Synthes The Titanium Femoral Nail System Technique Manual
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Synthes The Titanium Femoral Nail System Technique Manual

Solid and cannulated nails
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The Titanium
Femoral Nail System
Solid and Cannulated Nails
TECHNIQUE GUIDE
Standard Locking
130˙ Antegrade Locking
Spiral Blade Locking
Miss-A-Nail Locking
R

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Table of Contents
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Summary of Contents for Synthes The Titanium Femoral Nail System

  • Page 1 The Titanium Femoral Nail System Solid and Cannulated Nails TECHNIQUE GUIDE Standard Locking 130˙ Antegrade Locking Spiral Blade Locking Miss-A-Nail Locking...

  • Page 2: Table Of Contents

    Table of Contents Implant Specifications ..... . 2 Implant Chart ......7 Indications.

  • Page 3: Implant Specifications

    Implant Specifications 12 mm diameter proximal end Titanium Femoral Nails (green) Proximal flats 9 mm – 12 mm solid nails orient the specialty locking sleeves 10 mm – 15 mm cannulated nails Dynamic slot accepts 4.9 mm Material: locking bolt, 5.0 mm locking screw, Spiral Blade, or 5.0 mm Titanium - 6% aluminum - 7% niobium shaft screw.
  • Page 4 Standard Locking Implants (green) For all nails For 9 mm–12 mm solid nails and 10 mm–12 mm cannulated nails 20 mm 459.26–.100 12 mm Titanium End Caps 10 mm Protect proximal nail threads 0 mm 458.926–.999 from tissue ingrowth 4.9 mm Titanium Locking 0 mm extension •...
  • Page 5 Implant Specifications (continued) 130° Locking Implants (pink) For all nails For 9 mm–12 mm solid nails and 10 mm–12 mm cannulated nails 20 mm 10 mm 0 mm 130° 457.210 457.211 457.212 456.013 15 mm Titanium End Caps for 130° locking sleeves 130°...
  • Page 6 Spiral Blade Locking Implants (blue) For all nails 90° Spiral For 9 mm–12 mm solid nails and 10 mm–12 mm cannulated nails Front-cutting end 100° 110° 120° 456.70 –.120 Spiral Blades Cannulated Lengths: 70 –120 mm, • in 5 mm increments Cannulated for insertion •...
  • Page 7 Implant Specifications (continued) Miss-A-Nail Locking Implants (gold) 7.3 mm Titanium Cannulated Screws 16 mm cancellous thread • length for interfragmentary compression 7.3 mm Titanium Cannulated Screws Lengths: 70 –125 mm, • in 5 mm increments Accept 2.8 mm guide wire •...

  • Page 8: Implant Chart

    9–12 mm Solid Femoral Nails and 13–15 mm Cannulated 10–12 mm Cannulated Femoral Nails Femoral Nails Locking Sleeve not needed 12 mm End Caps 15 mm End Caps Standard Locking 459.012–.014 474.920 –.922 Sleeve 474.900 15 mm End Caps 130° Locking Sleeve 15 mm End Caps 130°...

  • Page 9: Indications

    Indications Indications for the STANDARD STANDARD Titanium Femoral Nail System include: Femoral shaft fractures • Subtrochanteric fractures • Ipsilateral femoral • neck/shaft fractures Impending pathologic • fractures Nonunions • Femoral shaft fractures For the femoral shaft fracture, two standard locking configurations are possible: Static transverse locking •...
  • Page 10 CASE 1 CASE 2...
  • Page 11 Indications (continued) Femoral shaft or 130° ANTEGRADE stable* subtrochanteric fractures For the femoral shaft or the stable subtrochanteric fracture, 130° antegrade locking is possible. CASE 3 * Lesser trochanter and medial buttress intact/attached to the proximal fragment...
  • Page 12 Subtrochanteric fractures SPIRAL BLADE For the subtrochanteric fracture with a detached lesser trochanter, the Spiral Blade provides secure fixation of the proximal fragment. The Spiral Blade is not indicated for intertrochanteric fractures. CASE 4...
  • Page 13 Indications (continued) Ipsilateral femoral neck/ MISS-A-NAIL shaft fractures For the ipsilateral femoral neck/shaft fracture, the Miss-A-Nail instruments permit insertion of titanium cannulated screws into the femoral head, anterior to the nail path, for fixation of the neck fracture prior to intramedullary fixation of the shaft fracture. The Miss-A-Nail instruments also permit screw insertion into the femoral head after nail insertion, for the occult neck fracture.

  • Page 14: Preoperative Implant Selection

    Preoperative Implant Selection For all locking procedures Use the AO Preoperative Planner rulers to determine Note that all ruler images are enlarged 15% to account the following measurements: for average radiograph magnification; however, deviations Nail length • in magnification levels are common. Nail diameter •...

  • Page 15: Opening The Femur

    Instruments for Opening the Femur Small Battery Drive with 14.4 V Battery Pack Set [105.954], specifically: Battery Casing for 14.4 V Battery Quick Coupling 532.032 for K-Wires 532.022 Large Quick Coupling Small Battery Drive 14.4 V Battery 532.015 532.010 532.033 3.2 mm Calibrated Guide Wire 13.0 mm Cannulated Drill Bit 292.69...
  • Page 16 Opening the Femur Position the patient Position the patient in the lateral decubitus or supine position, on a fracture or radiolucent operating table. Use of the Large Distractor is optional. Position the C-arm so true AP and lateral views are possible. Reduce the fracture.
  • Page 17 Opening the Femur (continued) Open the canal With a power drill or hand chuck, insert the 3.2 mm guide wire into the entry point. Pass the guide wire into the medullary canal to a depth of 100 mm, confirming direction and depth with the image intensifier.
  • Page 18 Reaming guidelines (optional technique) Under image intensification, reduce the fracture and insert the appropriate reaming rod into the canal as far as the distal metaphysis. Ream to desired diameter in 0.5 mm increments. Advance the reamer with a steady, moderate pressure. Do not force the reamer.

  • Page 20: Standard Locking

    Standard Locking The Titanium Femoral Nails allow two standard locking configurations (static transverse and dynamic transverse locking) for fixation of the femoral shaft fracture. Steps of the procedure: Fracture reduction • Insertion of the nail • Insertion of proximal and distal •...
  • Page 21 Implants and Instruments for Standard Locking 15 mm Titanium End Cap for 12 mm Titanium Standard Locking Sleeve End Cap (green) 474.92x (green) 459.01x Titanium Femoral Nails 46x.xx, 474.xxx Standard Locking Sleeve for 13–15 mm nails (green) 474.900 4.9 mm Titanium 5.0 mm Titanium Locking Bolt Locking Screw...
  • Page 22 Standard Locking For solid nails Assemble the insertion instruments Insert the appropriate connecting screw into the insertion handle. Couple the handle to the nail so the handle orients laterally (convex side of the nail bow faces anteriorly). For solid nails: Use Connecting Screw [357.54].
  • Page 23 Standard Locking (continued) Instrument Assembly Thread the driving cap onto the insertion handle. Slide the hammer onto the guide and pivot the handle to lock it in place. Thread this assembly into the proximal end of the driving cap, and finger-tighten the assembly.
  • Page 24 Insert the nail Manually insert the nail into the femoral opening using a twisting hand motion, with the insertion handle oriented laterally. Verify fracture reduction, and insert the nail as far as possible by hand. Monitor nail passage across the fracture under image intensifi- cation and use the insertion assembly to manipulate the...
  • Page 25 Standard Locking (continued) Lock proximally For static locking, insert a 4.9 mm locking bolt or 5.0 mm locking screw through the inferior, proximal hole in the nail. For added rotational control, insert a second bolt or screw through the dynamic slot. For subsequent, controlled axial dynamization of the fracture, remove the static locking bolt or locking screw at a later date.
  • Page 26 Note: There is no need to calculate bolt To minimize measuring errors, use the ‘pause and consider’ or screw length; the calibrated method: Temporarily stop the drill drill bit provides a direct measure- ment. However, since drill bit when the bit hits the far cortex. position directly represents locking Press the drill sleeve to the lateral bolt or locking screw position in...
  • Page 27 Standard Locking (continued) Lock distally For distal locking techniques, see pages 64– 65. Place the green end cap With the insertion handle If the nail end isn’t visible, in place, take an AP image remove the aiming arm, place intensification view of the a 3.2 mm guide wire through proximal femur.
  • Page 28 Remove the insertion instruments. Using the hexagonal screwdriver or ratchet wrench with socket extension, align the end cap with the nail axis to prevent cross-threading. Thread the green end cap into the nail until it seats fully. Use the ratchet wrench to insert the green end cap Use the hexagonal screwdriver to insert the green end cap...

  • Page 30: 130° Antegrade Locking

    ° Antegrade Locking The 130° locking sleeve allows fixation of the femoral shaft fracture or the stable subtrochanteric fracture (with lesser trochanter intact and attached to the proximal fragment). Steps of the procedure: Fracture reduction • Insertion of the nail and locking sleeve •...
  • Page 31 Implants and Instruments ° for 130 Antegrade Locking 15 mm Titanium Titanium Locking Sleeve End Cap (pink) (pink) 456.013 457.21x Titanium Femoral Nails 46x.xx, 474.xxx 4.9 mm Titanium 130° Locking Sleeve Locking Bolt for 13 –15 mm nails (pink) Hexagonal Screwdriver 459.xx 474.913 314.75...
  • Page 32 ° Antegrade Locking Enlarge the femoral opening Fully insert the broach into the femoral opening using a twisting hand motion, to accommodate the 15 mm diameter 130° locking sleeve. Assemble the implants Orient the pink 130° locking sleeve to the nail so the word “lateral”...
  • Page 33 Antegrade Locking ° (continued) Assemble the insertion instrumentation Assemble the insertion instruments to the nail and locking sleeve, as described on page 22. Note: The aiming arm is not needed for the 130° locking procedure. Insert the nail Manually insert the nail into the femoral opening using a twisting hand motion, with the insertion handle oriented...
  • Page 34 Seat the nail Using light blows of the hammer, seat the nail into the distal metaphysis, leaving the proximal nail end at or just below the level of the tip of the greater trochanter. If the nail has been inserted over a 2.5 mm Reaming Rod, remove the reaming rod.
  • Page 35 Antegrade Locking ° (continued) Insert the 4.9 mm Locking Bolt or 5.0 mm Locking Screw Extend the insertion site incision, or make a separate stab incision under the protection sleeve. Insert the 4.0 mm drill sleeve and trocar into the protection sleeve to bone.
  • Page 36 Note: There is no need to calculate bolt To minimize measuring errors, use the ‘pause and consider’ or screw length; the calibrated drill bit provides a direct method: Temporarily stop the measurement. However, since drill when the bit hits the far drill bit position directly represents cortex.
  • Page 37 Antegrade Locking ° (continued) Place the pink end cap With the insertion handle in If the nail end isn’t visible, place, take an AP image place a 3.2 mm guide wire intensification view of the through the hole in the proximal femur.
  • Page 38 Remove the insertion instruments. Using the hexagonal screwdriver or ratchet wrench with socket extension, align the end cap with the nail axis to prevent cross-threading. Thread the green end cap into the nail until it seats fully. As the final threads of the end cap turn into the nail, the surgeon will feel increased resistance.

  • Page 40: Spiral Blade Locking

    Spiral Blade Locking The Spiral Blade allows fixation of the subtrochanteric fracture, with or without a detached lesser trochanter, for secure fixation of the proximal fragment. Steps of the procedure: Fracture reduction • Insertion of the nail with locking sleeve •...
  • Page 41 Implants and Instruments for Spiral Blade Locking Titanium Spiral Blade 15 mm Titanium 456.xxx Titanium Locking Sleeve End Cap (blue) (blue) Titanium Femoral Nails 457.01x 456.01x 46x.xx, 474.xxx 4.9 mm Titanium Spiral Blade Locking Quick Coupling Locking Bolt Sleeve for 13 –15 mm for K-Wires 459.xx nails (blue) 474.91x...
  • Page 42 Spiral Blade Locking Enlarge the femoral opening Fully insert the broach into the femoral opening using a twisting hand motion. The opening must accommodate the blue 15 mm Locking Sleeve for Spiral Blade. If needed, adjust the insertion site location at this time. Ideally, the end of the Spiral Blade will rest in the center of the femoral head in the lateral view.
  • Page 43 Spiral Blade Locking (continued) Assemble the insertion instrumentation Assemble the insertion instruments to the nail and locking sleeve, as shown on page 21. Do not attach the Specialty Aiming Arm to the handle until the nail is fully inserted. It can loosen during nail insertion.
  • Page 44 Verify fracture reduction, and pass the nail as far as possible by hand with the insertion handle in this position. For cannulated nails: Insert the nail over the 2.5 mm Reaming Rod. The rod will pass through the opening in the side of the insertion handle.
  • Page 45 Spiral Blade Locking (continued) Verify nail insertion Insert the Spiral depth and rotation Blade guide wire Make a short incision under Nail insertion depth dictates Spiral Blade position in the the wire sleeve. Insert the coronal plane. 3.2 mm trocar into the wire sleeve to bone.
  • Page 46 Advance the guide wire into the femoral head until the tip is 5 –10 mm short of subchondral bone. Advance the guide wire Monitor wire placement with image intensification in the AP and lateral views. (The black section of the insertion handle is partially radiolucent.) If wire position is incorrect, remove the wire, adjust the...
  • Page 47 Spiral Blade Locking (continued) Insert the Spiral Blade Insert the Spiral Blade connecting screw into the Spiral Blade inserter. Thread the connecting screw into the Spiral Blade and tighten the assembly with the spanner wrench. Spiral Blade insertion assembly: The T-handle of the inserter is in the same plane as the Spiral Blade tip. The surgeon always has an external indicator of Spiral Blade tip position, facilitating easy insertion of the blade through the nail slot.
  • Page 48 Under image intensification, Note: If the Spiral Blade ensure that the bit has fully doesn’t enter the nail slot, penetrated the lateral cortex. ensure that: If a complete circle of cortex The Spiral Blade entry hole • is not removed, remove the is deep enough (complete protection sleeve and cortical circle removed);...
  • Page 49 Spiral Blade Locking (continued) Grip the blue handle of the inserter with one hand, and tap on the end of the connecting screw with the 700 gram hammer to insert the Spiral Blade. The blade should advance with each hammer blow. Monitor blade insertion radiographically.
  • Page 50 Lock distally For distal locking techniques, see pages 64 –65. Place the blue end cap (required) The 15 mm collar of the blue end cap statically locks the blue sleeve to the nail. Upon final seating of the end cap, the UHMWPE* tip deforms around the blade edge, further securing the Spiral Blade during the nonweightbearing period.
  • Page 51 Spiral Blade Locking (continued) Place the blue end cap (continued) If the proximal nail end is distal to the tip of the greater trochanter, note the position of the insertion handle barrel in relation to the tip of the greater trochanter on the image. If the indented ring is at the •...
  • Page 52 Remove the insertion instruments. Using the hexagonal screwdriver or ratchet wrench with socket extension, align the end cap with the nail axis to prevent cross-threading. Thread the blue end cap into the nail until it seats fully. Use the hexagonal screwdriver to Use the ratchet to insert the blue insert the blue end cap end cap...

  • Page 54: Miss-A-Nail Locking

    Miss-A-Nail Locking The Miss-A-Nail device allows screw fixation of the neck fracture prior to nail fixation of the shaft fracture. Steps of the procedure: Fracture reduction • Insertion of Miss-A-Nail instrument • assembly through the standard nail insertion site Cannulated screw fixation of the femoral •...
  • Page 55 Implants and Instruments for Miss-A-Nail Locking 5.0 mm Titanium Shaft Screw 13.0 mm Titanium 7.3 mm Titanium Cannulated Screws* 457.xxx Washer (optional) 408.xxx 419.99 Cannulated Hexagonal Screwdriver 3.2 mm Calibrated Guide Wires 314.05 292.69 Quick Coupling for K-Wires 532.022 Large Quick Coupling 532.015 Hexagonal Screwdriver 314.75...
  • Page 56 Miss-A-Nail Locking Reduce the neck fracture If the femoral neck fracture is displaced, perform meticulous reduction and temporarily stabilize the fracture. Open reduction may be necessary. When using K-wires, place them anterior and/or posterior to the anticipated path of Identify dummy nail entry the nail.
  • Page 57 Miss-A-Nail Locking (continued) Assemble the Miss-A-Nail instruments Insert the connecting screw into the insertion handle. Couple the handle to the short dummy nail. Use the ratchet wrench to secure the connecting screw to the dummy nail. Insert the dummy nail Insert the dummy nail Manually insert the dummy nail into the femoral opening.
  • Page 58 Select screw angle Under AP image intensification, lay a guide wire on the anterior thigh along the femoral neck axis. Adjust the angle of the guide wire until it is perpendicular to the fracture. This will allow the surgeon to place the screws perpen- dicular to the fracture for optimal fracture compression.
  • Page 59 Miss-A-Nail Locking (continued) Adjust for anteversion Readjust the image intensifier for a lateral view of the proximal femur. (The black portion of the aiming arm is partially radiolucent.) Rotate the insertion handle around the dummy nail until the wire sleeve is directed safely through the center of the femoral neck and into the femoral head.
  • Page 60 Adjust screw position Insert the second 2.8 mm wire sleeve into the inferior bushing of the Miss-A-Nail jig. Reposition the image intensifier for an AP image of the proximal femur. Independently adjust the two bushings of the Miss-A-Nail jig to maximize distance between the screws while remaining within the femoral neck.
  • Page 61 Miss-A-Nail Locking (continued) Insert the screws Make a stab incision under one wire sleeve. Insert the 2.8 mm trocar into the sleeve to bone and remove the trocar. Insert the 2.8 mm guide wire through the sleeve and into the femoral head. Allow the wire to “pull”...
  • Page 62 Remove the wire sleeve, slide the black measuring device over the wire, and measure for direct screw length. (This device measures to the tip of the guide wire.) Remove the measuring device. Insert the self-drilling/self- tapping screw into the femoral head through the protection sleeve using the cannulated screwdriver.
  • Page 63 Miss-A-Nail Locking (continued) Insert the second screw using the same technique. Insert the nail Proceed with standard nail insertion technique (pages 21–25). Insert the second screw Drill for shaft screw Insert the 3.2 mm calibrated Insert the 5.0 mm guide wire through the sleeve shaft screw and into the femoral head until it is just short of subchondral...
  • Page 64 Lock proximally Statically lock the shaft fracture by inserting a locking bolt or locking screw through the inferior, proximal hole. Follow standard proximal locking technique (see pages 24–25). Lock distally For distal locking techniques, see pages 64 – 65. Drill for the locking bolt or Insert the locking bolt or locking screw locking screw...

  • Page 65: Distal Locking

    Distal Locking (all procedures) Reconfirm reduction Confirm reduction/alignment of the distal fragment. To use the Radiolucent Drive: Align the image intensifier with the most distal hole in the nail until a perfect circle is visible in the center of the screen.
  • Page 66 Under image intensification, insert the tip of the 4.0 mm brad-point drill bit into the incision and place the bit oblique to the x-ray beam until the tip is centered in the locking hole. Center drill bit in locking hole Tilt the drive until the drill bit is in line with the beam and appears as a radiopaque solid...

  • Page 67: Implant Removal

    Implant Removal Remove the end cap Clear bone from the end cap. Use the ratchet wrench with socket extension or large hexagonal screwdriver to remove the end cap. Remove the end cap Remove the locking bolt(s) or locking screw(s) Using the screwdriver with holding sleeve, remove the locking bolt or locking screw.
  • Page 68 Remove the Spiral Blade Manually thread and finger- tighten the extraction screw into the hub of the Spiral Blade. Thread the hammer guide assembly into the extraction screw. Insert extraction screw Extract the Spiral Blade Extract the Spiral Blade. Maintain a loose grip on the extraction assembly, as it and the blade rotate clockwise upon extraction.
  • Page 69 Titanium Femoral Nail Standard Insertion and Locking Sets with Locking Bolts [105.655] with Locking Screws [105.657] 304.500 Titanium Femoral Nail Standard Insertion and Locking Set Graphic Case 305.580 Locking Screw Labels for Graphic Case (included in set 105.657) Note: For sterile implants, add “S” to set number.
  • Page 70 Instruments 292.69 3.2 mm Calibrated Guide Wire, 357.511 Insertion Handle 300 mm, 5 ea. 357.512 Cannulated Connecting Screw 314.11 Holding Sleeve for Hexagonal 357.515 Ball Hexagonal Screwdriver, 8 mm Screwdriver [314.75] 357.516 Cannulated Shaft, 8 mm Hex 314.75 Hexagonal Screwdriver 357.54 Connecting Screw 315.40...
  • Page 71 Titanium Femoral Nail Standard Insertion and Locking Sets [105.655] and [105.657] (continued) ◊ Implants for Standard Locking 12 mm Titanium End Caps for 9 –12 mm nails 20 mm ◊ 4.9 mm Titanium Locking Bolts in [105.655] 10 mm EXTENSION 459.012 0 mm, 2 ea.
  • Page 72 ◊ Titanium Femoral Nails Available individually only Titanium Solid Femoral Nails (9 mm–12 mm diameters) 9 mm diameter 10 mm diameter 11 mm diameter 12 mm diameter 464.30 300 mm 465.30 300 mm 467.30 300 mm 466.30 300 mm 464.32 320 mm 465.32 320 mm...
  • Page 73 Titanium Femoral Nail Specialty Locking Set [105.68] 304.520 Titanium Femoral Nail Specialty Locking Set Graphic Case Implant tray with lid for independent autoclaving and storage of back-up inventory. May also be purchased separately. Note: For sterile implants, add “S” to set number.
  • Page 74 Instruments SPIRAL BLADE MISS-A-NAIL 351.23 13.0 mm/3.2 mm Trocar 292.68 2.8 mm Threaded Guide Wire, 300 mm, 5 ea. 351.28 15.5 mm/13 mm Protection Sleeve 310.63 5.0 mm Cannulated Drill Bit, 351.89 Broach (also used for 130° locking) 300 mm/255 mm, 2 ea. 357.31 Inserter for Spiral Blade 312.05...
  • Page 75 Titanium Femoral Nail Specialty Locking Set [105.68] (continued) Implants 130° ANTEGRADE ◊ ° Titanium 15 mm Titanium End Caps ◊ Locking Sleeve for 130 ° Locking Sleeve 456.013 2 ea. EXTENSION 457.210 0 mm, 2 ea. 457.211 10 mm, 2 ea. 457.212 20 mm, 2 ea.
  • Page 76 MISS-A-NAIL 304.508 5.0 mm Titanium Shaft Screw Tray, with lid Also Available 7.3 mm Titanium Cannulated Screws, 5.0 mm Titanium 16 mm thread length ◊ Shaft Screws LENGTH 408.870 70 mm, 2 ea. LENGTH 408.875 75 mm, 2 ea. 457.070 70 mm, 2 ea.
  • Page 77 MISS-A-NAIL Also available for Miss-A-Nail locking with 6.5 mm Titanium Cancellous Screws 357.94 5.6 mm/3.2 mm Wire Sleeve, 150 mm, for use with Miss-A-Nail Jig Also available for Miss-A-Nail locking with 7.3 mm Titanium Cannulated Screws 311.689 Cannulated Tap for 6.5 mm and 314.17 Large Hexagonal Screwdriver with universal 7.3 mm Cannulated Screws...
  • Page 78 To order: (800) 523-0322 To order: (800) 668-1119 Fax: (610) 251-9056 Fax: (905) 567-3185 www.synthes.com © 1996 Synthes, Inc. or its affiliates. All rights reserved. Synthes is a trademark of Synthes, Inc. or its affiliates. Printed in U.S.A. Rev. 9/09 J2052-E...

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