38829 zimmer (page 1)ncb distal femoral plating system surgical technique 99 if a cortical screw is...

The right locking option for tough fractures

NCB® DistalFemoral Plating

System

Surgical Technique

Disclaimer This document is intended exclusively for experts in the field, i.e. physicians in particular, and is expressly not for the information of laypersons.The information on the products and/or procedures contained in this document is of a general nature and does not represent medical advice or recommendations. Since this information does not constitute any diagnostic or therapeutic statement with regard to any individual medical case, individual examination and advising of the respective patient are absolutely necessary and are not replaced by this document in whole or in part.The information contained in this document was gathered and compiled by medical experts and qualified Zimmer employees to the best of their knowledge. The greatest care was taken to ensure the accuracy and ease of understanding of the information used and presented. Zimmer does not assume any liability, however, for the up-to-dateness, accuracy, completeness or quality of the information and excludes any liability for tangible or intangible losses that may be caused by the use of this information.In the event that this document could be construed as an offer at any time, such offer shall not be binding in any event and shall require subsequent confirmation in writing.

3NCB Distal Femoral Plating System Surgical Technique

NCB Plating System –Distal FemoralSurgical Technique

Table of Contents

Indications 4

Patient Positioning 4

Open Technique

Incision 5

Reduction 5

Optional: Bone spacers 6

Insertion of the NCB Plate 6

Insertion of the NCB Screws 7

Tips and Pearls 10

Zimmer® MISTM Technique

Incision 11

Aiming arm assembly for insertion 11

Insertion of the NCB Plate 11

Reduction of the metaphyseal bone part 12

Insertion of the NCB Screws in the shaft 14

Implant Removal 17

Ordering Information

Implants 18

Sterilization Cases 20

Instruments 21

Planning Template 25

4 NCB Distal Femoral Plating System Surgical Technique

Indications

NCB Plating System is indicatedfor the temporary internalfixation and stabilization offractures and osteotomies in thedistal femur• Extra-articular or distal diaphyseal

fractures

• Complete intra-articular fracturesincluding cases with related coronalfractures

• Periprosthetic fractures

• Osteotomies

Note: Before operation it is recommendedto conduct a preoperative planningusing the X-ray template (REF 06.01240.000).

Patient PositioningLay the patient in supine position on aradiolucent table. Support the knee, butallow the leg to move freely. Make surethat a true lateral X-ray of the femur canbe obtained in this position. Avoid strongtraction and a completely extended kneebecause forces of the gastrocnemiusmuscle may generate hyperextension ofthe distal fragment.

To lessen the forces of the gastrocnemius,flex the leg approximately 20-40°.

X-ray template REF 06.01240.000


Open Technique

IncisionA lateral incision is recommended. Theskin incision starts at Gerdy’s tubercle andgoes on in a proximal direction to exposethe fracture zone (Fig. 1). The muscles areleft attached to the fracture fragmentsfor optimal blood supply. Do not strip the periosteum.

ReductionFor intra-articular fracture an arthrotomyis performed to anatomically reduce thejoint line.

Temporarily fix the bone fragments with2.0mm K-wires. Position the K-wires sothey will not interfere with the finalposition of the plate (Fig. 2).

Fig. 1

Fig. 2


Optional: Bone spacersBone spacers can be used in thediaphysis to avoid the contact of theplate with the bone surface. The spacersare available in sizes of 1mm, 2mm or3mm. Two of the blue 2mm spacers areusually used. Insert the appropriatebone spacers into the plate before plate insertion (Fig. 3).

The bone spacers allow the surgeon to apply screw compression as in conventional plating technique. Thisallows to use the plate for indirectfracture reduction and to obtain a feeling for the bone quality. The spacers can be removed after locking of the screws.

Insertion of the NCB plateInsert the plate between the vastuslateralis muscle and the periosteum.Keep the proximal end in continouscontact with the bone surface duringinsertion. Place the distal end of theplate against the lateral condyle.

Note: The plate is anatomically shapedto closely follow the shape of the bone.

Temporarily fix the plate with 2mm K-wires at both ends of the plate (Figs. 4 & 5).

3mm

2mm

1mm

Fig. 3

Fig. 4

Fig. 5


Insertion of the NCB screwsTwo screw types are offered with the NCBSystem. Cancellous screws are preferred for the epi- and metaphysis and corticalbone screws for system placement in thediaphysis.

For cancellous screws place the NCBDrill Guide 2.5mm into the plate hole and point toward the direction of thescrew axis.

Press the Drill Guide into the plate holein a perpendicular start position and tiltit into the needed direction. The DrillGuide needs to be in constant contactwith the bottom ring of the hole. The DrillGuide limits the possible angular rangeof 30° for placing a locked NCB Screw(Fig. 6). Use of the Drill Guide will helpprevent the choice of a screw angle outside the 30° cone.

Drill with the 2.5mm drill bit (Fig. 7). Ifthe bone is of good bone quality, it isrecommended to drill the near cortexwith a 4.3mm drill bit. Remove the DrillSleeve for this purpose.

The appropriate screw length isdetermined with the NCB Depth Gauge(Fig. 8).

Fig. 6

Fig. 7

Fig. 8


Insert the NCB Cancellous Screws usingthe NCB Torque-Limiting Screwdriver,6Nm and apply compression (Fig. 9).Cancellous screws are partially threadedand can be used for compression (Fig. 10).

In the epiphyseal and metaphysealarea screws should be tightened toreduce the fracture and to obtain close contact between the plate and thebone in order to buttress the fracture.

Remove the K-wire after screw insertion.

To lock the screw insert the LockingScrew Cap and tighten the screw withthe NCB Torque-Limiting Screwdriver,6Nm until a clicking sound is heard fromthe handle of the Torque Screwdriver(Fig. 11).

Fig. 9

Fig. 10

Fig. 11


If a cortical screw is used, use the NCB Drill Guide and drill with thedrill bit 4.3mm (Fig. 12). Drill throughboth cortices. In the case of hard corticalbone, tap the cortex with the 5mm tap.

Insert the NCB Screw using the NCB Torque Screwdriver, 6Nm (Fig. 13).

To lock the screw proceed as for thecancellous screws: insert the LockingScrew Cap and tighten the screw withthe NCB Torque-Limiting Screwdriver,6Nm until a clicking sound is heard fromthe handle of the Torque Screwdriver.

In the diaphyseal area bone spacerscan be used to prevent close contact.After locking of the screws the spacersshould be removed.

For the placement of additional screws,repeat steps above (Fig. 14).

Fig. 12

Fig. 13

Fig. 14


Tips and Pearls

The polyaxiality of the system allowssome varus/valgus correction duringsurgery.

For this purpose insert four screws asshown in the figure without tighteningthe screws. Place the two distal screwsanterior and posterior.

Now the fracture can be reduced byrotation around the bone axis of theproximal fragment and varus/valguscorrection of the distal fragment.

Confirm a satisfactory alignment withthe image intensifier and lock thescrews using the locking screws.

Afterwards complete the reduction byadding additional screws where needed.

When inserting locking screw caps, turn the screwdriver and cap counter-clockwise initially. The threads of thecap and the plate will “click,” indicatingthat the cap is properly aligned and lesslikely to cross-thread when turnedclockwise.


Zimmer MIS Technique

IncisionA lateral incision is recommended if asimple articular or extra-articular fracture is present. The skin incisionstarts at Gerdy’s tubercle and extendsapproximately 8mm in a proximaldirection (Fig. 15). The muscles are leftattached to the fracture fragments foroptimal blood supply. Do not strip the periosteum. For intra-articular fracturean arthrotomy is performed to anatomically reduce the joint line.

Before insertion of the plate anatomicallyreduce the intra-articular fracture and fix it with a 3.5mm screw or a 2.0mm K-wire (Fig. 16).

Aiming arm assembly for insertionAttach the NCB-DF Aiming Device left for a left NCB Plate and the rightaiming device for a right plate. Screw the two connection bolts into the NCBPlate at the metadiaphysis area andtighten them with the Hex Screwdriver(Fig. 17).

Insertion of the NCB plate1. Insert the plate in between the vastuslateralis muscle and periosteum. Keep the proximal end of the plate inclose contact with the bone duringinsertion. Place the distal end of theplate onto the lateral condyle (Fig. 18).

Fig. 15

Fig. 16

Fig. 17

Fig. 18


2. Make a stab incision at the mostproximal plate hole. Screw the NCB Stabilization Bolt into the most proximalhole of the NCB Plate (Fig. 19).

3. Adjust the correct distance betweenthe aiming arm and the plate bypushing the aiming arm along the stabilization bolt and securing the correct distance with the NCB SafetyLock Pin (Fig. 20). This helps ensure thetargeting of the rest of the diaphysealscrews.

Reduction of the metaphysealbone part1. Insert a 2mm Kirschner wire throughthe distal end of the plate for temporaryrepositioning of the condyles (Fig. 21).

Fig. 19

Fig. 20

Fig. 21


2. For placing a NCB Cancellous Screwin the metaphysis, drill with the 2.5mmdrill bit and the NCB Drill Guide (Fig. 22).

3. Insert a NCB Cancellous Bone Screwand apply compression if needed (Fig. 23).

4. Repeat drilling and insert a secondcancellous NCB Bone Screw (Fig. 24a).Repeat the procedure if more screws arerequired, then lock the screws withLocking Screw Caps.

Then adjust length and rotation underimage intensifier and insert the proximal K-wire (Fig. 24b).

Note: Only the most distal screws canbe locked if the Aiming Arm is on. Theother screws in the joint area need to be locked when the Aiming Arm is off atthe end of the operation.

Fig. 22

Fig. 23

Fig. 24b

Fig. 24a


Insertion of the NCB screws inthe plate shaftStart with placing a proximal screw closeto the fracture site.

1. Make a stab incision to access theplate hole. Insert the NCB Trocar, DrillGuide and Protection Sleeve Assembly(Fig. 25).

2. Screw the Drill Guide into the platehole (Fig. 26).

3. Screw and secure the ProtectionSleeve to the Aiming Arm (Fig. 27). Thesleeve will be in direct contact with theplate.

Fig. 25

Fig. 26

Fig. 27


4. Remove the Trocar and drill using the 4.3mm drill bit for the 5mm NCBScrew (Fig. 28). The marks on the drillbit can be used to determine the screwlength.

5. Alternatively, determine the screwlength can be determined using theNCB Depth Gauge (Fig. 29).

6. Insert the appropriate screw using theNCB Hexagonal Screwdriver (Fig. 30).The screw can also be used for repositioning of a fragment.

Fig. 28

Fig. 29

Fig. 30


7. For locking of the screw insert thelocking screw and tighten the screw withthe NCB Torque-Limiting Screwdriver,6Nm until a clicking sound is heard fromthe handle of the screwdriver (Fig. 31).

8. Repeat step 1 to 7 to insert additionalscrews.

9. To place a screw at the most proximalend exchange the NCB Stabilization Bolt (Fig. 32a) with the NCB Trocar, drillguide and protection sleeve assembly(Fig. 32b). Drill using the 4.3mm drill bitfor the 5mm NCB Screw and lock thescrew with the NCB Locking Screw asdescribed above.

Fig. 31

Fig. 32a

Fig. 32b


10. Remove the Aiming Arm if additionalscrews need to be placed at the positionwhere the Aiming Arm is attached.Repeat step 1 to 7 to place additionalNCB Screws.

Place additional NCB Cancellous Screwsin the joint area if needed.

Implant Removal

To remove the NCB Plate, first remove allLocking Cap Screws. Then loosen all theNCB Bone Screws without completelyremoving them (this prevents rotation ofthe bone plate when removing the lastscrew). After the last screw is loosened,then completely remove all bone screwsand plate.

L4.

2

M 8 x 0.75


Ordering Information – NCB-DF Implants

NCB Femoral Plate, leftProtasul®-64 Metal AlloyQuantity* Holes Length REF

1 5 167mm 02.03260.1052 9 246mm 02.03260.1092 13 324mm 02.03260.113

NCB Femoral Plate, rightProtasul-64 Metal AlloyQuantity* Holes Length REF

1 5 167mm 02.03260.0052 9 246mm 02.03260.0092 13 324mm 02.03260.013

NCB Locking Screw CapProtasul-64 Metal Alloy

Quantity* ∅ mm mm REF

20 8 3.5 02.03150.300

NCB Blind Screw InsertProtasul-64 Metal AlloyQuantity* ∅ mm mm REF

6 8 3.5 02.03150.310

NCB Spacer(red, green, blue)Protasul-64 Metal Alloy

Quantity* L mm mm Color REF

2 1 3.5 red 02.03150.3112 2 3.5 green 02.03150.3122 3 3.5 blue 02.03150.313

31.6

20L

16

5.7

31.6

20 L

16

5.7

* Indicates the quantity in the standard graphic case.

3.9

M 8 x 0.75


NCB Screw, self-tappingProtasul-64 Metal Alloy

Quantity* L mm ∅ mm mm REF

4 14 5.0 3.5 02.03150.0144 16 5.0 3.5 02.03150.0164 18 5.0 3.5 02.03150.0184 20 5.0 3.5 02.03150.0204 22 5.0 3.5 02.03150.0224 24 5.0 3.5 02.03150.0244 26 5.0 3.5 02.03150.0264 28 5.0 3.5 02.03150.0284 30 5.0 3.5 02.03150.0304 32 5.0 3.5 02.03150.0324 34 5.0 3.5 02.03150.0344 36 5.0 3.5 02.03150.0364 38 5.0 3.5 02.03150.0384 40 5.0 3.5 02.03150.0404 42 5.0 3.5 02.03150.0424 44 5.0 3.5 02.03150.0444 46 5.0 3.5 02.03150.0464 48 5.0 3.5 02.03150.0484 50 5.0 3.5 02.03150.0504 55 5.0 3.5 02.03150.0554 60 5.0 3.5 02.03150.0604 65 5.0 3.5 02.03150.0654 70 5.0 3.5 02.03150.0704 75 5.0 3.5 02.03150.0754 80 5.0 3.5 02.03150.0804 85 5.0 3.5 02.03150.085

NCB Cancellous Screw, self-tappingthread 32mmProtasul-64 Metal Alloy


4 50 5.0 3.5 02.03152.0504 55 5.0 3.5 02.03152.0554 60 5.0 3.5 02.03152.0604 65 5.0 3.5 02.03152.0654 70 5.0 3.5 02.03152.0704 75 5.0 3.5 02.03152.0754 80 5.0 3.5 02.03152.0804 85 5.0 3.5 02.03152.085

Cortical Screw, self-tappingProtasul-100 Metal Alloy


3 50 3.5 3.5 02.03131.0503 55 3.5 3.5 02.03131.0553 60 3.5 3.5 02.03131.0603 65 3.5 3.5 02.03131.0653 70 3.5 3.5 02.03131.0703 75 3.5 3.5 02.03131.0753 80 3.5 3.5 02.03131.0803 85 3.5 3.5 02.03131.085

∅ 6.2∅ 4.2∅ 5

L

1.75

∅ 6∅ 3.5∅ 2.5

L

1.25

∅ 2.9

∅ 6.2∅ 5∅ 4

L1.75

33

*Indicates the quantity in the standard graphic case.


NCB Plating System Sterilization Cases

NCB Standard Sterilization Casefor open technique (with content)

REF

02.00024.600

NCB Standard Sterilization Case for open technique, includesREF 02.00024.601 to .605 (no content)

REF

02.00024.610

NCB Sterilization CaseModule, instruments

REF

02.00024.603

NCB Sterilization CaseModule, implants

REF

02.00024.604

NCB Sterilization CaseModule, screw rack

REF

02.00024.605

NCB Sterilization Case LidREF

02.00024.601

NCB Sterilization Case Base (inox)REF

02.00024.602


NCB Drill Bit, with quick couplingQuantity* L mm ∅ REF

– 145 4.3 02.00024.0011 195 4.3 02.00024.002

NCB Plating System Standard Instruments

NCB Drill Guide, for NCB cancellous screws ∅ 5.0Quantity* ∅ REF

1 2.5 02.00024.010

NCB Drill Guide, for NCB Screws ∅ 5.0Quantity* ∅ REF

1 4.3 02.00024.011

NCB Locking Screw Clip for HexagonalDriversQuantity* L mm ∅ REF

— 95 5.0 02.00024.121

NCB Torque-Limiting Screwdriver, 6 NmQuantity* L mm ∅ REF

– 245 3.5 02.00024.0201 280 3.5 02.00024.021

NCB Depth Gauge for NCB screwsQuantity* L mm ∅ REF

1 110 5.0/4.5/4.0 02.00024.005

NCB Tap for quick couplingQuantity* L mm ∅ REF

1 145 5.0 02.00024.050

Drill Bit with quick couplingQuantity* L mm l ∅ REF

1 180 154 2.5 103.25.180

l

L ▲

▲

▲

▲

T-handle, with quick couplingQuantity* REF

1 100.90.210

Depth Gauge, small for screwsQuantity* L mm ∅ REF

1 110 3.5/4.0 100.90.025

Screw Forceps, self-holdingQuantity* REF

1 100.90.005

Double Drill GuidesQuantity* ∅ REF

1 2.5/3.5/4.0 100.40.035

*Indicates the quantity in the standard sterilization case.


Countersink, for quick coupling Quantity* ∅ REF

— 3.5/4.0 108.01.035

Holding SleeveQuantity* REF

1 109.01.060

Hexagonal Screwdriver, small hex 2.5mmQuantity* REF

1 109.01.020

Tap for quick couplingQuantity* L mm ∅ REF

1 110 3.5 106.35.110

L

Kirschner Wire, Stainless SteelQuantity* L mm ∅ REF

5 280 2.0 290.20.280

*Indicates the quantity in the standard sterilization case.


NCB Plating System MIS Instruments

NCB Graphic Case module Zimmer MISInstruments, includes additionalinstruments for the MIS technique (with content)Quantity** REF

1 02.00024.650

NCB Graphic Case module MISInstruments (no content)Quantity** REF

1 02.00024.606

NCB-DF Drill Bit 4.3Quantity** L mm REF

2 300 02.00024.003

NCB-DF Measuring DeviceQuantity** REF

1 02.00024.006

NCB-DF Hexagonal Screwdriver forMIS FemurQuantity** L mm REF

1 275 02.00024.023

NCB-DF Hexagonal Screwdriver shaftQuantity** L mm REF

1 180 02.00024.024

Assembly PinQuantity** REF

1 02.00002.001

**Indicates the quantity in the MIS sterilization case module.


NCB-DF Connection BoltQuantity** L mm REF

2 144 02.00024.073

NCB-DF Stabilization Boltfor Targeting DeviceQuantity** L mm REF

1 153 02.00024.074

NCB Safety Lock Pin for Targeting DeviceQuantity** REF

2 02.00024.076

NCB-DF Taps for quick couplingQuantity** L mm ∅ REF

1 250 5.0 02.00024.051

NCB-DF Soft Tissue Protection SleeveQuantity** ∅ REF

2 10.0/8.2 02.00024.060

NCB-DF Drill GuideQuantity** ∅ REF

1 8.2/4.3 02.00024.061

NCB-DF TrocarQuantity** ∅ REF

1 4.3 02.00024.062

NCB-DF Targeting Device for platesQuantity** Side REF

1 right 02.00024.0701 left 02.00024.071

**Indicates the quantity in the MIS sterilization case module.


Planning Template

X-ray template REF 06.01240.000

Contact your Zimmer representative or visit us at www.zimmer.com

06.0

1221

.012

2.5

ML

Prin

ted

in U

.S.A

. ©

2005

Zim

mer

, Inc

.Please refer to package insert for complete productinformation, including contraindications, warnings,precautions, and adverse effects.

38829 zimmer (page 1)ncb distal femoral plating system surgical technique 99 if a cortical screw is...

Documents