Hip T2 KnifeLight Recon Nailing System R2.
T2 Recon Nailing System Contributing Surgeons We greatly acknowledge and appreciate the contributions to this operative technique made by: Kevin W. Luke, M.D. Parkview Orthopaedic Group Assistant Clinical Professor Department of Orthopaedic Surgery University of Illinois Illinois, Chicago USA Anthony T. Sorkin, M.D. Rockford Orthopaedic Associates, LLP Clinical Instructor Dep.
This publication sets forth detailed recommended procedures for using Stryker Osteosynthesis devices and instruments. It offers guidance that you should heed, but, as with 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. All non-sterile devices must be cleaned and sterilized before use. Follow the instructions provided in our reprocessing guide (L24002000).
Contents 1. Introduction & Features Implant Features Technical Specifications Instrument Features 2. 3. 4. 5.
Introduction Introduction Implant Features Over the past decades antegrade and retrograde femoral nailing have become widely accepted choices for the treatment of femoral fractures. The T2 Recon Nail is the realization of excellent biomechanical intramedullary stabilization for internal femoral fixation with several locking options to address fracture variability.
Introduction Technical Specifications Recon Set Screw Nail Diameter 9, 11, 13 and 15mm (Left and Right) Sizes 280−480mm, in 20mm increments Antegrade Set Screw 0mm Note: • Proximal diameter is 13mm for the 9 and 11mm Nails and 15mm for the 13 and 15mm Nails. 0mm 26mm 70° 125°Nail angle 44mm • Check with your local representative regarding availability of nail sizes. 10.5mm 4° Medial Lateral bend 17.0mm 5.0mm Fully Threaded Locking Screws L = 25–120mm Antecurvature radius 2.0M 6.
Introduction Instrument Features A major advantage of the T2 instrument platform is the integration of core instruments that can be used not only for the complete T2 Nailing System, but for future Stryker Osteosynthesis nailing systems, thereby, reducing complexity and inventory. The T2 instrument platform offers precision and usability, as well as ergonomically styled targeting devices.
Precautions The T2 Recon Nail is indicated for: Stryker Osteosynthesis systems have not been evaluated for safety and use in MR environment and have not been tested for heating or migration in the MR environment, unless specified otherwise in the product labeling or respective operative technique.
Pre-Operative Planning An X-Ray Recon Template (1806-3080) is available for pre-operative planning. Thorough evaluation of pre-operative radiographs of the affected extremity is critical. Careful radiographic examination of the trochanteric region and neck regions can reduce the potential of intra-operative complications. Note: The X-Ray Recon Template features a scale of 1.15:1 which is adapted to conventional analoguous X-Rays.
Locking Options Recon Mode The T2 Recon Nail can be locked proximally with two 6.5mm Lag Screws (Recon Mode, Fig. 1) or with one 5mm Fully Threaded Screw (Antegrade Femoral Mode, Fig. 2). For both Recon and Antegrade Femoral applications, depending on fracture pattern, either static or dynamic distal locking can be used. Fig. 1 Antegrade Femoral Mode Fig.
Operative Technique Patient Positioning and Fracture Reduction Patient positioning for T2 Recon Nail insertion is surgeon dependent. However, it is recommended that patients are positioned in either the supine or lateral position on a fracture table to allow closed reduction of the fracture (Fig. 3). Manipulate and reduce the fracture in the usual fashion, according to the fracture type. Reduction should be achieved as anatomically as possible.
Operative Technique Entry Point • The Tip of the greater Trochanter The entry point is located at the junction of the anterior third and posterior two-thirds of the greater trochanter on the medial edge of the tip itself (Fig. 6). Note: Before opening the tip of greater trochanter, image intensifier views (A/P and M/L) should be used to confirm correct identification of the entry point. 1 anterior /3 2 Fig.
Operative Technique • Entry point with One Step Conical Reamer Alternatively, the 13mm diameter One Step Conical Reamer for the 9 and 11mm nails or the 15mm diameter Reamer for the 13 and 15mm nails may be used for opening the medullary canal and reaming of the trochanteric region. K-Wire Under image intensification control, the entry point is made with a Ø3.2 × 400mm Recon K-Wire which is attached to the Guide Wire Handle and advanced into the medullary canal.
Operative Technique Reaming The Ø 3 × 1000mm Ball Tip Guide Wire is inserted with the Guide Wire Handle through the fracture site to the level of the epiphyseal scar. The Ø 9mm Universal Rod with Reduction Spoon may be used as a fracture reduction tool to facilitate Guide Wire insertion through the fracture site (Fig. 10). Note: The Ball Tip at the end of the Guide Wire will stop the Bixcut reamer* head (Fig. 11). Fig.
Operative Technique The Guide Wire Pusher can be used to keep the Guide Wire in position during reamer shaft extraction. The metal cavity at the end of the blue Elastosil handle may be placed on the end of Guide Wire. Applying pressure to hold the Guide Wire in place while removing the drill under power. (Fig. 14). Fig. 14 When close to the Guide Wire end, place the Guide Wire Pusher with its funnel tip at the end of the power tool cannulation (Fig. 15).
Operative Technique Nail Selection Diameter The diameter of the selected nail should be at least 2.0mm smaller than that of the last reamer used. Length end of guide Wire Ruler is measurement reference Fig. 16a Nail length may be determined by measuring the remaining length of the Guide Wire. The Guide Wire Ruler may be used by placing it on the Guide Wire and reading the correct nail length at the end of the Guide Wire on the Guide Wire Ruler (Fig. 16a, b).
Operative Technique Assembly of Targeting Device First, assemble the Knob to the Targeting Device by aligning the arrow on the Knob with the white line on the Target Sleeve, (Fig. 18a) then push hard to click it. By turning the Knob clockwise to the position labeled (A), the sleeve inserted in target (A) position, which is the distal Recon Mode targeting hole, can be locked. (Fig.
Operative Technique Nail Insertion The nail is advanced through the entry point passing the fracture site to the appropriate level. If dense bone is encountered, first re-evaluate that sufficient reaming has been achieved, then, if necessary, the Strike Plate can be attached to the Targeting Arm and the Slotted Hammer may be used to further insert the nail (Fig. 19). Caution: The nail must progress smoothly, without excessive force.
Operative Technique Guided Locking for the Recon Mode Nail / Lag Screws Positioning Drive the T2 Recon Nail to the depth that correctly aligns the proximal screw holes parallel with the femoral head and neck under fluoroscopic control (Fig. 20). Two aspects regarding the Nail/Lag Screws position must be carefully checked with the image intensifier before drilling into the femoral head: - Alignment of the anteversion (M//L view) - Depth of nail insertion (A/P view). Fig.
Operative Technique Now attach the Recon Paddle Trocar to the T-Handle, AO Medium Coupling (Fig. 21). Then, advance them together with the Recon Tissue Protection Sleeve to the skin through the hole on the Target Device labeled (A). Make a small skin incision and push the assembly through until it is in contact with the lateral cortex. Then turn the Knob clockwise to the position labeled (A) (Fig. 22). Remove the Trocar and then insert the Recon K-Wire Sleeve through the Tissue Protection Sleeve.
Operative Technique Note: With the image intensifier, verify if the K-Wire is placed along the calcar region in the A/P view and central on the lateral view (correct anteversion) (Fig. 24). If the K-Wire is incorrectly positioned, the first step is to remove it and then to correct the nail position. More commonly, the nail is positioned too proximal and correction of the nail should be carried out either by hand or by using the Strike Plate placed into the Target Device.
Operative Technique Nail/Lag Screws Positioning with the One Shot Device The use of the One Shot device (1213-3010) is recommended to predetermine the optimal Lag Screw placement* (Fig. 26). The One Shot Device is made of carbon fiber and works by providing a target to indicate the position of the K-Wire on the fluoroscope screen. The target contains 3 radio-opaque wires embedded in the arm – a dashed inner wire and two solid outer wires.
Operative Technique To identify the accurate position, the dashed wire of the target must appear between the two solid wires at the desired position. If the position is incorrect the T2 Recon Nail position may be corrected by either pulling backwards or pushing forwards (Fig. 28). The K-Wire can then be placed into the femur and the targeting arm is held in place until the K-Wire’s position in the lateral view has been determined.
Operative Technique Solid Stepdrill Technique For the insertion of proximal screws in Recon Mode, the Solid Stepdrill Technique, which is mentioned in this chapter, is the recommended method to optimize the proximal targeting accuracy. Attach the Recon Paddle Trocar to the T-Handle, AO Medium Coupling as demonstrated in Fig. 21. Then slide the Tissue Protection Sleeve together with the Paddle Trocar assembly to the skin through the proximal target hole labeled (B).
Operative Technique Using the Recon Screwdriver the correct Lag Screw is inserted through the Tissue Protection Sleeve and threaded up to the subcondral part of the femoral head. The screw is near its proper seating position when the groove around the shaft of the screwdriver is approaching the end of the Tissue Protection Sleeve (Fig. 32, 32a). The required length of the second Lag Screw can be measured using the Recon Lag Screw Gauge. Remove the Distal K-Wire and K-Wire Sleeve.
Operative Technique Alternatively, the K-Wire can be used prior to drilling with the Solid Drill. Place a second Recon K-Wire into the K-Wire Inserter and attach it to the T-Handle or power tool. The K-Wire is then advanced through the K-Wire Sleeve until it reaches the subchondral bone of the femoral head. Warning: Correct placement of the K-Wire tip in subchondral bone must be checked with image intensifier in both A/P and M/L views.
Operative Technique Cannulated Stepdrill Technique As the Cannulated Stepdrill technique was also discussed in a previous version of the operative technique, the insertion of the proximal screws in Recon Mode using this method will also be mentioned as a potential option. After achieving a satisfactory position of the first Recon K-Wire slide the second Recon Tissue Protection Sleeve together with the Recon K-Wire Sleeve into the proximal target hole on the Targeting Arm, labeled (B).
Operative Technique Caution: Before proceeding with drilling for the selected Lag Screw, check the A/P fluoroscopic views to see if the two Recon K-Wires are parallel. The distal K-Wire Sleeve is removed while the Tissue Protection Sleeve remains in position (Fig. 36a). The cannulated Ø6.5mm Recon Stepdrill for Lag Screw (REF 1806-3025) is forwarded through the Tissue Protection Sleeve and pushed onto the lateral cortex. The stop on the drill will only allow drilling up to 5mm before the K-Wire ends (Fig.
Operative Technique Guided Locking for Antegrade Femoral Mode Now attach the Paddle Trocar, Antegrade and the AO T-Handle Medium Coupling (Fig. 39). Then, advance them together with the Long Tissue Protection Sleeve through the targeting hole for the Antegrade Femoral Mode (left or right) by pressing the safety clip (Fig. 40). The mechanism will keep the sleeve in place and prevent it from falling out. It will also prevent the sleeve from sliding during screw measurement.
Operative Technique Pre-drilling the lateral cortex Pre-drilling opens the lateral cortex for the drill entry. Pre-drilling helps to prevent a possible slipping of the drill on the cortex and may avoid deflection within the cancellous bone. The Paddle Trocar Assembly is then removed and the Drill Sleeve is inserted through the Long Tissue Protection Sleeve (Fig. 42).
Operative Technique Therefore, if the end of the Drill is 3mm beyond the far cortex, the end of the screw will also be 3mm beyond (Fig. 46). Check the position of the end of the Drill with image intensification before measuring the screw length. If the screw measurement using the Long Screw Gauge is preferred, first remove the Long Drill Sleeve and read the screw length directly at the end of the Long Tissue Protection Sleeve.
Operative Technique Freehand Distal Locking The freehand technique is used to insert Fully Threaded Locking Screws into both distal transverse holes in the nail. Rotational alignment must be checked prior to locking the nail. This is performed by checking a lateral view at the hip and a lateral view at the knee. The anteversion should be the same as on the contralateral side. Multiple locking techniques and radiolucent drill devices are available for freehand locking.
Operative Technique Repeat the locking procedure for the insertion of the second 5mm Fully Threaded Locking Screw into the oblong hole in a static position (Fig. 52). The T2 Recon Nail may be used in the dynamic locking mode. When the fracture pattern permits, dynamic lock ing may be utilized for transverse, rotationally stable fractures. While dynamic locking can only be performed at the end of the nail, this will require a freehand distal targeting of the oblong hole in a dynamic position.
Operative Technique Set Screw or End Cap Insertion After removal of the Target Device, a Set Screw or End Cap can be used. Set Screw, Recon Two different Set Srews are available (Fig. 53a): - a Recon Set Screw to tighten down on the Proximal Lag Screw for the Recon Mode - an Antegrade Set Screw to tighten down on the oblique Fully Threaded Screw for the Femoral Antegrade Mode Set Screw, Antegrade End Caps Standard Fig. 53a +5mm +10mm +15mm Fig.
Ordering Information – Implants T2 Recon Nail, Left T2 Recon Nail, Right Titanium REF Diameter mm Length mm Titanium REF Diameter mm Length mm 1846-0928S 1846-0930S 1846-0932S 1846-0934S 1846-0936S 1846-0938S 1846-0940S 1846-0942S 1846-0944S 1846-0946S 1846-0948S 9.0 9.0 9.0 9.0 9.0 9.0 9.0 9.0 9.0 9.0 9.0 280 300 320 340 360 380 400 420 440 460 480 1847-0928S 1847-0930S 1847-0932S 1847-0934S 1847-0936S 1847-0938S 1847-0940S 1847-0942S 1847-0944S 1847-0946S 1847-0948S 9.0 9.0 9.0 9.0 9.0 9.0 9.
Ordering Information – Implants 6.5mm Lag Screws 5mm Fully Threaded Locking Screws Titanium REF Diameter mm Length mm Titanium REF 1897-6065S 1897-6070S 1897-6075S 1897-6080S 1897-6085S 1897-6090S 1897-6095S 1897-6100S 1897-6105S 1897-6110S 1897-6115S 1897-6120S 1897-6125S 1897-6130S 6.5 6.5 6.5 6.5 6.5 6.5 6.5 6.5 6.5 6.5 6.5 6.5 6.5 6.
Ordering Information – Instruments REF Description T2 Basic Long 702429 Teardrop Handle, AO Coupling** 703165 Protection Sleeve, Retrograde*** 1806-0022 Guide Wire Ruler 1806-0032 Awl Plug 1806-0041 Awl 1806-0110 Universal Rod 1806-0125 Reduction Spoon 1806-0130 Wrench 8mm/10mm 1806-0135 Insertion Wrench, 10mm*** 1806-0150 Strike Plate 1806-0170 Slotted Hammer 1806-0185 Tissue Protection Sleeve, Long 1806-0203 Screwdriver, Self-Holding, Extra Short (3.
Ordering Information – Instruments REF Description T2 Recon Instruments 1806-3100 Target Device 1806-3101 Knob for Target Device 1806-3005 Nail Holding Screw, Recon 1806-3010 One Step Conical Reamer Ø13, Recon 1806-3015 One Step Conical Reamer Ø15, Recon 1806-3026S Solid Stepdrill for Lag Screw* 1806-3030S Recon K-Wire, Recon* 1806-3031S K-Wire, Recon, CoCr 1806-3035 Lag Screw Gauge, Recon 1806-3040 K-Wire Sleeve, Recon 1806-3041 Drill Sleeve for Solid Stepdrill 1806-3045 Tissue Pro
Ordering Information – Instruments REF Description T2 Recon Instruments 1213-3010 One Shot Device 702628 T-Handle, AO Medium Coupling** 1806-3065 Extraction Screwdriver 1806-0085S Guide Wire, Ball Tip, Ø3 × 1000mm, sterile* 1806-3047 T2 Paddle Trocar Recon Mode 1806-3048 T2 Paddle Trocar Antegrade Mode 1806-3080 X-Ray Template, Recon 1806-9990 T2 Recon Instrument Tray 1806-9991 T2 Recon Instrument Set, completely filled REF Description Optional Instruments 1806-0040 Awl, Curved 1806-
Ordering Information – Instruments Bixcut Complete range of modular and fixed-head reamers to match surgeon preference and optimize O. R. efficiency, presented in fully sterilizable cases. Large clearance rate resulting from reduced number of reamer blades coupled with reduced length of reamer head to allow for effective relief of pressure and efficient removal of material 3. Cutting flute geometry optimized to lower pressure generation3.
Ordering Information – Instruments Bixcut Fixed Head − AO Fitting** Bixcut Modular Head REF Description 0226-3090 0226-3095 0226-3100 0226-3105 0226-3110 0226-3115 0226-3120 0226-3125 0226-3130 0226-3135 0226-3140 0226-3145 0226-3150 0226-3155 0226-3160 0226-3165 0226-3170 0226-3175 0226-3180 0226-4185 0226-4190 0226-4195 0226-4200 0226-4205 0226-4210 0226-4215 0226-4220 0226-4225 0226-4230 0226-4235 0226-4240 0226-4245 0226-4250 0226-4255 0226-4260 0226-4265 0226-4270 0226-4275 0226-4280 Bixcut Shaft
Notes 42
Notes 43
Manufactured by: Stryker Trauma GmbH Prof.-Küntscher-Strasse 1-5 D-24232 Schönkirchen Germany www.osteosynthesis.stryker.com This document is intended solely for the use of healthcare professionals. A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does not dispense medical advice and recommends that surgeon‘s be trained in the use of any particular product before using it in surgery.
