part of the depuy synthes locking compression plate (lcp ) system...

Part of the DePuy Synthes Locking Compression Plate (LCP®) System

2.7 mm/3.5 mm LCP® Distal Fibula PlateSurgical Technique

Image intensifier control

2.7 mm/3.5 mm LCP® Distal Fibula Plates Surgical Technique DePuy Synthes 1

Introduction

Surgical Technique

Product Information

Table of Contents

2.7 mm/3.5 mm LCP Distal Fibula Plates 2

AO Principles 4

Indications 5

Preparation 6

Reduce Distal Fibula 8

Insert and Position Plate 9

Distal Screw Insertion 10

Shaft Screw Insertion 13

Confirm Reduction and Fixation 15

Implant Removal 16

Implants 17

Instruments 19

Set List 20

MR Information The 2.7 mm/3.5 mm LCP Distal Fibula Plates System has not been evaluated for safety and compatibility in the MR environment. It has not been tested for heating, migration or image artifact in the MR environment. The safety of the 2.7 mm/3.5 mm LCP Distal Fibula Plates System in the MR environment is unknown. Scanning a patient who has this device may result in patient injury.

2 DePuy Synthes 2.7 mm/3.5 mm LCP® Distal Fibula Plates Surgical Technique

2.7 mm/3.5 mm LCP Distal Fibula Plates. Part of the DePuy Synthes Locking Compression Plate (LCP) System.

The 2.7 mm/3.5 mm LCP® Distal Fibula Plates are part of the DePuy Synthes locking compression plate system that merges locking screw technology with conventional plating techniques.

The plates are available in stainless steel and titanium and feature an anatomic shape and profile, both distally and along the fibular shaft. The Combi holes in the LCP Plate shaft combine a dynamic compression unit (DCU) hole with a locking screw hole. Combi holes provide maximum flexibility with the options of axial compression and locking capability throughout the length of the plate shaft. K -wire holes accept K- wires (up to 2.0 mm) to temporarily fix the plate to the distal fibula, to temporarily reduce articular fragments, and to confirm the location of the plate, relative to the distal fibula.

Fixation with the 2.7 mm/3.5 mm LCP Distal Fibula Plates provides the same benefits of traditional plate fixation methods, with a few important improvements. Locking screws provide the ability to create a fixed-angle construct while using standard AO plating techniques. The ability to place locking screws is especially important in osteopenic bone, short bone fragments, and multifragment fractures, where screw purchase is compromised. These screws do not rely on plate- to- bone compression to resist patient load, but function similarly to multiple, small, angled blade plates.

Note: For information on fixation principles using conventional and locked plating techniques, please refer to the Small Fragment Locking Compression Plate (LCP) Technique Guide.


Anatomically shaped

Recesses for screwheads in coaxial holes minimize screw prominence to create a low-profile construct

Combi holes in shaft accept 3.5 mm locking screws, 3.5 mm cortex screws, and 4.0 mm cancellous bone screws

Five coaxial distal holes accept 2.4 mm and 2.7 mm locking and cortex screws to provide multiple screw options

Four K-wire holes in the head accept 2.0 mm K-wires

2.7 mm/3.5 mm LCP Lateral Distal Fibula Plate

2.7 mm/3.5 mm LCP Posterolateral Distal Fibula Plate

Anatomically shaped

Combi holes in shaft accept 3.5 mm locking screws, 3.5 mm cortex screws, and 4.0 mm cancellous bone screws

Six round locking holes and two coaxial holes accept 2.4 mm and 2.7 mm locking and cortex screws to provide multiple screw options

Recesses for screwheads in coaxial holes minimize screw prominence to create a low-profile construct

2.7 mm locking screw2.7 mm cortex screw2.4 mm cortex screw

Screw profiles in coaxial hole

2.7 mm/3.5 mm LCP Distal Fibula Plates. Part of the DePuy Synthes Locking Compression Plate (LCP) System.


AO Principles

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4_Priciples_03.pdf 1 05.07.12 12:08

4 DePuy Synthes Expert Lateral Femoral Nail Surgical Technique

AO PRINCIPLES

In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation1, 2.

1 Müller ME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal Fixation. 3rd ed. Berlin Heidelberg New York: Springer. 1991.

2 Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme. 2007.

Anatomic reductionFracture reduction and fixation to restore anatomical relationships.

Early, active mobilizationEarly and safe mobilization and rehabilitation of the injured part and the patient as a whole.

Stable fixationFracture fixation providing abso-lute or relative stability, as required by the patient, the injury, and the personality of the fracture.

Preservation of blood supplyPreservation of the blood supply to soft tissues and bone by gentle reduction techniques and careful handling.

In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation.1,2

Anatomic reductionFracture reduction and fixation to restore anatomical relationships.

Early, active mobilizationEarly and safe mobilization and rehabilitation of the injured part and the patient as a whole.

Stable fixationFracture fixation providing absolute or relative stability, as required by the patient, the injury, and the personality of the fracture.

Preservation of blood supplyPreservation of the blood supply to soft tissues and bone by gentle reduction techniques and careful handling.

1. Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation. 3rd ed. Berlin, Heidelberg, New York: Springer-Verlag; 1991.

2. Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme; 2007.


Indications

The 2.7 mm/3.5 mm LCP Distal Fibula Plates are indicated for fractures, osteotomies and nonunions of the metaphyseal and diaphyseal region of the distal fibula, especially in osteopenic bone.


Preparation

The techniques for implanting the lateral and posterolateral distal fibula plates are similar. The following describes implantation of a lateral plate.

1Preoperative planning

Required set

105.434/ Small Fragment LCP Instrument and Implant145.434 Set, with self-tapping screws

(stainless steel or titanium)

Complete the preoperative radiographic assessment and plan. Determine plate length and distal screw locations to ensure proper plate selection and position, and screw placement in the distal fibula.


2Position patient

Position the patient supine with a sandbag (bump) underneath the buttock of the affected side. This allows the foot to lie in a neutral position and prevents the normal external rotation of the leg. Elevate the leg on a padded rest with the knee slightly flexed to assist placement in a neutral position.

Visualization of the distal fibula under fluoroscopy in both the lateral and AP views is recommended.

Note: The direction of the locking screws is determined by the design of the plate, based on the average anatomy of the distal fibula. If manual contouring of the plate in the metaphyseal area is necessary, or if the patient’s normal anatomy is not well matched by the implant, the distal screw trajectories will be altered. The screw trajectories can be confirmed using the K-wire screw placement verification technique.

3Approach

Make a straight lateral or posterolateral surgical incision to expose the fibular fracture, the distal fibula, and the fibular diaphysis. A lateral incision directly over the fibula can accentuate plate prominence and the wound closure will be directly over the implant.

Alternatively, the incision can be placed along the posterolateral border of the fibula where there is improved soft tissue coverage.

Precaution: Be careful not to damage the superficial peroneal nerve proximally and anteriorly, or the sural nerve posteriorly.

Deep dissection allows exposure of the fibula along its length. An extraperiosteal approach to the fibula proximal to the fracture is usually preferred.

Preparation


Reduce Distal Fibula

4Reduce fibular fracture

Expose and clean the fracture site and reduce the fracture. It is critical that fibular length, alignment and rotation are accurately restored.

In spiral or oblique fracture patterns, a clamp can be applied for reduction. Provisional reduction can be maintained with pointed reduction forceps or K-wires.

Alternatively, in some fracture patterns, the plate can be used to assist with and guide the reduction. This may be especially important in comminuted fractures where a bridging technique is used.

Note: Application of an external fixator or distractor may facilitate obtaining fibular length, fracture reduction and visualization of the distal tibiofibular joint.

Confirm the reduction with image intensification. Temporary reduction can be obtained with clamps, multiple Kirschner wires, or independent lag screws if the fracture pattern allows. K-wires can be placed through the distal end of the plate to assist with temporary maintenance of the reduction and for plate placement. Options for maintaining the reduction depend on the fracture configuration and include:– Independent lag screws

– Lag screws through the plate

– Locking screws through the plate

Locking screws do not provide interfragmentary compression; compression must be achieved with standard lag screws or by using the plate itself to compress the fracture. The fracture must be reduced and compressed before fixation of the LCP Distal Fibula Plate with locking screws in simple fracture configurations. If a bridge plate technique is planned, the implant can be secured proximally and distally using locking screws, if the fibular length, alignment and rotation are correct.


5Insert plate

Expose the fibula proximally as needed for plate application. In the majority of circumstances, an open approach for plate application will be performed.

Occasionally, a submuscular plate insertion will be performed using a minimally invasive technique. The plate can be slid along the lateral fibular shaft and positioned with the distal end of the plate approximately 5 mm from the tip of the fibula.

Note: The 2.7 mm/3.5 mm posterolateral fibula plate is typically positioned 8–10 mm from the tip of the fibula.

6Position plate and fix provisionally

Temporarily hold the plate in position using any of the following options. These options also prevent plate rotation while inserting the first locking screw:– Standard plate holding forceps

– K-wires placed through the plate distally and/or proximally

– 2.7 mm cortex screw placed in one of the distal holes

– 3.5 mm cortex screw placed in a Combi hole

After plate insertion, check plate placement and alignment using fluoroscopy. Ensure proper reduction before inserting the first locking screw. Once locking screws are inserted, further reduction is not possible without loosening the locking screws.

Verify plate placement under image intensification to determine if final screw and plate placement are acceptable.

Insert and Position Plate


Distal Screw Insertion

7Distal screw insertion

Determine the combination of screws to be used for fixation. If a combination of locking and cortex screws will be used, cortex screws should be inserted first.

Note: To secure the plate to the fibula before locking screw insertion, it is recommended to pull the plate to the bone using a cortex screw.

Nonlocking screw insertion—fixation with 2.7 mm cortex screws

Instruments

311.43 Handle, with quick coupling

315.28* 2.7 mm Three-Fluted Drill Bit, quick coupling, 125 mm

319.006 Depth Gauge

323.062 2.0 mm Drill Bit with depth mark, quick coupling, 140 mm

323.26* 2.7 mm Universal Drill Guide

Use the 2.0 mm drill bit through the 2.7 mm universal drill guide to predrill the bone.

Measure for screw length using the depth gauge.

Select and insert the appropriate 2.7 mm cortex screw using the small hexagonal screwdriver.

* Found in the Small Fragment LCP Instrument and Implant Set


Locking screw insertionIf a locking screw will be used as the first screw, be sure the fracture is reduced and the plate is held securely to the bone. This prevents plate rotation as the screw is locked to the plate.

Instruments


313.353 Drill Guide

314.467 StarDrive Screwdriver Shaft, T8

314.468* Holding Sleeve for StarDrive Screwdriver Shaft, T8

319.006 Depth Gauge

323.061 2.0 mm Threaded Drill Guide, with Depth Gauge

323.062 2.0 mm Drill Bit with depth mark, quick coupling, 110 mm

511.776 Torque Limiting Attachment, 0.8 Nm, quick coupling

Insert the 2.0 mm threaded drill guide into a 2.7 mm locking hole until fully seated. Use the 2.0 mm drill bit to drill to the desired depth. Remove the 2.0 mm threaded drill guide.

Use the depth gauge to determine screw length.

Precaution: When determining appropriate screw length, ensure that the screw tip will not protrude past the articular surface.

* Also available



7. Distal screw insertionLocking screw insertion continued

Alternative technique: Direct measuring with calibrated drill bitDetermine where locking screws will be used. Screw the 2.0 mm threaded drill guide into a threaded hole until it is fully seated. Use the 2.0 mm drill bit with depth mark to drill to the desired depth. Determine the screw length directly from the 2.0 mm drill bit.

The 2.7 mm locking screw can be inserted manually or with power. For power insertion, use the T8 StarDriveTM Screwdriver shaft attached to the 0.8 Nm torque limiting attachment. For manual insertion, use a handle with quick coupling. Use a holding sleeve, if necessary. Insert additional locking screws, as planned.



8Shaft screw insertion

Nonlocking screw insertion—fixation with 3.5 mm cortex screws

Instruments

310.25* 2.5 mm Drill Bit



314.02* Small Hexagonal Screwdriver with Holding Sleeve or 314.03* Small Hexagonal Screwdriver Shaft

319.01* Depth Gauge

323.36* 3.5 mm Universal Drill Guide

Use the 2.5 mm drill bit through the 3.5 mm universal drill guide to predrill the bone. For the neutral position, press the drill guide down in the nonthreaded hole. To obtain compression, place the drill guide at the end of the nonthreaded hole away from the fracture (do not apply downward pressure on the spring-loaded tip).

Measure for screw length using the depth gauge for small screws.

Select and insert the appropriate 3.5 mm cortex screw using a small hexagonal screwdriver.

Shaft Screw Insertion

* Found in the Small Fragment LCP Instrument and Implant Set


8. Shaft screw insertion continued

Locking screw insertion

Instruments


312.648* 2.8 mm Threaded Drill Guide

314.115* StarDrive Screwdriver, T15

314.116* StarDrive Screwdriver Shaft, T15

319.01* Depth Gauge

511.770** Torque Limiting Attachment, 1.5 Nm or 511.773* Torque Limiting Attachment, 1.5 Nm, quick coupling

Insert the 2.8 mm threaded drill guide into a locking hole or Combi hole until fully seated. Use the 2.8 mm drill bit to drill to the desired depth. Remove the drill guide.

Use the depth gauge to determine screw length.

Insert screw.

* Found in the Small Fragment LCP Instrument and Implant Set** Also available

Shaft Screw Insertion


Confirm Reduction and Fixation

9Confirm reduction and fixation

Carefully assess the final reduction and fixation via direct visualization and image intensification. Confirm the stability of the fixation and that there is unrestricted motion at the ankle joint. Using AP and lateral fluoroscopic visualization, confirm reduction and appropriate positioning of the plate and screws.


Implant removal

Optional set

01.240.001 Screw Removal Set

Optional instrument

309.520* Conical Extraction Screw

Unlock all screws from the plate, then remove the screws completely from the bone. This prevents simultaneous rotation of the plate when unlocking the last locking screw.

If the screws cannot be removed with the screwdriver, insert the conical extraction screw with left-handed thread into the screwhead using a handle with quick coupling and loosen the locking screw by turning counterclockwise.

Implant Removal

* Found in Screw Removal Set 01.240.001


Screws Used with the 2.7 mm/3.5 mm LCP Distal Fibula PlatesStainless Steel and Titanium

4.0 mm Cancellous Bone Screws* – May be used in the DCU portion of the Combi holes

in the plate shaft

– Compress the plate to the bone or create axial compression

– Fully or partially threaded shaft

– Stainless steel or titanium

3.5 mm Cortex Screws, self-tapping*– May be used in the DCU portion of the Combi holes in the plate shaft

– Compress the plate to the bone or create axial compression

– Stainless steel or titanium

3.5 mm Locking Screws, self-tapping* – Used in the locking portion of the Combi holes in the plate shaft

– Create a locked, fixed-angle screw/plate construct

– Stainless steel or titanium alloy

2.7 mm Cortex Screws, self-tapping*– May be used in the distal locking holes

– Compress the plate to the bone


2.7 mm Locking Screws, self-tapping– Used in the distal locking holes


2.4 mm Cortex Screws, self-tapping** – May be used in the distal locking holes

– Compress the plate to the bone


2.4 mm Locking Screws, self-tapping** – Used in the distal locking holes


Screws available in implant-quality 316L stainless steel, commercially pure (CP) titanium, or titanium alloy (Ti-6AI-7Nb) as noted. * Found in the Small Fragment LCP Instrument and Implant Set** Found in the Modular Mini Fragment LCP Instrument and Implant Set


2.7 mm/3.5 mm LCP Lateral Distal Fibula Plates

– Right and left designs

– 3 to 11 shaft holes

– Lengths from 73 mm to 177 mm

2.7 mm/3.5 mm LCP Posterolateral Distal Fibula Plates

– Right and left designs

– 3 to 11 shaft holes

– Lengths from 77 mm to 181 mm

Implants

Plates available in implant-quality 22Cr-13Ni-5Mn stainless steel or titanium alloy (Ti-6AI-7Nb).


Instruments

313.353 Drill Sleeve for 2.0 mm Drill Bit

311.43 Handle with quick coupling


323.061 2.0 mm Threaded Drill Guide

323.062 2.0 mm Drill Bit with depth mark


319.006 Depth Gauge


2.7 mm/3.5 mm LCP Distal Fibula Plate Instrument and Implant SetsStainless Steel (01.112.077) and Titanium (01.112.080)

Graphic Case60.112.046 Graphic Case, for LCP Distal Fibula Plates

60.112.047 Tray for 2.7 mm/3.5 mm LCP Posterolateral Distal Fibula Plates

Instruments 311.43 Handle, with quick coupling

313.353 Drill Sleeve for 2.0 mm Drill Bit


319.006 Depth Gauge, for 2.0 mm and 2.4 mm screws

323.061 2.0 mm Threaded Drill Guide, with depth gauge

323.062 2.0 mm Drill Bit with depth mark, quick coupling, 2 ea.


Implants2.7 mm/3.5 mm LCP Lateral Distal Fibula Plates

Stainless Length Steel Titanium Holes (mm)

02.112.136 04.112.136 3 73 right

02.112.137 04.112.137 3 73 left

02.112.138 04.112.138 4 86 right

02.112.139 04.112.139 4 86 left

02.112.140 04.112.140 5 99 right

02.112.141 04.112.141 5 99 left

02.112.142 04.112.142 6 112 right

02.112.143 04.112.143 6 112 left

02.112.144 04.112.144 7 125 right

02.112.145 04.112.145 7 125 left

02.112.148 04.112.148 9 151 right

02.112.149 04.112.149 9 151 left

02.112.152 04.112.152 11 177 right

02.112.153 04.112.153 11 177 left

Posterolateral plates not shown

Note: For additional information, please refer to package insert.

For detailed cleaning and sterilizationinstructions, please refer towww.synthes.com/cleaning-sterilization orsterilization instructions, if provided.

www.synthes.com/cleaning-sterilization


Required Set105.434/ Small Fragment LCP Instrument and Implant 145.434 Set, with self-tapping screws

(stainless steel or titanium)

Also Available01.111.120 Modular Mini Fragment LCP Instrument

and Implant Set

01.112.042 2.7 mm/3.5 mm LCP Lateral Distal Fibula Plate Instrument and Implant Set

01.112.044 2.7 mm/3.5 mm Titanium LCP Lateral Distal Fibula Plate Instrument and Implant Set

01.112.075 2.7 mm/3.5 mm LCP Posterolateral Distal Fibula Plate Instrument and Implant Set

01.112.078 2.7 mm/3.5 mm Titanium LCP Posterolateral Distal Fibula Plate Instrument and Implant Set

01.112.076 2.7 mm/3.5 mm LCP Posterolateral Distal Fibula Plate Implant Upgrade Set

01.112.079 2.7 mm/3.5 mm Titanium LCP Posterolateral Distal Fibula Plate Implant Upgrade Set

01.240.001 Screw Removal Set

314.468 Holding Sleeve, for StarDrive Screwdriver Shaft, T8

323.36 3.5 mm Universal Drill Guide

511.770 Torque Limiting Attachment, 1.5 Nm

60.112.043 Screw Rack, for 2.7 mm/3.5 mm LCP Distal Fibula Set

2.7 mm/3.5 mm LCP Posterolateral Distal Fibula Plates

Stainless Length Steel Titanium Holes (mm)

02.112.106 04.112.106 3 77 right

02.112.107 04.112.107 3 77 left

02.112.108 04.112.108 4 90 right

02.112.109 04.112.109 4 90 left

02.112.110 04.112.110 5 103 right

02.112.111 04.112.111 5 103 left

02.112.112 04.112.112 6 116 right

02.112.113 04.112.113 6 116 left

02.112.114 04.112.114 7 129 right

02.112.115 04.112.115 7 129 left

02.112.118 04.112.118 9 155 right

02.112.119 04.112.119 9 155 left

02.112.122 04.112.122 11 181 right

02.112.123 04.112.123 11 181 left

2.7 mm Locking Screws, self-tapping, with T8 StarDrive Recess, 2 ea.

Stainless Steel Titanium Length (mm)

202.208 402.208 8

202.210 402.210 10

202.212 402.212 12

202.214 402.214 14

202.216 402.216 16

202.218 402.218 18

202.220 402.220 20

202.222 402.222 22

202.224 402.224 24

202.226 402.226 26

202.228 402.228 28

202.230 402.230 30

Note: For additional information, please refer to package insert.

For detailed cleaning and sterilizationinstructions, please refer towww.synthes.com/cleaning-sterilization orsterilization instructions, if provided.

2.7 mm/3.5 mm LCP Distal Fibula Plate Instrument and Implant SetsStainless Steel (01.112.077) and Titanium (01.112.080)

Limited Warranty and Disclaimer: DePuy Synthes products are sold with a limited warranty to the original purchaser against defects in workmanship and materials. Any other express or implied warranties, including warranties of merchantability or fitness, are hereby disclaimed.

Please also refer to the package insert(s) or other labeling associated with the devices identified in this surgical technique for additional information.

CAUTION: Federal Law restricts these devices to sale by or on the order of a physician.

Some devices listed in this surgical technique may not have been licensed in accordance with Canadian law and may not be for sale in Canada. Please contact your sales consultant for items approved for sale in Canada.

Not all products may currently be available in all markets.

© DePuy Synthes 2009–2017. All rights reserved.DSUS/TRM/1016/1123 4/17 DV

Synthes USA, LLC 1101 Synthes AvenueMonument, CO 80132

Manufactured or distributed by:Synthes USA Products, LLC 1302 Wrights Lane EastWest Chester, PA 19380

To order (USA): 800-523-0322 To order (Canada): 855-946-8999

Note: For recognized manufacturer, refer to the product label.

www.depuysynthes.com

www.depuysynthes.com

part of the depuy synthes locking compression plate (lcp ) system...

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