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S2™ Tibial Nail Compression
Operative Technique
Dr. George Anastopoulos, Dept. of Orthopaedics and TraumatologyGeneral Hospital „G. Gennimatas“AthensGreece
Prof. Kwok Sui Leung, M.D.Dept. of Orthopaedics and TraumatologyChinese University of Hong KongPrince of Wales Hospital, Hong Kong
David Seligson, M.D.Professor and Vice Chairman of the Department of Orthopaedic SurgeryUniversity of LouisvilleLouisville, KentuckyUSA
Adam Starr, M.D.Assistant Professor Department of Orthopedic SurgeryUniv. of Texas - Southwestern Medical CenterDallas, TexasUSA
Dr. Gilbert Taglang,Chief Surgeon - Emergency DepartmentCenter of Traumatology and Orthopaedics, CTO - StrasbourgFrance
Contributing Surgeon:
This publication sets forth detailed recommended procedures for using Stryker Trauma 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.
Introduction
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1. Introduction
1.1. Implant Features
1.2. Instrument Features
1.3. References
2. Indications
3. Pre-operative Planning
4. Operative Technique
4.1. Patient Positioning and Fracture Reduction
4.2. Incision
4.3. Entry Point
4.4. Unreamed Technique
4.5. Reamed Technique
4.6. Nail Selection
4.7. Distal Targeting Device Calibration
4.8. Nail Insertion
4.9. Distal Guided Locking Mode (via Distal Targeting Device)
4.10. Proximal Guided Locking Mode (via Target Device)
4.11. Static Locking Mode
4.12. Freehand Distal Locking
4.13. End Cap Insertion
4.14. Dynamic Locking Mode
4.15. Apposition/Compression Locking Mode
4.16. Nail Removal
Ordering Information - Implants
Ordering Information - Instruments
Contents
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1. Introduction 1.1. Implant Features
Introduction
The S2™ Nailing System represents the latest and most comprehensive development of the original intra-medullary principles presented by Prof. Gerhard Küntscher in 1940.
Stryker Trauma has created a new generation locking nail system, bringing together all the capabilities and benefits of separate nailing systems to create a single, integrated surgical resource for fixation of long bone fractures.
The S2™ Tibial Nail, Compression combines static, dynamic and apposition/compression locking mode options.
Furthermore, the S2™ Tibial Nail, Compression offers the following competitive advantages:
• Accomodates reamed or unreamed procedures.
• Provides solutions for very proximal and very distal tibia fractures.
• Distal Guided Locking option (via Distal Targeting Device).
Through the development of a common, streamlined and intuitive surgical approach, both in principle and in detail, the S2™ Tibial Nail Compression offers significantly increased speed and functionality for the treatment of fractures as well as simplifying the training requirements for all personnel involved.
The S2™ Tibial Nail, Compression is the realization of superior biomechanical intramedullary stabilization using small caliber, strong cannulated implants for internal fixation of the tibia.
In some indications, a controlled apposition/compression of bone fragments can be applied by introducing a Compression Screw from the top of the nail.
The Compression Screw is pushed against the proximal Partially Threaded Locking Screw that has been placed in the oblong hole, drawing the distal segment towards the fracture site. In stable fractures, this has the biomechanical advantage of creating active circumferential compression to the fracture site, transferring axial load to the bone, and reducing the function of the nail as a load-bearing device (1).
This ability to transfer load back to the bone can reduce the incidence of implant failure secondary to fatigue.Typical statically locked nails function as load-bearing devices and failure rates in excess of 20% have been reported (2).
The beneficial effect of apposition/compression in treating long-bone fractures in cases involving transverse and short oblique fractures that are axially stable is well documented (3,4).
The S2™ Tibial Nail, Compression may also be used for very proximal and very distal fractures.
Note:The most distal hole is centered at 5mm from the tip of the nail to better address hard to reach distal fractures.
Common 5mm cortical screws simplify the surgical procedure and promote a minimally invasive approach.• Fully Threaded Locking Screws
are available for regular locking procedures.
• Partially Threaded Locking Screws (Shaft Screws) are designed for use if apposition/compression is applied.
A Compression Screw to close the fracture site, and End Caps in four sizes are available to provide a ”best fit“ for every indication.
Note:The 8mm S2 Tibial Nail, Compression can only be locked distally with 4mm Fully Threaded Screws. As with all diameters of S2 Tibial Nail, Compression, the proxi-mal screws are 5mm.
All S2™ Tibial Nail Compression implants are made of Stainless Steel (316LVM).
The S2™Tibial Nails Compression are cannulated, not slotted and have a fluted profile for an optimal bending stiffness.
In addition, two longitudinal grooves (one on each side of the nail), between the 2 M/L Distal Locking Holes, are designed for the Distal Guided Locking Mode technique (via S2™ Distal Targeting Device). The main principle of this technique is based on easy nail detection with a Probe inserted into this groove. The groove is used to further guide the Probe into the Locking Hole. For detailed information about Distal Guided Locking Mode technique, please refer to the S2™ Distal Targeting Device – OP Technique, REF. NO. B1000012.
See the detailed chart on the next page for design specifications and size offering.
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4° Distal Bend(at 60mm from the tip)
Features
4.0mm Fully Threaded Locking Screws for 8mm Nails (Distal Holes only)L = 25−120mm
Standard+5mm+10mm+15mm
S2™ End Caps
S2™ Locking Screws
5.0mm Fully Threaded Locking ScrewsL = 25−120mm
10° Herzog bend(at 50mm from driving end)
5.0mm Partially Threaded Locking Screws L = 25−120mm
S2™ Compression Screw
19mm
35mm
45mm
25mm
15mm
5mm
Note:Screw length is measured from the top of the head to the tip.
Compression RangeTotal Length of Slot: 15mmLess Screw Diameter (−): 5mmMaximum Movement of Screw: 10mm
S2™ Tibial Nail, Compression
Diameter 8−14mmSizes 240−420mm (in 15mm increments)
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The major advantage of the instrument system is a break-through in the integration of the instrument platform which can be used not only for the complete S2™ Nailing System, but will be the platform for all future Stryker Trauma nailing systems, reducing complexity and inventory.The instrument platform offers advanced precision and usability, and features ergonomically styled targeting devices.
In addition to the advanced precision and usability, the instruments are number and color coded to indicate its usage during the surgical procedure. The number coding indicates the step during the surgical procedure in which the instrument is used.
1. T.E.Richardson, M. Voor, D. Seligson, Fracture Site Compression and Motion with Three Types of Intramedullary Fixation of the Femur, Osteosynthese International (1998), 6: 261−264.
2. Hutson et al., Mechanical Failures of Intramedullary Tibial Nails Applied without Reaming, Clin. Orthop. (1995), 315: 129−137.
3. M.E. Müller, et al. Manual of Internal Fixation, Springer-Verlag, Berlin.
4. O. Gonschorek, G.O. Hofmann, V. Bühren, Interlocking Compression Nailing: a Report on 402 Applications, Arch. Orthop. Trauma Surg (1998), 117: 430−437.
5. M.L.M.J. Goessens, R. Sijbers, J.S. Harbers, J.W.J.L. Stapert, Application of a proximal entry point for intramedullary nailing of the tibia, Osteosinthese International (2001) 9: 101−104
Step Color NumberOpening Red 1Reduction Brown 2Nail Introduction Green 3Guided Locking Light Blue 4Freehand Locking Dark Blue 5
DrillsDrills feature color coded rings:
4.2mm = GreenFor 5.0mm Fully Threaded Locking Screws and for the second cortex when using 5.0mm Partially Threaded Locking Screws (Shaft Screws).
5.0mm = BlackFor the first cortex when using 5.0mm Partially Threaded Locking Screws (Shaft Screws).
3.5mm = OrangeFor 4.0mm Fully Threaded Locking Screws for the distal hole only of the 8mm Tibial Nail.
1.2.Instrument Features 1.3. References
Features
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Fig. 1
S2 Tibial Nail CompressionScale: 1,10 : 110 % Magnification
Cat.-No.:1806-8009/Rev.:01
Nail diameters
Nail length range for all diameters : 240 - 420 mm
Ø8mm Ø14mm
Ø12mm
Ø11mm
Ø10mm
Ø9mm
Ø13mm
Manufacturer:
Stryker Trauma GmbHProf.-Küntscher Str. 1-524232 SchönkirchenGermany
0 10 20 30 40 50 60 70 80 90 100 110 120
L
240mm
255mm
270mm
285mm
300mm
330mm
315mm
345mm
360mm
375mm
390mm
405mm
420mm
+5 mm+10mm+15mm
End caps
Ø 11,5mmØ 11,5mm
Ø 8 mm
Ø 10 mm
Ø 11 mm
Ø 12 mm
Ø 13 mm
Ø 14 mm
Ø 9 mm
Ø 12mm
Ø 13mm
Ø 14mm
S2 Tibial Nail, CompressionLocking Options
Static
Dynamic / Compression
Locking screw positions before compression.For compression locking procedure please follow
Surgical-Technique
The S2™ Tibial Nail, Compression is indicated for:
• Open or closed tibial shaft fractures with a very proximal and/or very distal extent in which locking screw fixation can be obtained
• Multi-fragment fractures• Segmental fractures• Proximal or distal non-unions• Proximal or distal mal-unions• Pseudarthrosis• Corrective osteotomies• Pathologic and impending
pathologic fractures• Tumor resections
3. Pre-operative Planning
An X-Ray Template Tibia, Compression (1806-8009) is available for preoperative planning (Fig. 1).
Thorough evaluation of preoperative radiographs of the affected extremity is critical. Careful radiographic examination can prevent intra-operative complications. For standard mid-shaft fractures, the proper nail length should extend from just below the Tibial Plateau at the appropriate medio-lateral position to just proximal to the Epiphyseal Scar of the ankle joint.
This allows the surgeon to consider the apposition/compression feature of the S2™ Compression Tibial Nail knowing that 10mm of active apposition/compression is possible, prior to determining the final length of the implant. If apposition/compression is planned, the nail should be at least 10mm shorter.
Note:Check with local representative regarding availability of nail sizes.
2. Indications
Indications
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4.1. Patient Positioning and Fracture Reduction
a) The patient is placed in the supine position on a radiolucent fracture table and the leg is hyperflexed on the table with the aid of a leg holder, orb) The leg is free-draped and hung over the edge of the table (Fig. 2).
The knee is f lexed to >90°. A triangle may be used under the knee to accommodate flexion intra-operatively. It is important that the knee rest is placed under the posterior aspect of the lower thigh in order to reduce the opportunity of vascular compression and the risk of pushing the proximal fragment of the tibia forward.Anatomical reduction can be achieved by internal or external rotation of the fracture and by traction, adduction or abduction, and must be confirmed under image intensification. Draping must leave the knee and the distal end of the leg exposed.
4.2. Incision
A paratendenous incision is made from the patella extending down approximately 1.5−4cm in preparation of nail insertion. The Patellar Tendon may be retracted laterally or split at the junction of the medial third, and lateral two-thirds of the Patellar Ligament. This exposes the entry point (Fig. 3).
Fig. 3
Fig. 2
Operative Technique
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Fig. 5
Fig. 6
Fig. 4
M
Operative Technique
Based on radiological image, the medullary canal is opened through a superolateral plateau entry portal (5). The center point of the portal is located slightly medial to the lateral tibial spine as visualized on the A/P radiograph and immediately adjacent and anterior to the anterior articular margin as visualized on the true lateral radiograph.
Radiographic confirmation of this area is essential to prevent damage to the intra-articular structure during portal placement and nail insertion (Fig. 4). The opening should be directed with a central orientation in relation to the medullary canal. After penetrating the cortex with the 3×285mm K-Wire (1806-0050S), the Ø12mm Rigid Reamer (1806-2012) is used to access the medullary canal (Fig. 5). Alternatively, to penetrate the cortex, the Ø10mm Straight (1806-0045), or Curved (1806-0040) Awl may be used (Fig. 6).
Note:Guiding the Rigid Reamer over the K-Wire prior to K-Wire insertion within the Proximal Tibia will help to keep it straight while guiding the opening instrument centrally towards the canal. Do not use bent K-Wires.
4.3. Entry Point
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4.5. Reamed Technique
For reamed techniques, the 3×800mm Ball Tip Guide Wire (1806-0080S) is inserted through the fracture site. Except for the 8mm Tibial Nails, use of the Ball Tip Guide Wire does not require a Guide Wire exchange. The Universal Rod with Reduction Spoon may be used as a fracture reduction tool to facilitate Guide Wire insertion through the fracture site (Fig. 8).
Reaming (Fig. 9) is commenced in 0.5mm increments until cortical contact is appreciated. Final reaming should be 1mm−2mm larger than the diameter of the nail to be used.
Note: The proximal diameter of the 8mm−11mm diameter nails is 11.5mm. Additional proximal metaphyseal reaming may be required to facilitate nail insertion. Nail sizes 12−14mm have a constant diameter.
Operative Technique
4.4. Unreamed Technique
If an unreamed technique is preferred, the 3×800mm Smooth Tip Guide Wire (1806-0090S) is passed through the fracture site using the Guide Wire Handle (1806-0095 and 1806-0096) (Fig. 7). The Universal Rod (1806-0110) with Reduction Spoon (1806-0125), may be used as a fracture reduction tool to facilitate Guide Wire insertion (Fig. 8). Internal rotation during insertion will aid in passing the Guide Wire down the tibial shaft. The Guide Wire should lie in the center of the metaphysis and the diaphysis in both the A/P and Lateral views to avoid offset positioning of the nail. The Guide Wire Handle is removed leaving the Guide Wire in place.
Bixcut™ Reamer*The complete range of Bixcut™ reamers is available with either modular or fixed heads.The optimized cutting flute geometry is designed to reduce intramedullary pressure and temperature.This is achieved by the forward and side cutting face combination of the reamer blades. The large clearance rate resulting from the reduced number of reamer blades, coupled with the reduced length of the reamer head, relieves the intramedullary pressure and provides efficient removal of reamed material.
Note: The Ball Tip at the end of the Guide Wire will stop the Bixcut reamer head (Fig.10).
* See pages 25−26 for additional Bixcut™ Reamer system details.
Fig. 10
Fig. 9
Fig. 8
Fig. 7
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Operative Technique
4.6. Nail Selection
DiameterThe diameter of the selected nail should be 1.5−2mm smaller than that of the last reamer used.
LengthThe X-Ray Ruler Tibia Compression (1806-8014) may be used to determine nail diameter and length. The X-Ray Ruler may also be used as a guide to help determine final Locking Screw positions (Fig. 11).
Alternatively, nail length may be determined by measuring the remaining length of the Guide Wire. The Guide Wire Ruler (1806-0020) is placed on the Guide Wire and the correct nail length is read at the end of the Guide Wire on the Guide Wire Ruler (Fig. 12 & 13).
The Guide Wire Ruler is calibrated for 800 & 1000mm Guidewires with markings for the Tibia and Femur.
Note:Confirm the position of Guide Wire tip before measurement.
Upon completion of reaming, the appropriate size nail is ready for insertion.
End of Guide Wire Rulerequals Measurement Reference
End of Guide Wire Ruler
Hole Position Proximal
Hole Position Distal
nail diameters
nail length
Static
A/P Hole
M/L Holes
Fig. 11
Fig. 13
Fig. 12
Dynamic or Apposition/Compression
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4.7. Distal Targeting Device Calibration
Note:Calibration of the S2 Distal Targeting Device must be performed prior to nail insertion, if decided to be used for Distal Guided Locking procedure.
For detailed information about Calibration technique, please refer to the Operative Technique for ”S2™ Distal Targeting Device” (REF. NO: B1000012).
4.8. Nail Insertion
The selected nail is assembled onto the Nail Adapter (1806-8001) with the Nail Holding Screw (1806-8005) (Fig. 14). Securely tighten the Nail Holding Screw with the Universal Joint Socket Wrench (1806-0400) so that it does not loosen during nail insertion (Fig.15).
Note: If Calibration of the S2 Distal Targeting Device was performed before Nail Insertion, the nail is already assembled onto the Nail Adapter.
Note:Prior to insertion:
1. Recheck that the Nail is tightly secured to the Nail Adapter.2. Verify the correct position of the nail relative to the Nail Adapter: during insertion, the convexity of the Herzog bend must be placed posterior, with the Nail Adapter on the medial side of the tibia. 3. Check correct alignment by inserting a Drill bit through the assembled Tissue Protection- and Drill Sleeve placed in the required holes of the Targeting Device.
Fig. 14
Fig. 15
Operative Technique
4. The 8mm Tibial Nails require exchanging the Ø3×800mm Ball Tip Guide Wire (1806-0080S) for the Ø3×800mm Smooth-Tip Guide Wire (1806-0090S) prior to insertion. Use the Teflon Tube (1806-0073S) to facilitate the Guide Wire exchange.5. S2™ Tibial nails with diameters 9mm−14mm do not require a Guide Wire exchange.
The Strike Plate (1806-0150) is threaded into the Nail Adapter next to the Nail Holding Screw or directly into the Nail Holding Screw to avoid any unintentional bending moment during nail insertion.
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The Nail is inserted by hand over the Ø3×800mm Guide Wire (if used) and into the entry site of the proximal tibia (Fig. 16). Gently manipulate the nail to help avoid penetration of the posterior cortex. If the nail is deflected towards the posterior cortex, remove the nail, and hyperflex the knee. Under image control, use a straight reamer to ream an anterior tract in the proximal fragment.
The Nail is advanced through the entry point past the fracture site to the appropriate level. Remove the Guide Wire once the nail is past the fracture site.
The Slotted Hammer can be used on the Strike Plate (Fig. 17) if dense bone is encountered. Alternatively, the Universal Rod (1806-0110) may be attached to the Strike Plate and used in conjunction with the Slotted Hammer (1806-0170) to insert the nail (Fig. 18). A captured Sliding Hammer (1806-0175) is available as an ”optional“ addition to the basic instrument set.
When locking the S2™ Tibial Nail, Compression in a Static Mode, the nail is countersunk a minimum of 2mm to the cortex surface. When the implant is inserted in the Dynamic Mode or with active Apposition/Compression, the recommended insertion depth is 10 or 15mm, based on how much active compression is to be applied. The final nail depth should be well below the cortex surface to minimize irritation of the Patellar Tendon.
Operative Technique
Fig. 16
Fig. 17
Fig. 18
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4.9. Distal Guided Locking Mode (via Distal Targeting Device)
Note:If the S2 Distal Targeting Device is going to be used, Distal Guided Locking should always be performed before the Proximal Locking!
This is because the Distal Guided Locking technique requires free movement of the nail in the medullary canal. For detailed information about the Distal Guided Locking procedure, please refer to the S2™ Distal Targeting Device - Operative Technique (REF. NO. B1000012).
Note:The 8mm Tibia Nail cannot be locked distally in a Guided Mode (via Distal Targeting Device). This is because 4mm Fully Threaded Screws must be used for distal locking of the 8mm Tibia Nail, while the GuidedLocking procedure is only suitable for the 5mm Locking Screws.
Note:If the S2™ Distal Targeting Device will be used for Distal Guided Locking, the nail must be countersunk at least 10mm more than described abowe. The final insertion depth is reached after pulling back the nail 10mm, in a later step. Please refer to the S2™ Distal targeting Device Operative Technique (REF. NO: B1000012) for detailed information.
Repositioning of the nail should be carried out either by hand or by using the Strike Plate attached to the Target Device. The Universal Rod and Slotted Hammer may then be attached to the Strike Plate to carefully and smoothly retract the assembly. DO NOT hit on the Target Device (Fig. 18).
Attach the Targeting Adapter (1806-8001) to the Nail Adapter and lock it with the Fixation Screw (1806-1007).
Note:Remove the Guide Wire prior to drilling holes and inserting the Locking Screws.
Note:A chamfer is located on the proximal end of the nail to help identify the junction of the nail and insertion post under fluoroscopy. Three circum-ferential grooves are located on the insertion post of the Target Device Assembly at 2mm, 10mm and 15mm from the proximal end of the nail. Depth of insertion may be visualized with the aid of f luoroscopy (Fig. 19).
Additionally, a 3×285mm K-Wire may be inserted through the Target Device which identifies the junction of the nail and insertion post (Fig. 20).
Operative Technique
4.8. Nail Insertion (continued)
Fig. 20
Fig. 19
Static
Dynamic
Apposition/Compression
2mm
10mm
15mm
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Before locking the nail proximally, confirm that the Nail Holding Screw is securely tightened by using the Universal Socket Wrench, and check that the Fixation Screw (1806-1007) is firmly tightened by hand to ensure that the Targeting Adapter is fixed on the Nail Adapter.
The Target Device consists of four main parts (Fig. 21): 1. Nail Adapter, 2. Targeting Adapter 3. Nail Holding Screw and 4. Target Template,
Compression (1806-1017)
Note:Never tighten the Fixation Screw (3) in the groove (A) of the Targeting Arm!
Note:The Target Template, Compression can be placed into the Target Device in two directions. For the S2™ Tibial Nail, Compression, the arrow on the Target Template has to line up with the arrow on the Target Device.
Note:The Target Template, Compression will block all locking holes in the Targeting Adapter that cannot be used with the S2 Tibial Nail Compression.
Note:Do not use the Target Device without Target Template!
The Targeting Adapter with the Target Template, Compression placed on it, is designed to provide two options for proximal locking:Static Locking Mode (Fig. 22)Dynamic Locking Mode (Fig. 23)
4 Target Template
3 Fixation Screw
2 Targeting Adapter
A
1 Nail Adapter
Operative Technique
4.10. Proximal Guided Locking Mode (via Target Device)
Fig. 21
Fig. 22
Fig. 23
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4.11. Static Locking Mode
For Static Locking Mode of the S2 Tibial Nail Compres-sion, both proximal M/L screws may be used. In highly unstable, comminuted fractures, the M/L screw is placed in the static position of the oblong hole. This may further improve stability of the proximal fragment.
Note:If secondary dynamization is planned, the second M/L screw may be inserted in the dynamic postion of the oblong hole on the Target Template. This allows for controlled dynamization of the fracture in cases of delayed union after removal of the proximal M/L screw.
The Tissue Protection Sleeve, Long (1806-0185) together with the Drill Sleeve, Long (1806-0215) and the Trocar, Long (1806-0315) are positioned through the most distal static hole of the Target Template by pressing the Safety Clip (Fig. 24).
The Friction Locking mechanism will keep the sleeve in place and prevent it from falling out. It will also prevent the sleeve from sliding during screw measurement. To release the Tissue Protection Sleeve, the Safety Clip must be pressed again and held while removing the sleeve.
A small skin incision is made and the assembly is pushed through until the Tissue Protection Sleeve is in contact with the medial cortex of the tibia (Fig. 25)
The Trocar is removed, with the Tissue Protection Sleeve and Drill Sleeve remaining in position.
For accurate drilling, and easy determination of screw length, use the center tipped, calibrated 4.2×260 Drill (1806-4250S). The centered Drill is forwarded through the Drill Sleeve and pushed onto the cortex.
After drilling both cortices, the screw length may be read directly off the calibrated Drill at the end of the Drill Sleeve (Fig. 26).
Fig. 25
Fig. 26
Fig. 24
Operative Technique
free
locked
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If measurement with the Screw Gauge, Long (1806-0325) is preferred, first remove the Drill Sleeve and read the screw length directly at the end of the Tissue Protection Sleeve.
Note:The position of the end of the Drill as it relates to the far cortex is equal to where the end of the screw will be. Therefore, if the end of the Drill is 3mm beyond the far cortex, the end of the screw will also be 3mm beyond.
Note:The Screw Gauge, Long is calibrated so that with the bend at the end pulled back flush with the far cortex, the screw tip will end 3mm beyond the far cortex (Fig. 27).
Alternatively, stop the drill when it engages the far cortex and measure the drill bit depth off the calibrated drill. Add 5mm to this length to obtain the correct screw length.
When the Drill Sleeve is removed, the correct 5mm Fully Threaded Locking Screw is inserted through the Tissue Protection Sleeve using the Screwdriver Shaft, Long (1806-0227) with Teardrop Handle (702429) (Fig. 28).
The screw is advanced through both cortices. 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. 29).
Repeat the locking procedure for the more proximal M/L Locking Screw (Fig.30).
Operative Technique
50 mm
Fig. 27
Fig. 28
Fig. 30
Fig. 29
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The freehand technique is used to insert Locking Screws into both the M/L and A/P holes in the nail. Rotational alignment must be checked prior to locking the nail statically.
Multiple locking techniques and radiolucent drill devices are available for freehand locking. The critical step with any freehand locking technique is to visualize a perfectly round locking hole with the C-Arm.
The center-tipped Ø4.2×130 Drill (1806-4280S) is held at an oblique angle pointing to the center of the locking hole (Fig. 31). Upon X-Ray verification, the Drill is placed perpendicular to the nail and drilled through the medial 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 read directly off the calibrated Short Screw Scale (1806-0360) at the green ring on the center-tipped Drill (Fig. 32).As detailed in the proximal locking section, the position of the end of the drill is equal to the end of the screw as they relate to the far cortex (Fig. 33).
Alternatively, the Screw Gauge (1806-0480) for Freehand technique can be used insted of the Screw Scale, Short to determine the screw length.
Routine Locking Screw insertion is employed with the assembled Screw-driver Shaft, Long or Screwdriver Shaft, 3.5×85mm (1806-0292) and Teardrop Handle (Fig. 34).
Note:The Screwdriver Shaft, Long may be used in conjunction with the “optional” Long Screw Capture Sleeve (1806-0240).
4.12. Freehand Distal Locking
Fig. 32
Green Ring
Fig. 31
Fig. 2920mm
Fig. 33
Fig. 34
Operative Technique
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4.13. End Cap Insertion
After removal of the Target Device, an End Cap may be used. Four different sizes of End Caps are available to adjust nail length and to reduce the potential for bony ingrowth into the proximal threads of the nail (Fig. 36).
The End Cap is inserted with the Screwdriver Shaft (1806-0227) and Teardrop Handle (702429) after intra-operative radiographs show satisfactory reduction and hardware implantation (Fig. 37 & 38). Fully seat the End Cap to minimize the potential for loosening.
The Endcap will tighten down on the most proximal Locking Screw and prevent M/L movement of the nail.
The wound is closed in the usual manner.
Fig. 36
Note:Distal locking should always be performed with at least two screws, locking the hole nearest the fracture site first. Always lock the most proximal M/L hole. The distal hole configuration follows: M/L (most distal), A/P and M/L (most proximal).
Note:8mm Tibial Nails must always be locked distally with 4mm Fully Threaded Screws.
For the 8mm Tibial Nails, the Ø3.5×130 Drill (1806-3550S) is used to drill both cortices prior to inserting the 4mm Fully Threaded Locking Screws in the distal holes.
Note:As with all sizes of the S2 Tbial Nail, the 8mm Nails use 5.0mm Screws proximally.
Fig. 37
Fig. 38
Standard +5mm +10mm +15mm
Operative Technique
19
When the fracture profile permits, dynamic locking may be utilized for transverse, axially stable fractures. Controlled dynamization is performed by statically locking the nail distally with at least two screws, in a freehand or guided technique.
Note:The proximal end of the nail must be buried at least 10mm−15mm into the bone to reduce the Potential for impingement or irritation of the Patella Tendon if the nail migrates during dynamization.
In the Dynamic Locking Mode of the S2 Tibial Nail, Compression the Partially Threaded Locking Screw (Shaft Screw) is placed in the dynamic position of the M/L oblong hole. This allows the nail to move and the frac-ture to settle while providing torsional stability.
The Tissue Protection Sleeve, Long together with the Drill Sleeve, Long and the Trocar, Long are positioned through the dynamic locking hole of the Target Template placed on the Targeting Adapter. A small skin incision is made, and the assembly is pushed through, until the Tissue Protection Sleeve is in contact with the medial cortex of the tibia (Fig. 39).
Fig. 40
Fig. 41
Fig. 42
Operative Technique
4.14. Dynamic Locking Mode
The Trocar is removed, while the Tissue Protection Sleeve and the Drill Sleeve remain in position.In order to insert the Partially Threaded Screw, drill both cor-tices with the Ø4.2×340 Drill (1806-4260S). Next, drill the near cortex, ONLY, with the Ø5×230mm Drill (1806-5000S). The centre tipped Drill is for-warded through the Drill Sleeve and pushed onto the cortex (Fig.40).
Note:After the opposite cortex is drilled with the Ø4,2×320mm Drill, the correct screw length can be read directly off the calibrated Drill at the end of the Long Drill Sleeve. If measurement with the Screw Gauge, Long (1806-0325) is preferred, first remove the Long Drill Sleeve, and read the screw length directly at the end of the Long Tissue Protection Sleeve.
Routine Locking Screw insertion is employed with the assembled Long Screwdriver Shaft and Teardrop Handle (Fig. 41 & 42).
Fig. 39
20
Fig. 43
Fig. 44
Operative Technique
4.15. Apposition/Compression Locking Mode
In transverse or axially stable fracture patterns, active apposition/compression increases fracture stability, may enhance fracture healing and allow for early weight bearing. The S2 Tibial Compression Nail provides the option to treat a tibial fracture with active mechanical apposition/compression prior to leaving the operating room.
Note:Distal freehand static or guided locking with at least two screws must be performed prior to applying active, controlled aposition/compression to the fracture site.
If active apposition/compression is required, the Partially Threaded Locking Screw (Shaft Screw) is inserted via the Target Device in the dynamic position of the M/L oblong hole (Fig. 43). This allow for a maximum of 10mm, active controlled apposition/compression.
In order to insert the Partially Threaded Locking Screw (Shaft Screw), drill both cortices with the Ø4.2×340mm Drill (1806-4260S). Correct screw length may be read from the calibration on the Drill at the end of the Drill Sleeve. The near cortex ONLY is overdrilled using the Ø5×230mm Drill (1806-5000S).
After the Partially Threaded Screw (Shaft Screw) was inserted, the Nail Holding Screw securing the nail to the insertion post is removed, leaving the insertion post in contact with the nail. This will act as a guide for the Compression Screw (Fig. 44).
10mm
21
Operative Technique
The Compression Screw is inserted with the Screwdriver Shaft Long assembled with the Teardrop Handle (702429) through the insertion post (Fig. 45).
As the Compression Screw is advanced against the 5.0mm Partially Threaded Screw (Shaft Screw), it draws the distal fracture segment towards the fracture site, employing active apposition/compression (Fig. 46). Image intensification will enable the surgeon to visualise active apposition/compression. Some bending of the Partially Threaded Locking Screw may be seen.
Note:Prior to compressing the fracture, the nail must be countersunk a safe distance from the entry point to accommodate for the 10mm of active compression. The three grooves on the insertion post help attain accurate insertion depth of the implant.
Note:Apposition/compression should be carried out under fluoroscopy. Over-tightening of the Compression Screw onto the Partially Threaded Locking Screw (Shaft Screw) may result in the screw to fail.
Note:After inserting the Compression Screw, the End Cap can no longer be used.
Fig. 45
Fig. 46
22
Operative Technique
Nail removal is an elective procedure. If needed, the End Cap or Compression Screw are removed with the Screwdriver Shaft and Teardrop Handle (Fig. 47).
Note:DO NOT remove the more distal proximal Locking Screw prior to attaching the Universal Rod (1806-0110) to the proximal end of the nail. Doing so may result in the nail moving posteriorly, making it difficult to attach the Universal Rod to the nail.
The Universal Rod is inserted into the driving end of the nail. All Locking Screws are removed with the Screwdriver Shaft and Teardrop Handle (Fig. 48).
Note:The Screwdriver Shaft may be used in conjunction with the ”optional” Screw Capture Sleeve, Long (1806-0240). The Slotted Hammer or optional Sliding Hammer is used to extract the nail in a controlled manner(Fig. 49).
Close the wound in the usual manner.
4.16. Nail Removal
Fig. 47
Fig. 48 Fig. 49
23
1725-0824S1725-0825S1725-0827S1725-0828S1725-0830S1725-0831S1725-0833S1725-0834S1725-0836S1725-0837S1725-0839S1725-0840S1725-0842S
1725-0924S1725-0925S1725-0927S1725-0928S1725-0930S1725-0931S1725-0933S1725-0934S1725-0936S1725-0937S1725-0939S1725-0940S1725-0942S
1725-1024S1725-1025S1725-1027S1725-1028S1725-1030S1725-1031S1725-1033S1725-1034S1725-1036S1725-1037S1725-1039S1725-1040S1725-1042S
1725-1124S1725-1125S1725-1127S1725-1128S1725-1130S1725-1131S1725-1133S1725-1134S1725-1136S1725-1137S1725-1139S1725-1140S1725-1142S
1725-1224S1725-1225S1725-1227S1725-1228S1725-1230S1725-1231S1725-1233S1725-1234S1725-1236S1725-1237S1725-1239S1725-1240S1725-1242S
1725-1324S1725-1325S1725-1327S1725-1328S1725-1330S1725-1331S1725-1333S1725-1334S1725-1336S1725-1337S1725-1339S1725-1340S1725-1342S
1725-1424S1725-1425S1725-1427S1725-1428S1725-1430S1725-1431S1725-1433S1725-1434S1725-1436S1725-1437S1725-1439S1725-1440S1725-1442S
8.08.08.08.08.08.08.08.08.08.08.08.08.0
9.09.09.09.09.09.09.09.09.09.09.09.09.0
10.010.010.010.010.010.010.010.010.010.010.010.010.0
11.011.011.011.011.011.011.011.011.011.011.011.011.0
12.012.012.012.012.012.012.012.012.012.012.012.012.0
13.013.013.013.013.013.013.013.013.013.013.013.013.0
14.014.014.014.014.014.014.014.014.014.014.014.014.0
240255270285300315330345360375390405420
240255270285300315330345360375390405420
240255270285300315330345360375390405420
240255270285300315330345360375390405420
240255270285300315330345360375390405420
240255270285300315330345360375390405420
240255270285300315330345360375390405420
StSt Diameter Length REF mm mm
Ordering Information - Implants
StSt Diameter Length REF mm mm
S2™ Tibial Nail, CompressionS2™ Tibial Nail, Compression
Note:Implants are packed sterile.
24
Ordering Information - Implants
1796-5025S1796-5027S1796-5030S1796-5032S1796-5035S1796-5037S1796-5040S1796-5042S1796-5045S1796-5047S 1796-5050S1796-5052S1796-5055S1796-5057S1796-5060S1796-5065S1796-5070S1796-5075S1796-5080S1796-5085S1796-5090S1796-5095S1796-5100S1796-5105S1796-5110S1796-5115S1796-5120S
5.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.0
25.027.530.032.535.037.540.042.545.047.550.052.555.057.560.065.070.075.080.085.090.095.0
100.0105.0110.0115.0120.0
StSt Diameter Length REF mm mm
5mm Fully Threaded Locking Screws
1791-5025S1791-5030S1791-5035S1791-5040S1791-5045S1791-5050S1791-5055S1791-5060S1791-5065S1791-5070S1791-5075S1791-5080S1791-5085S1791-5090S1791-5095S1791-5100S1791-5105S1791-5110S1791-5115S1791-5120S
5.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.05.0
1722-0003S1722-0005S1722-0010S1722-0015S
8.011.511.511.5
+5+10+15
StSt Diameter Length REF mm mm
End Caps
253035404550556065707580859095
100105110115120
StSt Diameter Length REF mm mm
5mm Partially Threaded Locking Screws
Note:Outside of the U.S., Locking Screws and other specific products may be ordered non-sterile without the “S” at the end.
1796-4025S1796-4030S1796-4035S1796-4040S1796-4045S1796-4050S1796-4055S1796-4060S
4.04.04.04.04.04.04.04.0
2530354045505560
StSt Diameter Length REF mm mm
4mm Fully Threaded Locking Screws
1722-0001S
StSt Diameter Length REF mm mm
Compression Screw
— —
25
Ordering Information - Instruments
REF Description
S2™ Tibia Compression − Standard Instruments
X-Ray Ruler, Tibia, Compression
Guide Wire Ruler
Awl, Curved, Ø10mm
K-Wire 3×285mm (outside of U.S.)
Guide Wire Handle
Guide Wire Handle Chuck
Universal Rod
Reduction Spoon
Wrench 8mm/10mm
Strike Plate
S2 Nail Holding Screw (2 each)
Slotted Hammer
Tissue Protection Sleeve, Long
Drill Sleeve, Long
Screwdriver Shaft AO, Long
Screw Driver Shaft, 3.5×85mm
Trocar, Long
Screw Gauge, Long
Long Screw Gauge (20mm−80mm)
Socket Wrench, Universal Joint 10mm
Drill Ø3.5×130mm AO, (outside of the U.S. for 8 mm Tibia)
Drill Ø4.2×340, AO, (outside of U.S.)
Drill Ø4.2×180, AO, (outside of U.S.)
Drill Ø5.0×230, AO, (outside of U.S.)
Teardrop Handle, AO coupling
Rigid Reamer, Ø12mm
Target Template, Compression
Target Device, S2 (3 components)
S2 Nail Adapter
S2 Targeting Adapter
Fixation Screw
Dedicated Instrument Box, S2
1806-8014
1806-0020
1806-0040
1806-0050
1806-0095
1806-0096
1806-0110
1806-0125
1806-0130
1806-0150
1806-8005
1806-0170
1806-0185
1806-0215
1806-0227
1806-0292
1806-0315
1806-0325
1806-0480
1806-0400
1806-3550
1806-4260
1806-4270
1806-5000
702429
1806-2012
1806-8017
1806-8000
1806-8001
1806-8002
1806-1007
1806-8022
Note:Instruments designated “Outside of the U.S.” may not be ordered for the U.S. market.
26
REF Description
Optional Instruments
Ordering Information - Instruments
X-Ray Template, Tibia, Compression
Awl, Straight, Ø10mm
Awl, Curved, 90°Handle
K-Wire 3×285mm, sterile (U.S.)
Insertion Wrench, 10mm
Guide Wire, Ball Tip, 3×800mm (outside of U.S.)
Guide Wire, Ball Tip, 3×800mm, sterile (U.S.)
Guide Wire, Smooth Tip, 3×800mm (outside of U.S. for 8mm Tibia)
Guide Wire, Smooth Tip, 3×800mm, sterile (U.S for 8mm Tibia.)
Sliding Hammer
Screwdriver, Long
Screw Capture Sleeve, Long
Ratchet T-Handle AO
Extraction Rod, Conical, Ø8mm
Drill Ø3.5×130mm AO, sterile (U.S.for 8 mm Tibia)
Drill Ø4.2×340, AO, sterile (U.S.)
Drill Ø4.2×130, AO, sterile (U.S.)
Drill Ø5.0×230, AO, sterile (U.S.)
Screw Scale, Short
Screwdriver, Extra Short
Extraction Adapter
T-Handle, AO Coupling
Rigid Reamer, Ø11.5mm
Awl, Straight Ø11.5mm
Reaming Protector
Long Freehand Tissue Protection Sleeve
Long Drill Sleeve Ø 4.2mm
1806-8009
1806-0045
1806-0041
1806-0050S
1806-0135
1806-0080
1806-0080S
1806-0090
1806-0090S
1806-0175
1806-0232
1806-0240
1806-0270
1806-0350
1806-3550S
1806-4260S
1806-4280S
1806-5000S
1806-0360
1806-0202
1806-0340
702427
1806-2011
1806-0047
0140-0002
1806-0450
1806-0460
Special Order Items:
Note:Outside of the U.S., instruments with an „S“ may be ordered non-sterile without the „S“ at the end of the corresponding REF. Number.
27
Ordering Information - Instruments
Complete range of modular and fixed-head reamers to match sur-geon preference and optimize O. R. efficiency, presented in fully sterilizable cases.
Recent studies1 have demonstrated that the pressures developed within the medullary cavity through the introduction of unreamed IMnails can be far greater than those devel-oped during reaming − but this depends very much upon the design of the reamer.
After a three year development study2 involving several universities, the fac-tors that determine the pressures and temperatures developed during ream-ing were clearly established. These fac-tors 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 Mousavi, et al.; Pressure Changes During Reaming with Different
Parameters and Reamer Designs, Clinical Orthopaedics and Related Research
Number 373, pp. 295-303, 2000
Large clearance rate resulting from reduced number of reamer blades coupled with reduced length of reamer head to give effective relief of pressure and efficient removal of material.
Cutting f lute geometry optimized to lower pressure generation.
Forward- and side-cutting face combination produces efficient material removal and rapid clearance.
Double-wound shaft transmits torque effectively and with high reliability. Low-friction surface finish aids rapid debris clearance.
Smaller, 6 and 8mm shaft diameters significantly reduce IM pressure.
Bixcut™
Typical StandardReamer Ø14mm
Clearance area :32% of cross section
Bixcut™Reamer Ø14mm
Clearance area :59% of cross section
Bixcut™
28
REF Description Diameter mm
Bixcut™ Modular Head
REF Diameter Length mm mm
Bixcut™ Fixed Head − AO fitting
REF Description Length mm
Bixcut™ Shaft − AO fitting
REF Description Length mm
Bixcut™ Shaft − Modified Trinkle fitting (sterile)
REF Description
Bixcut™ Trays
REF Diameter Length mm mm
Bixcut™ Fixed Head − Modified Trinkle fitting+
0226-30900226-30950226-31000226-31050226-31100226-31150226-31200226-31250226-31300226-31350226-31400226-31450226-31500226-31550226-31600226-31650226-31700226-31750226-31800226-41850226-41900226-41950226-42000226-42050226-42100226-42150226-42200226-42250226-42300226-42350226-42400226-42450226-42500226-42550226-42600226-42650226-42700226-42750226-4280
Bixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut Head
9.09.5
10.010.511.011.512.012.513.013.514.014.515.015.516.016.517.017.518.018.519.019.520.020.521.021.522.022.523.023.524.024.525.025.526.026.527.027.528.0
0226-30000226-8240
Shaft, AOShaft, AO
450240
0227-3000(S)0227-8240(S)
Shaft, Mod. TrinkleShaft, Mod. Trinkle+
450240
0225-6000
0225-6001
0225-8000
Tray, Modular Head (up to size 22.0mm)Tray, Modular Head (up to size 28.0mm)
Tray, Fixed Head (up to size 18.0mm)
0227-50600227-50650227-50700227-60750227-60800227-60850227-60900227-60950227-61000227-61050227-61100227-81150227-81200227-81250227-81300227-81350227-81400227-81450227-81500227-81550227-81600227-81650227-81700227-81750227-8180
6.0*6.5*7.0*7.58.08.59.09.5
10.010.511.011.512.012.513.013.514.014.515.015.516.016.517.017.518.0
400400400480480480480480480480480480480480480480480480480480480480480480480
0225-50600225-50650225-50700225-60750225-60800225-60850225-60900225-60950225-61000225-61050225-61100225-81150225-81200225-81250225-81300225-81350225-81400225-81450225-81500225-81550225-81600225-81650225-81700225-81750225-8180
6.0*6.5*7.0*7.58.08.59.09.5
10.010.511.011.512.012.513.013.514.014.515.015.516.016.517.017.518.0
400400400480480480480480480480480480480480480480480480480480480480480480480
+ Use with Stryker Power Equipment
* Use with 2.2mm×800mm Smooth Tip and 2.5mm×800mm Ball Tip Guide wires only.
Note:Federal law (U.S.A) restricts this device to sale by or on the order of a licensed physician.
Ordering Information - Instruments
29
Notes
30
Notes
31
The information presented in this brochure is intended to demonstrate a Stryker product. Always refer to the package insert, product label and/or user instructions before using any Stryker product. Products may not be available in all markets. Product availability is subject to the regulatory or medical practices that govern individual markets. Please contact your Stryker representative if you have questions about the availability of Stryker products in your area.
Products referenced with ™ designation are trademarks of Stryker. Products referenced with ® designation are registered trademarks of Stryker.
Literature Number : B1000016LOT B3804
Copyright © 2004 StrykerPrinted in Germany
Stryker Trauma GmbHProf.-Küntscher-Strasse 1-5D-24232 SchönkirchenGermany
www.trauma.stryker.com
