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FEMORAL NAILING SYSTEM

OPERATIVE TECHNIQUE

Contributing Surgeons

Prof. Dr. med. Volker BührenChief of Surgical Services

Medical Director of Murnau Trauma CenterMurnau, Germany

Joseph D. DiCicco III, D.O.Director Orthopaedic Trauma Service

Good Samaritan HospitalDayton, Ohio

Associate Clinical Professor of Orthopaedic SurgeryOhio University and Wright State University

USA

Thomas G. DiPasquale, D.O.Associate Director, Orthopaedic Trauma Service

Florida Orthopaedic InstituteTampa General Hospital

Clinical Associate Professor of OrthopaedicsOhio University and Michigan State University

Clinical Assistant Professor of OrthopaedicsUniversity of South Florida

USA

This publication sets forth detailed recommended procedures for using Stryker HowmedicaOsteonics devices and instruments. It offers guidance that you should heed, but, aswith any such technical guide, each surgeon must consider the particular needs of

each patient and make appropriate adjustments when and as required.

A workshop training is required prior to first surgery.

FEMORAL NAILING SYSTEM

TABL E O F CO N TENTS

1. Introduction

1.1. Implant Features

1.2. Instrument Features

1.3. References

2. Indications

3. Pre-operative Planning

4. Locking Options

5. Retrograde Technique

5.1. Patient Positioning

5.2. Incision

5.3. Entry Point

5.4. Unreamed Technique

5.5. Reamed Technique

5.6. Nail Selection

5.7. Nail Insertion

5.8. Guided Locking Mode (via Target Device)

5.9. Static Locking Mode

5.10. Freehand Proximal Locking

5.11. End Cap Insertion

5.12. Dynamic Locking Mode

5.13. Apposition/ Compression Mode

5.14. Advanced Locking Mode

5.15. Nail Removal

6. Antegrade Technique

6.1. Patient Positioning and Fracture Reduction

6.2. Incision

6.3. Entry Point



6.6. Nail Selection

6.7. Nail Insertion



6.10. Freehand Distal Locking



6.13. Apposition/Compression Mode


6.15. Nail Removal

7. Implants

8. Instruments

9. Bixcut™ Reamers

4

4

6

6

7

7

8

10

10

10

11

12

12

13

14

16

17

19

20

20

21

22

23

24

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24

25

25

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28

29

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31

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36

38

4

I N TROD U CT I ON

1. Introduction

Over the past several decades antegrade femoral nailinghas become the treatment of choice for most femoral shaftfractures. Retrograde femoral nailing has expanded theuse of intramedullary nails (1,2). Complicated multipletrauma injuries, associated pelvic and acetabular fractures,ipsilateral femoral shaft fractures, supracondylar andintercondylar fractures, may be better managed byutilizing retrograde femoral nailing techniques (3,4,5,6,7).

The T2™ Femoral Nailing System is one of the firstfemoral nailing systems to offer an option for either anantegrade or a retrograde approach to repair fractures ofthe femur.

One Implant, Two Approaches

Stryker Howmedica Osteonics has created a newgeneration locking nail system, bringing together all thecapabilities and benefits of separate antegrade andretrograde nailing systems to create a single, integratedsurgical resource for fixation of long-bone fractures.

Furthermore, the development of the T2™ FemoralNailing System offers the competitive advantages of:

• Not limiting the approach to a certain nailing technique• Accommodating reamed or unreamed procedures• Providing locking options for all types of fractures,

plus the Advanced Locking Mode for increased rotational stability

Through the development of a common, streamlined andintuitive surgical approach, both in principle and in detail,the T2™ Femoral Nailing System offers significantlyincreased speed and functionality for the treatment offractures as well as simplifying the training requirementsfor all personnel involved.

1.1. Implant Features

The T2™ Femoral Nailing System is the realization ofsuperior biomechanical intramedullary stabilization usingsmall caliber, strong, cannulated implants for internalfixation of long bones.

According to the fracture type, the system offers the optionof different locking modes. In addition to static locking, a controlled dynamization with rotational stability is optional.

In some indications, a controlled apposition/compressionof bone fragments can be applied by introducing aCompression Screw from the top of the nail. To furtherincrease rotational stability, the nail can be lockedstatically after using the controlled dynamization andapposition/compression option.

The Compression Screw is pushed against the PartiallyThreaded Locking Screw (Shaft Screw) that has beenplaced in the oblong hole, drawing either the distal or theproximal segment towards the fracture site. In stablefractures, this has the biomechanical advantage ofcreating active circumferential compression to thefracture site, transferring axial load to the bone, andreducing the function of the nail as a load bearing device(8).

This ability to transfer load back to the bone can reducethe incidence of implant failure secondary to fatigue.Typical statically locked nails function as load bearingdevices, and failure rates in excess of 20% have beenreported (9).

The beneficial effect of apposition/compression in treatinglong-bone fractures in cases involving transverse and shortoblique fractures that are axially stable is welldocumented (10,11).

Common 5mm cortical screws simplify the surgicalprocedure and promote a minimally invasive approach.Fully Threaded Locking Screws are available for regularlocking procedures. Partially Threaded Locking Screws(Shaft Screws) are designed if apposition/compression isapplied. Special Condyle Screws with adjustable washersfor improved fit are designed to fix fragments in thecondyle area.

Compression Screws to close the fracture site and EndCaps are available in various sizes to provide a “best fit”for every indication.

All implants of the T2™ Femoral Nailing System are gun-drilled and made of Type II anodized titanium alloy(Ti6AL4V) for enhanced biomechanical and biomedicalperformance.

See the detailed chart on the next page for the designspecifications and size offerings.

5

IMPL AN T FEATURES

60

47.5

32.5

15

0mm

CompressionRange*

NailsDiameter 9 - 15mmSizes 240 - 480mm

Note: Screw length ismeasured from top of head to tip.

5.0mm Fully ThreadedLocking ScrewsL = 25-120mm

5.0mm PartiallyThreaded Locking Screws(Shaft Screws)L = 25-120mm

5.0mm Condyle ScrewsL = 40-120mm

Compression Screws

Femur AdvancedCompression Screw

Standard +5mm +10mm +15mm

Standard

+5mm

+10mm

+15mm

Condyle Nut

0mm

15

25

32.5

42.5

50

60

47.5

32.5

15

0mm

*Compression RangeTotal Length of Slot 15mmLess Screw Diameter (-) 5mm

Maximum Movement of Screw 10mm

45mm

Antegrade

50mm

25mm

AdvancedCompressionScrew

CompressionRange*

45

35

Retrograde

3540

End Caps

6

I NSTRU M E NT FEATURES

1.2. Instrument Features

The major advantage of the instrument system is abreakthrough in the integration of the instrument platformwhich can be used not only for the complete T2™ NailingSystem, but will be the platform for all future nailingsystems, reducing complexity and inventory.

The instrument platform offers advanced precision andusability, and features ergonomically styled targetingdevices.

In addition to the advanced precision and usability, theinstruments are color, number and symbol coded toindicate its usage during the surgical procedure.

Color and number coding indicates the step during theprocedure in which the instrument is used. This color codesystem is marked on the trays to easily identify the correctinstrument.

Step Color Number

Opening RedReduction BrownNail Introduction GreenGuided Locking Light BlueFreehand Locking Dark Blue

Symbol coding on the instruments indicates the type ofprocedure and must not be mixed.

Symbol

Square = Long instruments, Femur

Triangular = Short instruments, Tibia and Humerus

DrillsDrills feature color-coded rings:

4.2mm = GreenFor 5.0mm Fully Threaded Locking Screws and for thesecond cortex when using 5.0mm Partially ThreadedLocking Screws (Shaft Screws).

5.0mm = BlackFor the first cortex when using 5.0mm Partially ThreadedLocking Screws (Shaft Screws) and for both cortices whenusing Condyle Screws.

1.3. References

1. Janzing HMJ et al.: The Retrograde Intramedullary Nail:Prospective Experience in Patients Older than Sixty-fiveYears. Journal of Orthopaedic Trauma 12 (5) 330-333,1998

2. Koval KJ et al.: Distal Femoral Non-union: Treatmentwith a Retrograde Inserted Locked Intramedullary Nail,Journal of Orthopaedic Trauma, Vol. 9 N°4, pp. 285-291,1995

3. Herscovici D Jr. and Whiteman KW: Retrograde Nailingof the Femur Using an Intercondylar Approach. ClinicalOrthopaedics and related Research, 332, 98-104, 1996

4. Roy Sanders, Kenneth J. Koval et al.: RetrogradeReamed Femoral Nailing. Journal of Orthopaedic Trauma1993; Vol. 7, No. 4: 293-302

5. Ostrum F.D., et al., A Prospective Comparison ofAntegrade and Retrograde Intramedullary Nailing, Friday,October 9, 1998 Session V, 11:31 a.m. OTA Vancouver

6. Ostrum F.D., Joseph DiCicco, RetrogradeIntramedullary Nailing of Femoral Diaphyseal Fractures,Journal of orthopaedic Trauma, Vol. 12, N° 7, pp. 464-468, 1998

7. Lucas SE et al.: Intramedullary Supracondylar Nailing ofFemoral Fractures. A Preliminary Report of the GSHSupracondylar Nail. Clinical Orthopaedics and RelatedResearch 296 200-206, 1993

8. T.E. RICHARDSON, M. VOOR, D. SELIGSON, FractureSite Compression and Motion with Three Types ofIntramedullary Fixation of the Femur, OsteosyntheseInternational (1998), 6: 261-264

9. HUTSON et al., Mechanical Failures of IntramedullaryTibial Nails Applied without Reaming, Clin. Orthop.(1995), 315 : 129-137

10. M.E. MULLER, et al.,Manual of Internal Fixation,Springer-Verlag, Berlin, 1991

11. O. GONSCHOREK, G.O. HOFMANN, V. BÜHREN,Interlocking Compression Nailing: a Report on 402Applications. Arch. Orthop. Trauma Surg (1998), 117: 430-437.

12. Mehdi Mousavi, et al., Pressure Changes DuringReaming with Different Parameters and Reamer Designs,Clinical Orthopaedics and Related Research, Number373, pp. 295-303, 2000.

12456

7

I N D I CAT IONS

2. Indications

The T2™ Femoral Nail is indicated for:

• Open and closed shaft fractures• Ipsilateral shaft fractures• Segmental fractures• Supracondylar fractures

including those with intra-articular extension• Comminuted fractures with or without bone loss• Fractures distal to a hip prosthesis• Fractures proximal to a total knee arthroplasty• Pathologic and impending pathologic fractures• Tumor resections• Non-unions• Pseudarthrosis• Mal-unions• Corrective osteotomies

3. Pre-operative Planning

An X-Ray Template is available for pre-operative planning.

Thorough evaluation of pre-operative radiographs of theaffected extremity is critical. Careful radiographicexamination of the trochanteric region and intercondylarregions can prevent intra-operative complications.

The proper nail length when inserted antegrade shouldextend from the Tip of the Greater Trochanter to theEpiphyseal Scar.

The retrograde nail length is determined by measuring thedistance between a point 5mm - 15mm proximal to theIntercondylar Notch to a point at/or proximal to the LesserTrochanter.

In either approach this allows the surgeon to consider theapposition/compression feature of the T2™ Femoral Nail,knowing that up to 10mm of activeapposition/compression is possible, prior to determiningthe final length of the implant. If apposition/compression isplanned, the nail should be at least 10mm shorter.

Note: Check with local representative regarding availability of nail sizes.

Antegrade

Retrograde

8

LOCK IN G OP T I ON S

Static Mode

Antegrade

Retrograde

4. Locking Options

9

L O CK IN G O PT IONS

Dynamic Mode Apposition/Compression Mode Advanced Locking Mode

10

RETROGR ADE TECHN IQ UE

5. Retrograde Technique

5.1. Patient PositioningRetrograde nail insertion is performed with the patient supine on aradiolucent table. The affected lower extremity and hip region arefreely draped, and the knee is placed over a sterile bolster. This willallow for 45 degrees of knee flexion. Manual traction through aflexed knee or a distraction device may be used to facilitatereduction for most acute femoral shaft fractures.

5.2. IncisionA 3cm midline skin incision is made extending from the inferiorpole of the Patella to the Tibial Tubercle, followed by a medialparapatellar capsular incision. This should be sufficient to exposethe Intercondylar Notch for retrograde nail insertion. Occasionally,a larger incision may be needed, especially if the fracture has intra-articular extension and fixation of the condyles is necessary.

Distal femoral fractures are often complicated by intra-articularfracture line extension. These fractures should be anatomicallyreduced and secured with the aid of titanium Asnis III®6.5mm/8.0mm Large Cannulated Screws in the anterior andposterior aspect of the femoral condyles. This will allow foradequate space when inserting the nail retrograde. CannulatedScrews are advantageous, allowing the surgeon to use intra-operative radiographs to check Guide Wire placement prior toscrew insertion. An alternative is to reduce and maintain reductionof the femoral condyles with a pointed reduction forceps.

5mm

11

RETRO GRADE TECHN IQUE

Fig. 1

Fig. 2

Fig. 3

Fig. 4

*Outside of the U.S., product with an “S” may be ordered non-sterile without the “S” at the end of the corresponding Cat. Number.

5.3. Entry Point

The 3 x 285mm K-Wire (1806-0050S)* can easily be fixedto the Guide Wire Handle (1806-0095 and 1806-0096)(Fig. 1). With the condyles secured, the entry point forretrograde nail insertion is made by centering the 3 x285mm K-Wire through the Retrograde Protection Sleeve(703165) and positioning within the Intercondylar Notchanterior to Blumensaat‘s line on the M/L radiograph usingthe Slotted Hammer (1806-0170) (Fig. 2).

This point is found by palpating a distinct ridge justanterior to the Posterior Cruciate Ligament (Fig. 2).

The K-Wire is advanced manually or with the SlottedHammer approximately 10cm confirming its placementwithin the center of the distal femur on an A/P and Lateralradiograph.

The Retrograde Protection Sleeve is contoured to fit theprofile of the Intercondylar Notch. It is designed to helpreduce the potential for damage during reaming, and alsoprovide an avenue for the reamer debris to exit the kneejoint (Fig. 3).

When the inner Retrograde K-Wire Guide is removed, theØ12mm Rigid Reamer (1806-2012) is inserted over the 3x 285mm K-Wire and through the Retrograde ProtectionSleeve. The distal most 8cm of the femur is reamed (Fig. 4).

The Ø12mm Rigid Reamer is used for nails 9mm - 11mmin diameter. Larger nail diameters may be reamed with aflexible reamer 1mm larger than the nail.

Note: Prior to advancing the K-Wire within the distalfemur, check the correct guidance through the Ø12mmRigid Reamer. Do not use bent K-Wires.

12



If an unreamed technique is preferred, the 3 x 1000mmBall Tip Guide Wire (1806-0085S) is passed through thefracture site using the Guide Wire Handle. The UniversalRod (1806-0110) with Reduction Spoon (1806-0125) maybe used as a fracture reduction tool to facilitate GuideWire insertion (Fig. 5). Internal rotation during insertionwill aid in passing the Guide Wire down the femoral shaft.The Guide Wire is advanced until the tip rests at/or justabove the Lesser Trochanter. The Guide Wire should lie inthe center of the metaphysis in the A/P and M/L views toavoid offset positioning of the nail. The Guide WireHandle is removed, leaving the Guide Wire in place.


For reamed techniques, the 3 x 1000mm Ball Tip GuideWire is inserted through the fracture site and does notrequire a Guide Wire exchange. The Universal Rod withReduction Spoon may be used as a fracture reduction toolto facilitate Guide Wire insertion through the fracture site(see Fig. 5).

Note: The Ball Tip at the end of the Guide Wire will stopthe reamer head.

Reaming (Fig. 6) is commenced in 0.5mm increments untilcortical contact is appreciated. Final reaming should be1mm larger than the diameter of the nail to be used.

Note: The diameter of the driving end of the 9mm -11mm diameter nails is 11.5mm. Additional metaphysealreaming may be required to facilitate nail insertion. Nailsizes 12-15mm have a constant diameter.

Note: Thoroughly irrigate the knee joint to remove anydebris.

Bixcut™ Reamer

The complete range of Bixcut™ reamers is available witheither modular or fixed heads.

The optimized cutting flute geometry is designed to largelyreduce intramedullary pressure and temperature. This is achieved by the forward and side cutting facecombination of the reamer blades. The large clearancerate resulting from the reduced number of reamer blades,coupled with the reduced length of the reamer head,relieves the intramedullary pressure and provides efficientremoval of reamed material.

See pages 38-39 for additional Bixcut™ Reamer system details.

Typical StandardReamer Ø14mm

Clearance area = 32% ofcross section

Reamer Ø14mm

Clearance area = 59% ofcross section

Fig. 5

Fig. 6

Relative Area of Reamer

Effects of Cutting Flutes

TM

13


5.6. Nail Selection

Diameter

The diameter of the selected nail should be 1mm smallerthan that of the last reamer used. Alternatively, the naildiameter may be determined using the Femur X-Ray Ruler(1806-0015) (Fig. 7.1 and 7.2).

Fig. 7.1 Hole Positions (nondriving end) Antegrade orRetrograde*

1. Static Locking - both M/L holes2. Oblong hole - depending on Antegrade or

Retrograde; static or dynamic modes - A/P3. Static Locking - A/P

Fig. 7.2 Hole Positions (driving end) Antegrade orRetrograde*

1. Static Locking - both M/L holes2. Oblong hole - depending on Antegrade or

Retrograde; static, dynamic, apposition/compression, advanced locking modes - M/L

Length

Nail length may be determined by measuring the remaininglength of the Guide Wire. The Guide Wire Ruler (1806-0020) may be used by placing it on the Guide Wire readingthe correct nail length at the end of the Guide Wire on theGuide Wire Ruler (Fig. 8 and Fig. 9).

Alternatively, the X-Ray Ruler (1806-0015) may be used todetermine nail diameter and length (Fig. 7.1, 7.2).Additionally, the X-Ray Ruler can be used as a guide forlocking screw positions.

Note: If the fracture is suitable for apposition/compression, the implant selected should be 10-15mmshorter than measured to help avoid migration of the nailbeyond the insertion site.

Fig. 7.1

Fig. 7.2

Fig. 8

Fig. 9

Length Hole Positions(driving end)

Static and Dynamic SlotLocking Options

3 1 2 1

330 mm

Length Calibration

Length Scale Diameter Scale

*see pages 8-9 for detailed illustrations of Antegrade and Retrograde Locking Options.

1 2 1

End of Guide Wire Ruler equals Measurement Reference

14


5.7. Nail Insertion

The selected nail is assembled onto the Femoral TargetDevice (1806-1005) with the Femoral Nail Holding Screw(1806-0165) (Fig. 10). Tighten the Nail Holding Screwwith the Universal Joint Socket Wrench (1806-0400)securely so that it does not loosen during nail insertion.

Upon completion of reaming, the appropriate size nail isready for insertion. Unique to the T2™ Femoral Nail, the3 x 1000mm Ball Tip Guide Wire does not need to beexchanged. The Strike Plate (1806-0150) may be threadedinto the hole next to the Nail Holding Screw and the nailis advanced through the entry point past the fracture site tothe appropriate level.

Additionally, the 3 x 285mm K-Wire may be insertedthrough the Targeting Device which identifies the junctionof the nail and insertion post (see Fig. 10.1).

Insertion of the 3 x 285mm K-Wire into the lateral cortexmay also help to lock the targeting device to the distalfemur and prevent rotation of the nail in cases where theApposition/Compression Locking Mode is utilized.

Note: Curvature of the nail must match the curvature ofthe femur.

Fig. 10

Fig. 10.1

TargetingArm

NailHandle

FixationScrew

Nail Holding Screw

Strike Plate

K-Wire Hole

Fig. 13

15


The Slotted Hammer can be used on the Insertion Wrenchthat is placed onto the Nail Holding Screw to insert thenail over a Guide Wire (Fig. 11).

Note: Prior to insertion, check for correct assembly intothe nail by passing a Drill Bit through the Target Device.DO NOT hit the Target Device. Only hit upon theInsertion Wrench.

Technical Tip: A chamfer is located on the driving end ofthe nail to denote the end under X-Ray. Threecircumferential grooves are located on the insertion post at2mm, 10mm, and 15mm from the driving end of the nail.Depth of insertion may be visualized with the aid offluoroscopy.

Repositioning should be carried out either by hand or byusing the Strike Plate attached to the Target Device. TheUniversal Rod and Slotted Hammer may then be attachedto the Strike Plate to carefully and smoothly extract theassembly (Fig. 12). DO NOT hit on the Target Device.

When locking the retrograde nail in the Static Mode, thenail is countersunk a minimum of 5mm to the chondralsurface. When the implant is inserted in the DynamicMode, without active apposition/compression, therecommended insertion depth is 10mm. When the implant is inserted with activeapposition/compression or in the Advanced LockingMode, the recommended depth of insertion is 15mm (Fig.13).

Note: Remove the Guide Wire prior to drilling andinserting the Locking Screws.

Fig. 11

Fig. 12

StaticDynamicApposition/Compression

2 mm5 mm10 mm15 mm

15mm compression slot allows10mm of compression

16



Before locking the nail distally, the Nail Holding Screwmust be firmly tightened using the Universal Joint SocketWrench to ensure that the nail is correctly aligned with theTarget Device.

The Target Device is designed to provide four options forproximal locking (Fig. 14.1 - 14.3).

In Static Locking Mode, all three indicated holes may beused (Fig. 14.1).1. Static2. Static3. Static

In controlled Dynamic Mode, and/or controlledApposition/Compression Mode, the dynamic hole isrequired. This hole is also used for compression (Fig.14.2).4. Dynamic

In Advanced Locking Mode, the dynamic hole is required.After utilizing compression with the AdvancedCompression Screw, either or both static holes are used.(Fig. 14.3).4. Dynamic1. Static3. Static

The Long Tissue Protection Sleeve (1806-0185) togetherwith the Long Drill Sleeve (1806-0215) and the LongTrocar (1806-0315) is inserted into the Target Device bypressing the safety clip (Fig. 15). The mechanism will keepthe sleeve in place and prevent it from falling out. It willalso prevent the sleeve from sliding during screwmeasurement. To release the Tissue Protection Sleeve, thesafety clip must be pressed again.

Fig. 14.1

Fig. 14.2

Fig. 14.3

Fig. 15

3 21

4

14

3

released locked

17



When treating supracondylar fractures, three screwsshould be used whenever possible. The screw placedwithin the oblong hole should be in the static position.Always start with the most proximal screw.

If secondary dynamization is planned, it is recommendedto dynamize at the proximal portion of the nail. This isachieved by putting a Fully Threaded Locking Screw at theproximal location of the A/P oblong hole at the top of thenail. This allows dynamization of the fracture in case ofdelayed union after removal of the most proximal screw.

The Long Tissue Protection Sleeve together with the LongDrill Sleeve and Long Trocar, are positioned through thestatic locking hole on the Target Device. A small skinincision is made, and the assembly is pushed through untilit is in contact with the lateral cortex of the femur (Fig. 16).

The Trocar is removed, with the Tissue Protection Sleeveand the Drill Sleeve remaining in position.

To ensure accurate drilling and easy determination ofscrew length, use the center tipped, Ø4.2x340 calibratedDrill (1806-4260S). The centered Drill is forwardedthrough the Drill Sleeve and pushed onto the cortex.

After drilling both cortices, the screw length may be readdirectly off of the calibrated Drill at the end of the DrillSleeve. If measurement with the Screw Gauge, Long ispreferred, first remove the Drill Sleeve, Long and read thescrew length directly at the end of the Tissue ProtectionSleeve, Long (Fig. 17 and Fig. 18).

Note: The position of the end of the Drill as it relates tothe far cortex is equal to where the end of the screw willbe. Therefore, if the end of the Drill is 3mm beyond thefar cortex, the end of the screw will also be 3mm beyond.

Important: The Screw Gauge, Long is calibrated so thatwith the bend at the end pulled back flush with the farcortex, the screw tip will end 3mm beyond the far cortex(Fig. 18).

When the Drill Sleeve is removed, the correct LockingScrew is inserted through the Tissue Protection Sleeveusing the Long Screwdriver Shaft (1806-0227) withTeardrop Handle (702429). The screw is advancedthrough both cortices. The screw is near its’ proper seatingposition when the groove around the shaft of thescrewdriver is approaching the end of the TissueProtection Sleeve (Fig. 19).

Fig. 16

Fig. 17

Fig. 18

50 mm

Fig. 19

50 mm

18


5.9. Static locking Mode (continued)

Repeat the locking procedure for the other staticallypositioned Cross Locking Screws.

Condyle Screw Locking

If a Condyle Screw is to be inserted, both cortices aredrilled with the Ø5x340mm Drill (1806-5020S) (Fig. 20).After drilling both cortices, the screw length may be readdirectly off of the calibrated Drill at the end of the DrillSleeve. The Condyle Screw K-Wire (0152-0218S) isinserted from the lateral side through the Tissue ProtectionSleeve to the medial side. At the medial point of theperforation a skin incision is made for the Condyle Screw.

From the medial side, the Condyle Screw is now broughtforward over the Condyle Screw K-Wire and inserted usingthe Condyle Screw Screwdriver (1806-0255).

To insert the Condyle Nut, the Tissue Protection Sleeveand the Drill Sleeve are removed, and the K-Wire iswithdrawn to the medial side. This allows for the nut to bepositioned between the Target Device and the level of theskin and onto the Condyle Screw K-Wire (Fig. 21).

Alternatively, if the patient anatomy allows, the CondyleScrew may be introduced from Lateral to Medial in asimilar manner as described above (Fig. 21a).

Using both Condyle Screw Screwdrivers, the Condyle Nutand the Condyle Screw are tightened. Once tightened, theK-Wire is removed.

The adjustable screw washer of the Condyle Screw andthe Condyle Nut adapt to the surface of the boneeliminating the need to countersink both.

The geometry of the implant allows three Condyle Screwsto be used. At least two of the three distal holes should beengaged with either Locking Screws and/or CondyleScrews (Fig. 22). Always lock the most proximal hole.

Note: If necessary, contour the bone geometry tooptimize the seating of the washer.

Fig. 20

Fig. 21

Fig. 22

Fig. 21a

Condyle Screw-introduced M-L

Condyle Screw-introduced L-M

19


5.10. Freehand Proximal Locking

The freehand technique is used to insert Locking Screwsinto both the A/P oblong hole and A/P round hole in thenail. In Static, Apposition/Compression and AdvancedLocking Mode, the Locking Screw placed in the oblonghole should be positioned in the distal position. Rotationalalignment must be checked prior to locking the nailstatically.

Note: Only one Locking Screw is inserted in the DynamicLocking Mode. The Locking Screw is placed in theproximal position of the A/P oblong hole in order tooptimize dynamization at the proximal end of the nail.

The M/L holes may also be used alternatively or inaddition to A/P Locking Screws by adjusting the C-arm andleg position to locate the holes.

Multiple locking techniques and radiolucent drill devicesare available for freehand locking. The critical step withany freehand locking technique, proximal or distal, is tovisualize a perfectly round locking hole, or perfectlyoblong locking hole with the C-Arm.

The center-tipped Ø4.2x230 Drill (1806-4290S) is held atan oblique angle to the center of the locking hole (Fig. 23and 24). Upon X-Ray verification, the Drill is placedperpendicular to the nail and drilled through the anteriorand posterior cortex. Confirm that the Drill passes throughthe hole in the nail in both the A/P and M/L planes by X-Ray.

After drilling both cortices the screw length may be readdirectly off of the calibrated Screw Scale, Long (1806-0365) at the green ring on the center-tipped Drill (Fig. 25).As with proximal locking (Fig. 18, p.17), the position of theend of the drill is equal to the end of the screw as theyrelate to the far cortex.

Routine Locking Screw insertion is employed with theassembled Long Screwdriver Shaft and the TeardropHandle (Fig. 26).

Fig. 23

Fig. 24

Fig. 25

Fig. 26

Green Ring

40 mm

20



After removal of the Target Device, an End Cap is used.Four different sizes of End Caps are available to adjust naillength and to reduce the potential for bony ingrowth intothe proximal thread of the nail (Fig. 27).

Technical Tip: All End Caps are designed to tighten downonto the locking screw at the working end of the nail. Thiswill help prevent the nail from M/L sliding.

The End Cap is inserted with the Long Screwdriver Shaftand Teardrop Handle after intra-operative radiographsshow satisfactory reduction and hardware implantation(Fig. 28). Fully seat the End Cap to minimize the potentialfor loosening.

Note: Final verification of implants should be confirmedby X-Ray at this time.

Thoroughly irrigate the wound to prevent debris fromremaining within the knee joint. Close the wound usingstandard technique.


When the fracture profile permits, controlled dynamiclocking may be utilized for transverse or axially stablefractures. While dynamic locking can be performed ateither end of the nail, routine retrograde dynamic lockingshould utilize the oblong hole at the proximal end of thenail. The potential for nail migration into the joint isthereby reduced.

Retrograde dynamization is performed by staticallylocking the nail distally via the Target Device.

The freehand Locking Screw is then placed in the dynamicposition of the oblong hole. This allows the nail to moveand the fracture to settle while torsional stability ismaintained (Fig. 29).

Fig. 27

Fig. 28

Fig. 29


21


5.13. Apposition/Compression Locking Mode

In transverse or axially stable fracture patterns, activeapposition/compression increases fracture stability, mayenhance fracture healing, and allow for early weightbearing. The T2™ Femoral Nail provides the option totreat a femur fracture with active mechanicalapposition/compression prior to leaving the operatingroom.

Note: Proximal freehand static locking with at least twoFully Threaded Locking Screws must be performed priorto applying active, controlled apposition/compression tothe fracture site.

If active apposition/compression is required, a PartiallyThreaded Locking Screw (Shaft Screw) is inserted via theTarget Device in the dynamic position of the oblong hole.This will allow for a maximum of 10mm of active,controlled apposition/compression. In order to insert theShaft Screw, drill both cortices with the Ø4.2x340 Drill(1806-4260S). Next, drill the near cortex, ONLY, with theØ5x230mm Drill (1806-5000S).

Note: After the opposite cortex is drilled with theØ4.2x340mm Drill, the correct screw length can be readdirectly off of the calibrated Drill at the end of the DrillSleeve.

After the Shaft Screw is inserted, the Nail Holding Screwsecuring the nail to the insertion post is removed, leavingthe insertion post intact with the nail (Fig. 30). This will actas a guide for the Compression Screw. The CompressionScrew is inserted with the Compression Screwdriver Shaft(1806-0268) assembled on the Teardrop Handle throughthe insertion post. When the ring marked with an “F” onthe Compression Screwdriver Shaft is close to the Target Device, it indicates the engagement of theapposition/compression feature of the nail.

Note: The ring marked with a “T” is for the TibialCompression Screw.

The Long Tissue Protection Sleeve is removed and theCompression Screw is gently tightened utilizing the two-finger technique. As the Compression Screw is advancedagainst the 5.0mm Partially Threaded Locking Screw (ShaftScrew), it draws the proximal fracture segment towards thefracture site, employing active apposition/compression(Fig. 31). Image intensification will enable the surgeon tovisualize active apposition/compression (Fig. 32). Somebending of the transverse Shaft Screw may be seen.

Note: Apposition/compression must be carried out underX-Ray control. Over compression may cause the nail orthe Shaft Screw to fail.

Technical Tip: When compressing the nail, the implantmust be inserted a safe distance from the entry point toaccommodate for the 10mm of active compression. Thethree grooves on the insertion post help attain accurateinsertion depth of the implant.

Fig. 30

Fig. 31

Fig. 32

Compression Screws are available in different lengths. Ashort Advanced Compression Screw to enable theAdvanced Locking Mode and longer Compression Screwsfrom Standard to +15mm provide a “best fit“ for everyindication. An End Cap can only be inserted when usingthe Advanced Compression Screw or when not usingcompression.

22



In order to achieve additional fixation and to reduce theload on the Partially Threaded Locking Screw (ShaftScrew), the design of the T2™ Femoral Nail provides theopportunity to insert an additional Fully ThreadedLocking Screw into the hole nearest the driving end of thenail after apposition/compression is utilized. Anadditional Fully Threaded Locking Screw should beinserted in either the more proximal or more distal of thestatic holes depending on the fracture stability.

Affix the Compression Screw on the self-retainingCompression Screwdriver Shaft. Remove the NailHolding Screw leaving the Target Device in place (Fig.33). Advance the Compression Screw through the TargetDevice until the ring marked with an “F” on theCompression Screwdriver Shaft is close to the TargetDevice (Fig. 34).

To insert the AdvancedCompression Screw, followthe OP-Technique underApposition/CompressionLocking Mode section(5.13) on the previous page.

Technical Tip: As previously described, it may be easier to insert the Compression Screw prior to fully seating the nail.

To reattach the Target Device to the nail, detach theTeardrop Handle from the Compression Screwdriver Shaftand screw the Nail Holding Screw over the CompressionScrewdriver Shaft into its required position.

Prior to guided locking via the Target Device, the NailHolding Screw must be tightened using the UniversalJoint Socket Wrench.

To insert the most distal Screw, follow the lockingprocedure for static locking (Fig. 20-22).

Fig. 34

Fig. 35

Fig. 36

Fig. 37

Fig. 33

23


5.15. Nail Removal

Nail removal is an elective procedure. If needed, the EndCap and Compression Screw (if Advanced Locking Modewas utilized after the most distal screw is extracted) areremoved with the Long Screwdriver Shaft and TeardropHandle (Fig. 38).

Note: As an alternative to removing the AdvancedCompression Screw (if used), it can be just disengagedfrom the Partially Threaded Locking Screw (Shaft Screw)by turning the Compression Screwdriver one full turn ina counter-clockwise direction. There is no need toremove it from the nail.

The Universal Rod is inserted into the driving end of thenail. All Locking Screws are removed with the LongScrewdriver Shaft and Teardrop Handle (Fig. 39). The“optional” Long Screw Capture Sleeve (1806-0240) maybe used on the Screwdriver.

The Slotted Hammer is used to extract the nail in acontrolled manner (Fig. 40). A captured Sliding Hammer(1806-0175) is available as an “optional” addition to thebasic instrument set.

Fig. 38

Fig. 39

Fig. 40

24

ANTEGR A DE TECHN IQ UE

6. Antegrade Technique

6.1. Patient Positioning and Fracture Reduction

Patient positioning for antegrade femoral nail insertion issurgeon dependent. The patient may be positioned supine orlateral on a fracture table, or simply supine on a radiolucenttable.

6.2. Incision

The design of the implant allows for insertion either throughthe Piriformis Fossa or the Tip of the Greater Trochanter.

Piriformis FossaA skin incision is made beginning at the level of the GreaterTrochanter extending proximal and slightly posterior, in linewith the Gluteus Muscle, exposing the Piriformis Fossa forantegrade femoral nail insertion.

Tip of the Greater TrochanterWith experience, the Tip of the Greater Trochanter can belocated by palpation, and a horizontal skin incision is madefrom the Greater Trochanter to the Iliac Crest.

25

AN TEGRADE TECHN IQUE

6.3. Entry Point

The Tip (Medial Edge) of the Greater Trochanter (A)The medullary canal is opened with the Curved Awl(1806-0040) at the junction of the anterior third andposterior two-thirds of the Greater Trochanter, on themedial edge of the tip itself (Fig. 41). Image intensification(A/P and Lateral) is used for confirmation.

Piriformis Fossa (B)Alternatively, the implant may be introduced in thePiriformis Fossa, with a starting point just medial to theGreater Trochanter and slightly posterior to the central axisof the femoral neck.

Once the Tip of the Greater Trochanter or the PiriformisFossa (Fig. 42) has been penetrated, the 3 x 1000mm BallTip Guide Wire (1806-0085S) may be advanced throughthe cannulation of the Curved Awl with the Guide WireHandle (1806-0095 and 1806-0096) (Fig. 43).


If an unreamed technique is preferred, the nail may beinserted with or without the Ball Tip Guide Wire.

Fig. 41

Fig. 43Fig. 42

26


Fig. 45

Fig. 46

Fig. 44

End of Guide Wire Rulerequals Measurement Reference


If the procedure will be performed using a reamedtechnique, the 3 x 1000mm Ball Tip Guide Wire isinserted with the Guide Wire Handle through thefracture site to the level of the Epiphyseal Scar or themid-pole of the Patella and does not need a GuideWire exchange. The Ø9mm Universal Rod (1806-0110) with Reduction Spoon (1806-0125), or theReduction Tip (special order 1806-0120), may be usedas a fracture reduction tool to facilitate Guide Wireinsertion through the fracture site (Fig. 44), and in anunreamed technique, may be used as a “sound” to helpdetermine the diameter of the medullary canal.

Note: The Ball Tip at the end of the Guide Wire willstop the reamer head.

Reaming is commenced in 0.5mm increments untilcortical contact is appreciated (Fig. 45). Final reamingshould be 1mm larger than the diameter of the nail tobe used.

Note: The proximal diameter (driving end) of the9mm - 11mm diameter nails is 11.5mm. Nail sizes 12-15mm have a constant diameter.

6.6. Nail Selection

DiameterThe diameter of the selected nail should be 1mmsmaller than that of the last reamer used. Alternatively,the diameter may be determined using the Femur X-rayRuler (1806-0015) with the different diametersmatching with the radiographs (see Fig. 7.1 on page13).

LengthNail length may be determined with the X-Ray Ruler ormay be determined by measuring the remaining lengthof the Guide Wire. The Guide Wire Ruler (1806-0020)may be used by placing it on the Guide Wire readingthe correct nail length at the end of the Guide Wire onthe Guide Wire Ruler (Fig. 46 and 47).

Note: If the fracture is suitable forapposition/compression, the implant selected shouldbe 10-15mm shorter than measured, to help avoidmigration of the nail beyond the insertion site.

Fig. 47

27


6.7. Nail Insertion

The selected nail is assembled onto the Target Devicewith the Nail Holding Screw (Fig. 48.1). Tighten the NailHolding Screw with the Universal Joint Socket Wrench(1806-0400) securely so that it does not loosen duringnail insertion.

Upon completion of reaming, the appropriate size nail isready for insertion. Unique to the T2™ Femoral Nail the3 x 1000mm Ball Tip Guide Wire does not need to beexchanged. The Strike Plate (1806-0150) is threadedinto the Target Device and the nail is advanced throughthe entry point past the fracture site to the appropriatelevel.

Note: Curvature of the nail must match the curvatureof the femur.

The Slotted Hammer can be used on the Strike Plate (Fig.49.1), or if dense bone is encountered, the UniversalRod may be attached to the Nail Holding Screw andused in conjunction with the Slotted Hammer to insertthe nail (Fig. 49.2).

Note: Prior to insertion, check for correct assembly bypassing a drill bit through the Target Device andthrough the nail holes to help check alignment. DO NOT hit the Target Device. Only hit on the Strike Plate.

Fig. 48.1

Fig. 49.1

Fig. 49.2

Fig. 48.2

K-Wire

28

Technical Tip: A chamfer is located on the working end ofthe nail to denote the end under X-Ray. Threecircumferential grooves are located on the insertion post at2mm, 10mm, and 15mm from the driving end of the nail(Fig. 50). Depth of insertion may be visualized with the aidof fluoroscopy.

When locking the antegrade nail in the static mode, the nailis countersunk a minimum of 5mm (Fig. 51).

When the implant is inserted in the dynamic mode, withoutactive apposition/compression, or when the implant isinserted with active apposition/compression, therecommended depth of insertion is 15mm (Fig. 52).

Additionally, the 3 x 285mm K-Wire may be insertedthrough the Target Device which indicates the junction ofthe nail and insertion post (see Fig 48.2 on p. 27).

Insertion of the 3 x 285mm K-Wire into the lateral cortexmay also help to lock the Target Device to the proximalfemur and prevent rotation of the nail in cases where theApposition/Compression Locking Mode is utilized.

Repositioning should be carried out either by hand or byusing the Strike Plate on the top of the Target Device. The Universal Rod and Slotted Hammer may then beattached to the Strike Plate to carefully and smoothly extractthe assembly.

Note: Remove the Guide Wire prior to drilling andinserting the Locking Screws.


Prior to guided locking via the Target Device the NailHolding Screw must be firmly tightened using the UniversalJoint Socket Wrench, to help ensure that the nail is in correctalignment with the Target Device (Fig. 53).

The Target Device is designed with four locking holes.According to the selected locking mode, the appropriateholes are used (see Fig. 14.1.-14.3 on p. 16).

The Long Tissue Protection Sleeve (1806-0185) together withthe Long Drill Sleeve (1806-0215) and the Long Trocar(1806-0315) is inserted into the Target Device by pressingthe safety clip (see Fig. 15 on p.16). The mechanism willkeep the sleeve in place and prevent it from falling out. Itwill also prevent the sleeve from sliding during screwmeasurement. To release the Tissue Protection Sleeve, thesafety clip must be pressed again.

Fig. 50

Fig. 51

Fig. 52

Fig. 53


Static

Dynamic

Apposition/Compression

2 mm

5 mm10 mm

15 mm

29


The Long Tissue Protection Sleeve together with the LongDrill Sleeve and the Long Trocar are positioned throughthe static locking hole on the Target Device. A small skinincision is made, and the assembly is pushed through untilit is in contact with the lateral cortex of the femur (Fig. 54).The Trocar is removed while the Tissue Protection Sleeveand the Drill Sleeve remain in position.

To help ensure accurate drilling, and easy determination ofscrew length, use the center tipped, calibrated Ø4.2x340Drill (1806-4260S). The centered Drill is forwardedthrough the Drill Sleeve and pushed onto the cortex.

After drilling both cortices, the screw length may be readdirectly off of the calibrated Drill at the end of the DrillSleeve (Fig. 55 and see Fig. 17 and 18 on p. 17).

When the Drill Sleeve is removed, the correct LockingScrew is inserted through the Tissue Protection Sleeveusing the Long Screwdriver Shaft (1806-0227) withTeardrop Handle (702429) (Fig. 56). The screw isadvanced through both cortices. The screw is near its’proper seating position when the groove around the shaftof the screwdriver is approaching the end of the TissueProtection Sleeve (see Fig. 19 on p. 17).

Repeat the locking procedure for the other statically positioned Locking Screws (Fig. 57). The most proximalM/L hole (nearest the driving end of the nail) is notgenerally utilized in the antegrade mode.

Note: In unstable fracture patterns, static locking shouldalways be performed with at least two Locking Screwsdistal and two Locking Screws proximal.

Fig. 54

Fig. 55

Fig. 56

Fig. 57


30


6.10. Freehand Distal Locking

The freehand technique is used to insert Fully ThreadedLocking Screws into both distal M/L holes in the nail.Rotational alignment must be checked prior to locking thenail statically.

Multiple locking techniques and radiolucent drill devices areavailable for freehand locking. The critical step with anyfreehand locking technique, proximal or distal, is tovisualize a perfectly round locking hole or perfectly oblonglocking hole with the C-Arm.

The center-tipped Ø4.2x180 Drill (1806-4270S) is held at anoblique angle to the center of the locking hole (Fig. 58 and59). Upon X-Ray verification, the Drill is placedperpendicular to the nail and drilled through the lateral andmedial cortex. Confirm in both the A/P and M/L planes by X-Ray that the Drill passes through the hole in the nail.

After drilling both cortices, the screw length may be readdirectly off of the Long Screw Scale (1806-0365) at the greenring on the center tipped Drill (see Fig. 25 on p. 19).Alternatively, the optional Depth Gauge, Standard Style forFreehand Locking (1806-0390), may be used after drilling todetermine the length of screw needed.

Routine Locking Screw insertion is employed with theassembled Long Screwdriver Shaft and Teardrop Handle (Fig.60).

Note: The Screwdriver Shaft may be used in conjunctionwith the Long Screw Capture Sleeve (1806-0240).


After removal of the Target Device, an End Cap is used. Fourdifferent sizes of End Caps are available to adjust nail lengthand to reduce the potential for bony ingrowth into theproximal thread of the nail. (see Fig. 27 on p. 20)

Technical Tip: All End Caps are designed to tighten downonto the Locking or Condyle Screw at the driving end of thenail. This will help prevent the nail from M/L sliding.

The End Cap is inserted with the Long Screwdriver Shaft andTeardrop Handle after intra-operative radiographs showsatisfactory reduction and hardware implantation (Fig. 61).Fully seat the End Cap to minimize the potential forloosening.

Note: Final verification of implants should be confirmed byX-Ray at this time.

Thoroughly irrigate the wound to prevent debris fromremaining. Close the wound using the standard technique.

Fig. 58

Fig. 59

Fig. 60

Fig. 61

31



When the fracture profile permits, dynamic locking maybe utilized for transverse, axially stable fractures. Whiledynamic locking can be performed at either end of thenail, routine antegrade dynamic locking should utilize theM/L oblong hole at the Target Device.

The Partially Threaded Locking Screw is placed in thedynamic position of the oblong hole via the Target Device.This allows the nail to move and the fracture to settle whileproviding torsional stability (Fig. 62).

Antegrade dynamization is performed by statically lockingthe nail distally with two M/L Fully Threaded LockingScrews in a freehand technique.

Fig. 62

32


6.13. Apposition/Compression Locking Mode

In transverse, axially stable fracture patterns, active apposition/compression increases fracture stability, may enhance fracturehealing, and allow for early weight bearing. The T2™ Femoral Nail gives the option to treat a femur fracture with activemechanical apposition/compression prior to leaving the operating room.

Note: Distal freehand static locking with at least two Fully Threaded Locking Screws must be performed prior to applyingactive, controlled apposition/compression to the fracture site.

If active apposition/compression is required, a Partially Threaded Locking Screw (Shaft Screw) is inserted via the Target Devicein the dynamic position of the oblong hole. This will allow for a maximum of 10mm of active, controlledapposition/compression. In order to insert the Shaft Screw, drill both cortices with the Ø4.2x340 Drill (1806-4260S). Next,drill the near cortex, ONLY, with the Ø5x230mm Drill (1806-5000S).

Technical Tip: As previously described, it may be easier to insert the Compression Screw prior to fully seating the nail.

Note: After the opposite cortex is drilled with the Ø4.2x340mm Drill, the correct screw length can be read directly off ofthe calibrated Drill at the end of the Drill Sleeve.

After the Shaft Screw is inserted, the Nail Holding Screwsecuring the nail to the insertion post is removed, leaving theinsertion post intact with the nail (Fig. 63). This will act as aguide for the Compression Screw. The Compression Screw isinserted with the Compression Screwdriver Shaft (1806-0268) and Teardrop Handle through the insertion post (Fig.64). When the ring marked with an “F” on the CompressionScrewdriver Shaft is close to the Target Device, it indicatesthe engagement of the apposition/compression feature of thenail.

Note: The ring marked with a “T” is for the TibialCompression Screw.

The Long Tissue Protection Screw is removed and theCompression Screw is gently tightened utilizing the two-finger technique. As the Compression Screw is advancedagainst the 5.0mm Partially Threaded Locking Screw (ShaftScrew), it draws the distal fracture segment towards thefracture site, employing active apposition/compression (Fig.65). Image intensification will enable the surgeon tovisualize active apposition/compression. Some bending ofthe transverse Shaft Screw may be seen.

Note: Apposition/compression must be carried out underX-Ray control. Over compression may cause the nail or theShaft Screw to fail.

Technical Tip: When compressing the nail, the implant mustbe inserted a safe distance from the entry point toaccommodate for the 10mm of active compression. Thethree grooves on the insertion post help attain accurateinsertion depth of the implant.

Compression Screws are available in different lengths. Ashort Advanced Compression Screw to enable the AdvancedLocking Mode and longer Compression Screws fromStandard to +15mm provide a “best fit“ for every indication.An End Cap can only be inserted when using the AdvancedCompression Screw or when not using compression.

Fig. 63

Fig. 64

Fig. 65

33



In order to achieve additional fixation and to reduce the loadon the Partially Threaded Locking Screw (Shaft Screw), anadditional Locking Screw should also be inserted in themore proximal or more distal of the holes depending onfracture-stability.

6.15. Nail Removal

Nail removal is an elective procedure. If needed, the EndCap and Compression Screw are removed with the LongScrewdriver Shaft and Teardrop Handle (Fig 66).

Note: As an alternative to removing the AdvancedCompression Screw (if used), it can be just disengaged fromthe Partially Threaded Locking Screw (Shaft Screw) byturning the Compression Screwdriver one full turn in acounter-clockwise direction. There is no need to remove itfrom the nail.

The Universal Rod is inserted into the driving end of the nail.All Locking Screws are removed with the Long ScrewdriverShaft and Teardrop Handle. The “optional” Long ScrewCapture Sleeve may be used on the Screwdriver Shaft.

The Slotted Hammer is used to extract the nail in acontrolled manner (Fig. 67). A captured Sliding Hammer(1806-0175) is available as an “optional” addition to thebasic instrument set.

Fig. 66

Fig. 67

34

IMPLAN T S

T2™ Femoral Locking Nail Cat. Number Dia. x Length Cat. Number Dia. x Length

Implants in sterile packagingNote: Check with local representative regarding availability of nail sizes.+ These sizes not included in standard implant set (U.S.)

+1825-0914S Ø9x140 mm+1825-0916S Ø9x160 mm+1825-0918S Ø9x180 mm+1825-0920S Ø9x200 mm+1825-0922S Ø9x220 mm+1825-0924S Ø9x240 mm1825-0926S Ø9x260 mm1825-0928S Ø9x280 mm1825-0930S Ø9x300 mm1825-0932S Ø9x320 mm1825-0934S Ø9x340 mm1825-0936S Ø9x360 mm1825-0938S Ø9x380 mm1825-0940S Ø9x400 mm1825-0942S Ø9x420 mm+1825-0944S Ø9x440 mm+1825-0946S Ø9x460 mm+1822-0948S Ø9x480 mm

+1825-1014S Ø10x140 mm+1825-1016S Ø10x160 mm+1825-1018S Ø10x180 mm+1825-1020S Ø10x200 mm+1825-1022S Ø10x220 mm+1825-1024S Ø10x240 mm1825-1026S Ø10x260 mm1825-1028S Ø10x280 mm1825-1030S Ø10x300 mm1825-1032S Ø10x320 mm1825-1034S Ø10x340 mm1825-1036S Ø10x360 mm1825-1038S Ø10x380 mm1825-1040S Ø10x400 mm1825-1042S Ø10x420 mm1825-1044S Ø10x440 mm+1825-1046S Ø10x460 mm+1825-1048S Ø10x480 mm

+1825-1114S Ø11x140 mm+1825-1116S Ø11x160 mm+1825-1118S Ø11x180 mm+1825-1120S Ø11x200 mm+1825-1122S Ø11x220 mm+1825-1124S Ø11x240 mm1825-1126S Ø11x260 mm1825-1128S Ø11x280 mm1825-1130S Ø11x300 mm1825-1132S Ø11x320 mm1825-1134S Ø11x340 mm1825-1136S Ø11x360 mm1825-1138S Ø11x380 mm1825-1140S Ø11x400 mm1825-1142S Ø11x420 mm1825-1144S Ø11x440 mm+1825-1146S Ø11x460 mm+1825-1148S Ø11x480 mm

+1825-1224S Ø12x240 mm1825-1226S Ø12x260 mm1825-1228S Ø12x280 mm1825-1230S Ø12x300 mm1825-1232S Ø12x320 mm1825-1234S Ø12x340 mm1825-1236S Ø12x360 mm1825-1238S Ø12x380 mm1825-1240S Ø12x400 mm1825-1242S Ø12x420 mm1825-1244S Ø12x440 mm1825-1246S Ø12x460 mm+1825-1248S Ø12x480 mm

+1825-1314S Ø13x140 mm+1825-1316S Ø13x160 mm+1825-1318S Ø13x180 mm+1825-1320S Ø13x200 mm+1825-1322S Ø13x220 mm+1825-1324S Ø13x240 mm+1825-1326S Ø13x260 mm+1825-1328S Ø13x280 mm1825-1330S Ø13x300 mm1825-1332S Ø13x320 mm1825-1334S Ø13x340 mm1825-1336S Ø13x360 mm1825-1338S Ø13x380 mm1825-1340S Ø13x400 mm1825-1342S Ø13x420 mm1825-1344S Ø13x440 mm1825-1346S Ø13x460 mm1825-1348S Ø13x480 mm

+1825-1414S Ø14x140 mm+1825-1416S Ø14x160 mm+1825-1418S Ø14x180 mm+1825-1420S Ø14x200 mm+1825-1422S Ø14x220 mm+1825-1424S Ø14x240 mm+1825-1426S Ø14x260 mm+1825-1428S Ø14x280 mm1825-1430S Ø14x300 mm1825-1432S Ø14x320 mm1825-1434S Ø14x340 mm1825-1436S Ø14x360 mm1825-1438S Ø14x380 mm1825-1440S Ø14x400 mm1825-1442S Ø14x420 mm1825-1444S Ø14x440 mm1825-1446S Ø14x460 mm1825-1448S Ø14x480 mm

+1825-1514S Ø15x140 mm+1825-1516S Ø15x160 mm+1825-1518S Ø15x180 mm+1825-1520S Ø15x200 mm+1825-1522S Ø15x220 mm+1825-1524S Ø15x240 mm+1825-1526S Ø15x260 mm+1825-1528S Ø15x280 mm+1825-1530S Ø15x300 mm+1825-1532S Ø15x320 mm+1825-1534S Ø15x340 mm+1825-1536S Ø15x360 mm+1825-1538S Ø15x380 mm+1825-1540S Ø15x400 mm+1825-1542S Ø15x420 mm+1825-1544S Ø15x440 mm+1825-1546S Ø15x460 mm+1825-1548S Ø15x480 mm

35

IMPLANTS5mm Fully ThreadedLocking Screws

1891-5025S1891-5030S1891-5035S1891-5040S1891-5045S1891-5050S1891-5055S1891-5060S1891-5065S1891-5070S1891-5075S1891-5080S1891-5085S1891-5090S1891-5095S1891-5100S1891-5105S1891-5110S1891-5115S1891-5120S

5mm Partially ThreadedLocking Screws Cat. Number Dia. x Length

Ø5x 25 mmØ5x 30 mmØ5x 35 mmØ5x 40 mmØ5x 45 mmØ5x 50 mmØ5x 55 mmØ5x 60 mmØ5x 65 mmØ5x 70 mmØ5x 75 mmØ5x 80 mmØ5x 85 mmØ5x 90 mmØ5x 95 mmØ5x100 mmØ5x105 mmØ5x110 mmØ5x115 mmØ5x120 mm

Condyle Screws End Caps Cat. Number Dia. x Length

Nut for CondyleScrew

AdvancedCompression Screw, Femur Cat. Number Dia. x Length

1825-0001S Ø8 mm


(Shaft Screws)

Note: Outside of the U.S., Locking Screws and other specific products may be orderednon-sterile without the “S” at the end of the corresponding Cat. Number.

1822-0003S1822-0005S1822-0010S1822-0015S

Ø8.0mmØ11.5x 5mmØ11.5x10mmØ11.5x15mm

Cat. Number

1896-5025S1896-5030S1896-5035S1896-5040S1896-5045S1896-5050S1896-5055S1896-5060S1896-5065S1896-5070S1896-5075S1896-5080S1896-5085S1896-5090S1896-5095S1896-5100S1896-5105S1896-5110S1896-5115S1896-5120S

Cat. Number 1895-5040S1895-5045S1895-5050S1895-5055S1895-5060S1895-5065S1895-5070S1895-5075S1895-5080S1895-5085S1895-5090S1895-5095S1895-5100S1895-5105S1895-5110S1895-5115S1895-5120S

1895-5001S

Cat. Number

1825-0000S1825-0005S1825-0010S1825-0015S

Dia. x Length

Ø5x 25 mmØ5x 30 mmØ5x 35 mmØ5x 40 mmØ5x 45 mmØ5x 50 mmØ5x 55 mmØ5x 60 mmØ5x 65 mmØ5x 70 mmØ5x 75 mmØ5x 80 mmØ5x 85 mmØ5x 90 mmØ5x 95 mmØ5x100 mmØ5x105 mmØ5x110 mmØ5x115 mmØ5x120 mm

Dia. x Length Ø5x 40 mmØ5x 45 mmØ5x 50 mmØ5x 55 mmØ5x 60 mmØ5x 65 mmØ5x 70 mmØ5x 75 mmØ5x 80 mmØ5x 85 mmØ5x 90 mmØ5x 95 mmØ5x100 mmØ5x105 mmØ5x110 mmØ5x115 mmØ5x120 mm

Ø5 mm

Dia. x Length

Ø8 mmØ8 mm, 5mmØ8 mm,10mmØ8 mm,15mm

Compression Screws

36

I NSTRU M E NTS *

Cat. Number Description

1806-6005

1806-0015

1806-0020

1806-0040

1806-0050

1806-0095

1806-0096

1806-0110

1806-0125

1806-0130

1806-0135

1806-0150

1806-0165

1806-0170

1806-0185

1806-0215

1806-0227

1806-0255

1806-0268

1806-0292

1806-0315

1806-0325

1806-0365

T2™ Femur Instrument Set, Basic

X-Ray Ruler, Femur

Guide Wire Ruler

Awl, Curved, Ø10mm

K-Wire 3 x 285mm (outside of U.S.)

Guide Wire Handle

Guide Wire Handle Chuck

Universal Rod

Reduction Spoon

Wrench 8mm/10mm

Insertion Wrench, 10mm

Strike Plate

Nail Holding Screw, Femur

Slotted Hammer

Tissue Protection Sleeve, Long

Drill Sleeve, Long

Screwdriver Shaft AO, Long

Screwdriver, Condyle Screw (2 each)

Screwdriver Shaft, Compression

Screw Driver Shaft, 3.5 x 85mm

Trocar, Long

Screw Gauge, Long

Screw Scale, Long

*Instruments designated “Outside of the U.S.” may not be ordered for the U.S. market.

37

I N STRUMENTS

Cat.Number Description

1806-0400

1806-1005

1806-2012

1806-4260

1806-4270

1806-4290

1806-5000

1806-5020

1806-9010

1806-9025

702429

703165

0152-0218

Optional:

0152-0218S

1806-0005

1806-0045

1806-0050S

1806-0085

1806-0085S

1806-0175

1806-0232

1806-0237

1806-0240

1806-0270

1806-0300

1806-0350

1806-4260S

1806-4270S

1806-4290S

1806-5000S

1806-5020S

Socket Wrench, Universal Joint 10mm

Target Device, Femur (2 components)

Rigid Reamer Ø12mm

Drill Ø4.2x340, AO, (outside of U.S.)





Screw Tray

Femur Instrument Tray

Teardrop Handle, AO coupling

Protection Sleeve, Retrograde

K-Wire for Condyle Screw, (outside of U.S.)

K-Wire for Condyle Screw, sterile (U.S.)

X-Ray Template, Femur

Awl, Straight, ‚Ø10mm

K-Wire 3 x 285mm, sterile

Guide Wire, Ball Tip, 3 x 1000mm (outside of U.S.)

Guide Wire, Ball Tip, 3 x 1000mm, sterile (U.S.)

Sliding Hammer

Screwdriver, Long

Screwdriver, Short

Screw Capture Sleeve, Long

Ratchet T-Handle AO

Screw Driver Shaft, Ball Tip

Extraction Rod, Conical, Ø8mm

Drill Ø4.2x340, AO, sterile (U.S.)





Special Order Items:

1806-0120

1806-0200

1806-0340

702427

703166

1806-2011

1806-0047

0140-0002

1806-0390

1806-1007

Reduction Tip

Screwdriver, Extra Short

Extraction Adapter

T-Handle, AO Coupling

Freehand Drill Sleeve

Rigid Reamer, Ø11.5mm

Awl, Straight Ø11.5mm

Reaming Protector

Depth Gauge, Standard Style

for Freehand Locking

Target Device Locking Nut, Spare

38

I NSTRUM ENT S

There are two answers to the reaming question.This is one...

The other is

Recent studies1 have demonstrated that the pressures

developed within the medullary cavity through the

introduction of unreamed IM nails can be far greater than

those developed during reaming – but this depends very

much upon the design of the reamer.

After a three year development study2 involving several

universities, the factors that determine the pressures and

temperatures developed during reaming were clearly

established. These factors were applied to the development

of advanced reamers that demonstrate significantly better

performance than the best of previous designs.

1 Jan Paul M. Frolke, et al.; Intramedullary Pressure in Reamed Femoral

Nailing with Two Different Reamer Designs. Eur. J. of Trauma, 2001 #5

2 Medhi Massau, et al.; Pressure Changes During Reaming with Different

Parameters and Reamer Designs, Clinical Orthopaedics and Related

Research Number 373, pp.295-303,2000

Forward- and side-cuttingface combination producesefficient material removaland rapid clearance.

Typical StandardReamer Ø14mm

Clearance area:32% of cross section

Reamer Ø14mm

Clearance area :59% of cross section

Complete range of modular and fixed-headreamers to match surgeon preference andoptimize O.R. efficiency, presented in fullysterilizable cases.

™

* Data on file at Howmeduica Osteonics

*

I N STRUMENTS

39

Smaller, 6 and 8 mm shaftdiameters designed to reduceIM pressure.

Modular Fixed Head Fixed HeadHead Modified Trinkle fitting + AO-fitting

Diameter Cat.no. Cat.no. Length Cat.no. Length*6.0 Fixed Head only 0227 - 5060 400 mm 0225 - 5060 400 mm*6.5 Fixed Head only 0227 - 5065 400 mm 0225 - 5065 400 mm*7.0 Fixed Head only 0227 - 5070 400 mm 0225 - 5070 400 mm7.5 Fixed Head only 0227 - 6075 480 mm 0225 - 6075 480 mm8.0 Fixed Head only 0227 - 6080 480 mm 0225 - 6080 480 mm8.5 Fixed Head only 0227 - 6085 480 mm 0225 - 6085 480 mm9.0 0226 - 3090 0227 - 6090 480 mm 0225 - 6090 480 mm9.5 0226 - 3095 0227 - 6095 480 mm 0225 - 6095 480 mm10.0 0226 - 3100 0227 - 6100 480 mm 0225 - 6100 480 mm10.5 0226 - 3105 0227 - 6105 480 mm 0225 - 6105 480 mm11.0 0226 - 3110 0227 - 6110 480 mm 0225 - 6110 480 mm11.5 0226 - 3115 0227 - 8115 480 mm 0225 - 8115 480 mm12.0 0226 - 3120 0227 - 8120 480 mm 0225 - 8120 480 mm12.5 0226 - 3125 0227 - 8125 480 mm 0225 - 8125 480 mm13.0 0226 - 3130 0227 - 8130 480 mm 0225 - 8130 480 mm13.5 0226 - 3135 0227 - 8135 480 mm 0225 - 8135 480 mm14.0 0226 - 3140 0227 - 8140 480 mm 0225 - 8140 480 mm14.5 0226 - 3145 0227 - 8145 480 mm 0225 - 8145 480 mm15.0 0226 - 3150 0227 - 8150 480 mm 0225 - 8150 480 mm15.5 0226 - 3155 0227 - 8155 480 mm 0225 - 8155 480 mm16.0 0226 - 3160 0227 - 8160 480 mm 0225 - 8160 480 mm16.5 0226 - 3165 0227 - 8165 480 mm 0225 - 8165 480 mm17.0 0226 - 3170 0227 - 8170 480 mm 0225 - 8170 480 mm17.5 0226 - 3175 0227 - 8175 480 mm 0225 - 8175 480 mm18.0 0226 - 3180 0227 - 8180 480 mm 0225 - 8180 480 mm18.5 0226 - 418519.0 0226 - 419019.5 0226 - 419520.0 0226 - 420020.5 0226 - 420521.0 0226 - 421021.5 0226 - 421522.0 0226 - 422022.5 0226 - 422523.0 0226 - 423023.5 0226 - 423524.0 0226 - 424024.5 0226 - 424525.0 0226 - 4250 25.5 0226 - 425526.0 0226 - 4260

Shaft, AO 0226 - 3000 450 mmShaft, Mod. trinkle 0227 - 3000 or 3000S for sterile shafts (U.S.) 450 mmShaft, AO 0226 - 8240 284 mmShaft, Mod. trinkle+ 0227 - 8240 or 8240S for sterile shafts (U.S.) 284 mmTray, Modular Head 0225 - 6000 (9.0 - 22.0mm)Tray, Modular Head 0225 - 6001 (6.0 - 26.0mm)Tray, Fixed Head 0225 - 8000 (6.0 - 18.0mm)

Large clearance rate resulting from reduced number of reamer blades coupled withreduced length of reamer head designedto give effective relief of pressureand efficient removal of material.

Double-wound shaft designed to transmit torque effectivelyand with high reliability. Low-friction surface finish designed toaid rapid debris clearance.

Cutting flute geometry designed to optimize to lower pressuregeneration.

Power Adaptors.AO Reamer to Stryker® Power4103-210 Stryker® System 4 Rotary Hand Piece 4100-210 Stryker® System 2000 (4100 Cordless) Available through: Stryker® Instruments Division sales force

* Use with 2.2mm x 800mm Smooth Tip and2.5mm x 800mm Ball Tip Guide wires only.

+ Use with Stryker Power Equipment

NOTES:

howost.com

Stryker® is a registered trademark of Stryker Corporation. T2™, Gamma™ and Bixcut™ are trademarks of Howmedica Osteonics Corp.©Howmedica Osteonics 2005 Lit. No. B1000004 2M 07/06 MC/OI Rev. 1 Printed in U.S.A.

The T2™ Tibial Nailing System represents the latest and most comprehensive developmentof the original intramedullary principles presented by Prof. Gerhard Küncher in 1940. Inaddition to End Caps in different lengths, four different locking options, including anAdvanced Apposition/Compression Mode, the system features a common, streamlinedinstrumentation system and intuitive surgical approach.

The T2™ Humeral Nailing System is one of the first humeral nailing systems to offer anoption for either an antegrade or a retrograde approach within the same implant, thusreducing the learning curve and inventory. The main advantages include four differentlocking options (static, dynamic, apposition/compression, advanced) and End Caps indifferent lengths to provide a “best fit” in each indication.

The Trochanteric Gamma® Locking Nail and the Long Gamma® LockingNail, were designed by surgeons. Combining the strength and biomechanical

advantages of the existing Gamma® family, they are the “Gold Standard“ for proximalfemoral fractures with more than 500,000 implanted world-wide.

For more than 15 years, children from all over the world have been treated successfullyusing the Metaizeau Pediatric Nailing System. The main advantages of the system includea simple and fast technique, closed reduction, limited hospital stay, and minimaldisturbance of bone growth. The nail can be adapted to the patient, to provide a “best fit“for every case.

The I.M. Saw is suitable for closed osteotomies of the femur and tibia in all cases whichallow the use of intramedullary nails for fragment fixation. Closed osteotomies withsubsequent fragment fixation are indicated for correction of rotational deformities, angulardeformities along the axis, and lengthening and shortening procedures.

After a three year study involving several universities, the factors that determine thepressures and temperatures developed during reaming were clearly established. Thesefactors were then applied to the development of advanced reamers that demonstratesignificantly better performance than the best of previous designs.

ManufacturerEU Operations

Stryker® Trauma GmbHProf.-Küntscher-Strasse 1–5

D-24232 SchönkirchenGermany

TIBIA

HUMERUS

METAIZEAU (Not cleared for sale in the U.S.)

I.M. SAW (Not available in the U.S.)

REAMING SYSTEM

U.S. OperationsAllendale, NJ(800) 447-7836howost.com

REF NO: B1000004

femoral nailing system operative · pdf filefemoral nailing system operative technique. ......

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