5 mm, 02.200.070 self-tapping, lengths 16 70 mm 214.818 Cortex Screws B 4.5 mm, self-tapping, 214.870 lengths 18 70 mm Locking screws, self-tapping, stainless steel 202.206 Locking Screws Stardrive B 2.7 mm 202.260 (head LCP 2.4), lengths 6 60 mm 213.016 Locking Screws B 3.5 mm, 213.060 lengths 16 60 mm 212.104 Locking Screws Stardrive B 3.5 mm, 212.124 lengths 16 60 mm 213.318 Locking Screws B 5.0 mm, 213.375 lengths 18 75 mm 212.203 Locking Screws Stardrive B 5.0 mm, 212.224 lengths 18 75 mm All implants are also available sterile packed. Add Suffix S to part number. 44 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Instruments Aiming Blocks 03.108.033 Aiming Block for Screws B 2.7 mm, for LCP Pediatric Hip Plates 2.7 03.108.001 Aiming Block for Screws B 3.5 mm, for LCP Pediatric Hip Plates 03.108.002 Aiming Block for Screws B 5.0 mm, for LCP Pediatric Hip Plates Positioners for Aiming Blocks 03.108.034 Positioner for Aiming Block, for LCP Pediatric Hip Plates 2.7 03.108.006 Positioner for Aiming Block LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 43
Instruments Positioners for Osteotomy 03.108.039 Positioner for Osteotomy, for LCP Pediatric Hip Plates 2.7 03.108.008 Positioner for Osteotomy 44 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Drill Sleeves and Reduction Sleeve 03.108.036 LCP Drill Sleeve 2.7, for Drill Bits B 2.0 mm, for LCP Pediatric Hip Plates 2.7 03.108.009 LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate 03.108.010 LCP Drill Sleeve 5.0, for Drill Bits B 4.3 mm, for LCP Pediatric Hip Plate 03.108.004 Reduction Sleeve 4.3/ 2.8 03.108.037 Direct Measuring Device for Kirschner Wires B 2.0 mm, for LCP Pediatric Hip Plates 2.7 03.108.003 Direct Measuring Device for Kirschner Wires B 2.8 mm, length 200 mm LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 45
Instruments Positioning Wires, Guide Wires and Adapter 292.200 Kirschner Wire B 2.0 mm with trocar tip, length 150 mm, Stainless Steel 292.790 Kirschner Wire B 2.0 mm with threaded tip, length 150 / 15 mm, Stainless Steel 292.650 Guide Wire B 2.0 mm with threaded tip with trocar, length 230 mm, Stainless Steel 03.108.005 Kirschner Wire B 2.8 mm with spade point tip 03.108.040 Kirschner Wire Adaptor 46 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Drill Bits 323.062 Drill Bit B 2.0 mm, with double marking, length 140/115 mm, 3-flute, for Quick Coupling 310.284 LCP Drill Bit B 2.8 mm with Stop, length 165 mm, 2-flute, for Quick Coupling 310.250 Drill Bit B 2.5 mm, length 110/85 mm, 2-flute, for Quick Coupling 310.280 Drill Bit B 2.7 mm, length 125/100 mm, 2-flute, for Quick Coupling 310.310 Drill Bit B 3.2 mm, length 145/120 mm, 2-flute, for Quick Coupling 310.430 LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 47
Instruments Drill Guides 312.240 Double Drill Guide 2.7/2.0 323.260 Universal Drill Guide 2.7 323.360 Universal Drill Guide 3.5 312.280 Double Drill Guide 3.5/2.5 312.460 Double Drill Guide 4.5/3.2 48 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Depth Gauges 319.010 Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm 03.503.036 Depth Gauge for MatrixMANDIBLE, measuring range from 6 to 40 mm 319.100 Depth Gauge for Screws B 4.5 to 6.5 mm, measuring range up to 110 mm LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 49
Instruments Screwdrivers and Screwdriver shafts 314.070 Screwdriver, hexagonal, small, B 2.5 mm, with Groove 313.302 Screwdriver Stardrive, T8, cylindrical, with Groove, shaft B 3.5 mm 314.041 Screwdriver Stardrive 3.5, T15, with Groove, length 200 mm 314.164 Screwdriver Stardrive 4.5/5.0, T25, with Groove, length 240 mm 314.270 Screwdriver, hexagonal, large, B 3.5 mm, with Groove, length 245 mm 50 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
313.304 Screwdriver Shaft Stardrive, T8, cylindrical, with Groove, shaft B 3.5 mm, for AO/ASIF Quick Coupling 314.030 Screwdriver Shaft, hexagonal, small, B 2.5 mm 314.116 Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling 314.119 Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling 314.152 Screwdriver Shaft 3.5, hexagonal, self-holding LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 51
Instruments Bone Holding Forceps and Reduction Forceps 399.091 Bone Holding Forceps, self-centering, soft lock, length 191 mm 399.121 Bone Holding Forceps, self-centering, soft lock, length 239 mm 399.098 Reduction Forceps, toothed, soft lock, length 194 mm 399.124 Reduction Forceps, toothed, soft lock, length 250 mm 55 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
Torque Limiters 03.110.005 Handle for Torque Limiters 0.4/0.8/1.2 Nm 397.705 Handle for Torque Limiter Nos. 511.770 and 511.771 511.776 Torque Limiter, 0.8 Nm, with AO/ASIF Quick Coupling 511.770 Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive 511.771 Torque Limiter, 4 Nm, for Compact Air Drive and Power Drive LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 53
Instruments Positioning Plates 333.060 Positioning Plate, triangular, length 45 mm, 90 /50 /40 333.070 Positioning Plate, triangular, length 45 mm, 80 /70 /30 333.080 Positioning Plate, triangular, length 45 mm, 100 /60 /20 Others 03.108.007 Instrument for Medialization 313.300 Combined Holding Sleeve for Cortex Screws Stardrive B 2.4/2.7 mm, T8, for Screwdriver Shafts B 3.5 mm 54 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
LCP Pediatric Plate System Module Overview Modules for implants, standard 68.108.032 Modular Tray for LCP Pediatric Plates 2.7, size 1/2, without Contents, Vario Case System 68.108.030 Modular Tray for LCP Pediatric Plates 3.5, size 1/2, without Contents, Vario Case System 68.108.031 Modular Tray for LCP Pediatric Plates 5.0, size 1/2, without Contents, Vario Case System Modules for instruments, standard 68.108.041 Modular Tray for Instruments for LCP Pediatric Plates 2.7, size 1/2, without Contents, Vario Case System Labeling clips 68.108.033 Labeling Clip for LCP Pediatric Plates 3.5, Vario Case System 68.108.034 Labeling Clip for LCP Pediatric Plates 5.0, Vario Case System 68.108.035 Labeling Clip for LCP Pediatric Plates 2.7, Vario Case System 68.108.043 Labeling Clip for Instruments for LCP Pediatric Plates 3.5 and 5.0, Vario Case System 68.108.044 Labeling Clip for Instruments for LCP Pediatric Plates 2.7, Vario Case System 68.108.045 Labeling Clip for General Instruments, for LCP Pediatric Plates 3.5 and 5.0, Vario Case System 68.108.040 Modular Tray for Instruments for LCP Pediatric Plates 3.5 and 5.0, size 1/1, without Contents, Vario Case System 68.108.042 Modular Tray for General Instruments, for LCP Pediatric Plates 3.5 and 5.0, size 1/1, without Contents, Vario Case System LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 55
Bibliography Kay M.R., Rethlefsen P.T., Hale J.M, Skaggs D., Tolo V. (2003) J of Pediatric Orthopaedics 23: 150-154. Comparison of Proximal and Distal Rotational Femoral Osteotomy in Children with Cerebral Palsy. Mortazavi S.M.J., Heidari P., Esfandiari H., Motamedi M. (2008). J of Haemophilia 4, 85-90. Trapezoid supracondylar femoral extension osteotomy for knee flexion contractures in patients with haemophilia. Oppenheim W.L., Fischer S.R., Salusky I. (1997). J of Pediatric Orthopaedics 17: 41-49. Surgical Correction of Angular Deformity of the Knee in Children with Renal Osteodystrophy. Piripiris M., Trivett A., Baker R., Rodda J., Nattrass G.R., Graham H.K. (2003). J of Bone and Joint Surgery Vol 85-B. No. 2. Femoral derotation osteotomy in spastic diplegia. Proximal or Distal? Hefti F et al. (1998) Kinderorthopädie in der Praxis. Berlin Heidelberg New York: Springer Morrissy RT, Weinstein SL (2001) Atlas of Pediatric Orthopedic Surgery. Philadelphia: Williams & Wilkins-Verlag Müller M.E., Schneider R. et al., AO manual of internal fixation. 3rd Edition ed. 1991, Berlin-Heidelberg-New York: Springer. 55 DePuy Synthes LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique
MRI Information Torque, Displacement and Image Artifacts according to ASTM F 2213-06, ASTM F 2052-06e1 and ASTM F2119-07 Non-clinical testing of worst case scenario in a 3 T MRI system did not reveal any relevant torque or displacement of the construct for an experimentally measured local spatial gradient of the magnetic field of 3.69 T/m. The largest image artifact extended approximately 169 mm from the construct when scanned using the Gradient Echo (GE). Testing was conducted on a 3 T MRI system. Radio-Frequency-(RF-)induced heating according to ASTM F2182-11a Non-clinical electromagnetic and thermal testing of worst case scenario lead to peak temperature rise of 9.5 C with an average temperature rise of 6.6 C (1.5 T) and a peak temperature rise of 5.9 C (3 T) under MRI Conditions using RF Coils [whole body averaged specific absorption rate (SAR) of 2 W/kg for 6 minutes (1.5 T) and for 15 minutes (3 T)]. Precautions: The above mentioned test relies on non-clinical testing. The actual temperature rise in the patient will depend on a variety of factors beyond the SAR and time of RF application. Thus, it is recommended to pay particular attention to the following points: It is recommended to thoroughly monitor patients undergoing MR scanning for perceived temperature and/or pain sensations. Patients with impaired thermo regulation or temperature sensation should be excluded from MR scanning procedures. Generally it is recommended to use a MR system with low field strength in the presence of conductive implants. The employed specific absorption rate (SAR) should be reduced as far as possible. Using the ventilation system may further contribute to reduce temperature increase in the body. LCP Pediatric Condylar Plate 90, 3.5 and 5.0 Surgical Technique DePuy Synthes 55
DSEM/TRM/0815/0458 09/15 Synthes GmbH Eimattstrasse 3 4436 Oberdorf Switzerland Tel: +41 61 965 61 11 Fax: +41 61 965 66 00 www.depuysynthes.com This publication is not intended for distribution in the USA. All surgical techniques are available as PDF files at www.depuysynthes.com/ifu 0123 DePuy Synthes Trauma, a division of Synthes GmbH. 2015. All rights reserved. 036.001.065