Technique Guide - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · 4 Synthes VEPTR Technique Guide ... inadvertent rubbing or bumping of

VEPTR – Vertical ExpandableProsthetic Titanium Rib. A newtreatment concept for paediatric three-dimensional thoracic deformities.

Technique Guide

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Please note that specialised training is mandatory.

In order to perform procedures associated with the VEPTRsystem, a wide range of additional basic spine surgeryinstruments are required. For further details contact yourlocal Synthes representative.

Table of Contents

Image intensifier control

Treatment Concept 3

Indications 4

Contraindications 5

Construct Options 6

Implants 10

Instruments 15

Overview Surgical Technique 19

Primary Procedure 20

Expansion Procedure 38

Replacement Procedure 40

Introduction

Product Information

Surgical Technique

2 Synthes VEPTR Technique Guide

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VEPTR – Vertical ExpandableProsthetic Titanium Rib. A newtreatment concept for paediatric three-dimensional thoracic deformities.

ConceptThree-dimensional thoracic approach totreat patients with complex chest walland/or spinal deformities where thethorax is unable to support normal res-piration or lung growth (Thoracic Insuf-ficiency Syndrome).

Designed to mechanically stabilize anddistract the thorax to improve respira-tion and lung growth in infantile andjuvenile patients.

VEPTR devices control and may correctscoliosis.

Devices are attached perpendicularly tothe patient’s natural ribs (superior at-tachment point) and to more caudalribs, a lumbar vertebra or to the ilium(inferior attachment point). This is donethrough a standard thoracotomy inci-sion by performing an opening wedgethoracostomy.

Regular expansion, anatomic distrac-tion, and replacement of componentsthrough less invasive surgery.

Goals of treatment:– Increase thoracic volume– Scoliosis correction– Thoracic symmetry by lengthening

the concave, restricted hemithorax– Improve thoracic function– Avoiding growth inhibition proce-

dures– Maintain these improvements

throughout the growth of the child


Indications

Primary Thoracic Insufficiency Syndrome (TIS) due to three-dimensional deformity of the thorax– Progressive thoracic congenital scoliosis with concave

fused ribs– Progressive thoracic congenital scoliosis with flail chest due

to absent ribs– Progressive thoracic congenital, neurogenic or idiopathic

scoliosis without rib abnormality – Hypoplastic thorax syndromes

– Jeune’s Syndrome– Jarcho-Levine Syndrome– Cerebro costal mandibular syndrome– Others

– Congenital chest wall defect, posterolateral– Acquired chest wall defect, posterolateral

– Chest wall tumor resection– Traumatic flail chest– Surgical separation of conjoined twins

Secondary Thoracic Insufficiency due to lumbar kyphosis(non gibbus)

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Contraindications

The VEPTR device should not be used under the followingconditions:– Inadequate strength of bone (ribs/spine) for attachment of

the VEPTR– Absence of proximal and distal ribs for attachment of the

VEPTR– Absent diaphragmatic function– Inadequate soft tissue for coverage of the VEPTR– Age beyond skeletal maturity for use of the VEPTR– Age below 6 months– Known allergy to any of the device materials– Infection at the operative site

Warnings and precautionsPatients implanted with the VEPTR should not be braced. TheVEPTR device is designed to allow for thoracic cavity growthand the restrictive nature of a brace would not help the con-dition, but defeat its purpose.

Patients may require additional wound protection to preventinadvertent rubbing or bumping of the wound.

Patients with a diagnosis of spina bifida should have an oc-clusive dressing over the wound site to keep the site dry.


Construct Options

The VEPTR set contains 220 mm and 70 mm radius constructs.

220 mm radius constructs are used to treat most of theVEPTR indications and are the standard VEPTR constructs.

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70 mm radius constructs are used to treat hypoplastic thorax syndromes.

A hypoplastic low thorax volume (as seen with Jeune’s Syn-drome) requires the use of a 70 mm rib-to-rib construct(70 mm implants include: Cranial Rib Support, Caudal RibSupport, Extension Bar). These constructs are placed bilater-ally in separate procedures.

Surgical technique for 70 mm radius constructsAfter inserting both the Cranial and Caudal Rib Support, freethe central segment of the selected hemithorax by makingtransverse incisions in the periosteum to enable anterior andposterior osteotomies.

Perform anterior and posterior osteotomies from ribs threethrough eight. Distract the mobilized chest segment postero-laterally.

Place retractors subperiosteally to protect the underlyinglung.

Choose 2–3 sites in the central portion of the mobilized seg-ment to insert the 2.0 mm Titanium Rod which will holdthe ribs to the construct. Bend the rod to form a gentle curveusing the Wire Bending Pliers.

Assemble the construct as stated in the rib-to-rib constructsection.

After the construct has been completely assembled andlocked, use the Pliers to again grasp rods and contouraround implanted rib-to-rib construct, leaving space to re-move the locks and expand the construct.

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Construct Options

Rib-to-lumbar lamina– Attaches to rib and to lumbar spine– Components available in 220 mm radius

1 Cranial Rib Support2 Closing Half-Ring3 Lock for Rib Support4 Lumbar Extension Rod5 Extension Bar6 Closure for Extension Bar7 Lamina Hook

Rib-to-ilium– Attaches from rib to ilium– Components available in 220 mm radius

1 Cranial Rib Support2 Closing Half-Ring3 Lock for Rib Support4 Lumbar Extension Rod5 Extension Bar6 Closure for Extension Bar7 Extension connector8 Ala Hook


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Rib-to-rib– Attaches to the cranial and to the caudal rib– Components available in 220 mm or 70 mm radius

Rib-to-rib 220 mm radius1 Cranial Rib Support2 Closing Half-Ring3 Lock for Rib Support4 Caudal Rib Support5 Extension Bar6 Closure for Extension Bar

Rib-to-rib 70 mm radius1 Cranial Rib Support2 Closing Half-Ring3 Lock for Rib Support4 Caudal Rib Support5 Extension Bar6 Closure for Extension Bar

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Cranial Rib Support, Titanium Alloy (TAN), gold– Attaches to the Closing Half-Ring and Extension Bar to

support the cranial rib

In 220 mm radius, standard size, in neutral angulation

Art. No. Angulation

497.057 Neutral

In 70 mm radius, standard size, in neutral angulation

Art. No. Angulation

497.061 Neutral

Caudal Rib Support, Titanium Alloy (TAN), gold– Attaches to the Closing Half-Ring and Extension Bar to

support the caudal rib

In 220 mm radius, available in sizes 4–13 in neutral, right and left angulation

Art. No. Angulation Sizes

497.065–497.069 Neutral 4–8

497.225–497.229 Neutral 9–13

497.071–497.075 Right angled 4–8

497.230–497.234 Right angled 9–13

497.076–497.080 Left angled 4–8

497.235–497.239 Left angled 9–13

In 70 mm radius, available in sizes 4–11 in neutral, right and left angulation

Art. No. Angulation Sizes

497.085–497.089 Neutral 4–8

497.241–497.243 Neutral 9–11

497.091–497.095 Right angled 4–8

497.244–497.246 Right angled 9–11

497.096–497.100 Left angled 4–8

497.247–497.249 Left angled 9–11

Implants


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Closing Half-Ring, Titanium Alloy (TAN), gold– Attaches to the Cranial or Caudal Rib Support to encircle

the cranial or caudal rib(s)

Standard size

Art. No.

497.126 Closing Half-Ring for Rib Support

Extended

Art. No.

497.129 Closing Half-Ring for Rib Support, large

Locks, Titanium Alloy (TAN)– Lock for Rib Support (blue) connects the Closing Half-Ring

to the Cranial Rib Support or the Caudal Rib Support

Art. No.

497.128 Lock for Rib Support, blue

– Closure for Extension Bar (gold) connects the Extension Barto the Cranial Rib Support, Caudal Rib Support or LumbarExtension Rod

Art. No.

497.125 Closure for Extension Bar, gold


Extension Bar, Titanium Alloy (TAN)– Attaches the Cranial Rib Support to the Caudal Rib Sup-

port or Lumbar Extension Rod

In 220 mm radius, available in sizes 4–13

Art. No. Sizes

497.103–497.112 4–13

In 70 mm radius, available in sizes 4–11

Art. No. Sizes

497.115–497.122 4–11

Lumbar Extension Rod, Titanium Alloy (TAN)– Attaches the Extension Bar to the Lamina Hook or the

Extension Connector– Available in sizes 6–13 to correspond with 220 mm radius

Extension Bar– Rod � 6.0 mm

Art. No. Sizes

497.131–497.134 6–9

497.251–497.254 10–13

Implants

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Lamina Hook, Titanium Alloy (TAN)– Used with the Lumbar Extension Rod to connect to the

lumbar lamina– Available as left and right angled– 3.5 mm setscrew secures the placement

Art. No. Angulation

497.261 Left angled

497.262 Right angled

Ala Hook, Pure Titanium– Used with the Lumbar Extension Rod and Extension

Connector to attach to the ilium– Available in left and right contours– Rod � 5.0 mm

Ala Hook, 45°

Art. No. Contours

497.257 left

497.258 right

Ala Hook, 90°

Art. No. Contours

04.601.001 left

04.601.000 right


Implants

Extension Connector � 5.0/6.0, Titanium Alloy (TAN)– Connects the Ala Hook to the Lumbar Extension Rod– Accepts � 5.0 mm and � 6.0 mm rods

Art. No.

498.167 Extension Connector � 5.0/6.0mm

Rod � 2.0mm, Pure Titanium– Holds osteotomized ribs against the construct

Art. No.

497.127 Rod � 2.0 mm

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Below a description of all VEPTR specific instruments. A detailed overview of all required instruments (standard ornew) for a VEPTR surgery can be found in the VEPTR setlist.

388.452 Lock Removal Pliers, for VEPTR

Used to remove the locks (497.125 and497.128) from the constructs for expan-sion procedures or removing constructs.

388.453 or Holding Forceps for Closing Half Ring for388.465 VEPTR

For holding and placing the Closing HalfRing around the ribs.

388.456 or Lock Crimper, for VEPTR388.474

Attaches the locks around the constructfor proper closing.

388.457 Distraction Pin for VEPTR, temporary

Allows temporary distraction of theconstructs and is used during expansionof a construct.

Instruments


388.458 Iron for Rib Support

Used to align/adjust the Extension Bar andthe Cranial Rib Support. Goes aroundthe Cranial Rib Support and is used withthe Iron for Extension Bar.

388.459 Iron for Extension Bar

Used to align/adjust the Extension Bar andthe Cranial Rib Support. Goes around theExtension Bar and is used with the Iron forRib Support.

388.461 Holding Forceps for Rib Support

Holds the Cranial and the Caudal RibSupports.

388.462 Lock Removal Device, for VEPTR

Used to remove the locks (497.125 and497.128) from the construct.

388.464 Spreader for Rib Support

Used for the expansion of the ExtensionBar from the Caudal Rib Support. Allows aprimary, limited expansion. The LargeSpreaders (388.471 or 388.472) can nowbe placed to expand the construct further.

Instruments

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388.466 Positioner for Rib Support

Used to adjust the Cranial Rib Support andthe Extension Bar.

388.467 Rib Support Feeler

Prepares the ribs for the Cranial RibSupport (or Caudal Rib Supportrespectively). The Feeler has the sameshape as the rib support devices.

388.468 Holding Forceps for Extension Bar

For holding the Extension Bar and pushingit over the Cranial Rib Support and CaudalRib Support.

388.471 Rib Distraction Pliers

Used to expand the Extension Bar from theCaudal Rib Support or Lumbar ExtensionRod.

388.472 Distractor for Extension Bar, curved

Used to expand the Extension Bar from theCaudal Rib Support or Lumbar ExtensionRod.


388.475 Lock Inserter, lateral

Attaches the locks around the construct toclose the construct.

388.486 Foot for Rib Retractor, for No. U22-64010

Fits in the Rib Retractor to distract the ribs.

388.493 Inserter for Rib Support Lock

Used to pick up and hold the locks(497.125 and 497.128) and attach thelocks to the constructs.

388.495 Hook Holding Forceps for VEPTR

Used to bring the hooks in position at thelamina.

Instruments

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Overview Surgical Technique

Primary procedure

1. Patient positioning 20

2. Cranial exposure 20

3. Insertion cranial implants 21

3.1 Identify cranial rib

3.2 Prepare rib for implants

3.3 Select proper Cranial Rib Support angulation and radius

3.4 Seat Cranial Rib Support

3.5 Select proper Closing Half-Ring size

3.6 Insert Closing Half-Ring

3.7 Insert Lock for Rib Support

4. Distract chest wall if necessary 26

5. Select appropriate Extension Bar 27

6. Determine appropriate matching implants and construct assemble

A Lumbar extension 28

Lamina Hook for rib-to-lumbar lamina constructAla Hook for rib-to-ilium constructs

6.1 Select the appropriate lumbar extension

6.2 Determine contour and cut to length, if necessary

6.3 Insert caudal Distraction Lock

6.4 Insert caudal implants– Lamina Hook– Ala Hook

6.5 Align the lumbar extension to the caudal implant– Lamina Hook– Ala Hook

6.6 Align Extension Bar to Cranial Rib Support

6.7 Insert Closure for Extension Bar

6.8 If using a Lamina Hook, distract if necessary and tighten

B Rib-to-rib 35

6.1 Choose the appropriate caudal rib

6.2 Select the appropriate Caudal Rib Support

6.3 Insert the caudal implants

6.4 Assemble the construct

6.5 Lock the construct

Expansion procedure

1. Patient positioning 38

2. Exposure 38

3. Remove the lock 38

4. Distraction 39

5. Final locking 39

Replacement procedure

Replacement 40

Patient positioning and cranial exposure remain the samefor all types of VEPTR constructs described on pages 8 to 9 regardless of the construct being implanted.

Primary Procedure


1Patient positioning

Place the patient in a lateral decubitus position similar to thatrequired for a standard thoracotomy.

To protect against brachial plexus injury, do not flex theshoulder more than 90°.

2Cranial exposure

Make a J-shaped thoracotomy incision without disruptingthe periosteum overlying the ribs.

Retract the skin flaps.

Continue the incision and elevate the paraspinal muscles medially only to the tips of the transverse processes.

Gently elevate the scapula to expose the middle and poste-rior scalene muscle.

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3Insertion cranial implants

Required instruments

Standard Hammer

U44-483-20 Periosteal Elevator, curved

388.453 or Holding Forceps for Closing Half-Ring, 388.465 for VEPTR



388.467 Rib Support Feeler


388.488 Clip for Rib Support for No. 388.494

388.489 Clip for Closing Half-Ring for No. 388.494


388.494 Pliers for Closing Half-Ring and Rib Support

398.408 Periosteal Elevator, slightly curved blade

3.1Identify cranial rib

Identify the cranial rib to be used as the cranial point of at-tachment. Mark this point and confirm location using radi-ographic imaging.

Because of the risk of brachial plexus impingement, do notchoose the first rib as the cranial point of attachment.


3.2Prepare rib for implants

Make a one centimeter incision into the intercostal musclesabove and below the rib where the Cranial Rib Support willattach. Insert the Periosteal Elevator with slightly curvedblade or the curved Periosteal Elevator to carefully elevatethe periosteum adjacent to the lung. Take care to preservethe soft tissue surrounding the rib to protect rib vascularityand the neurovascular bundle.

3.3Select proper Cranial Rib Support

Choose a 220 mm or 70 mm radius Cranial Rib Support:– A 220 mm Rib Support is used with either a lumbar exten-

sion or a 220 mm radius Caudal Rib Support.– A 70 mm Rib Support is used solely with 70 mm Caudal

Rib Support.

Use the Rib Support Feeler to prepare the rib for the CranialRib Support and the Closing Half-Ring.

Primary Procedure

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3.4Seat Cranial Rib Support

Using the Holding Forceps for Rib Support, seat the under-side of the Cranial Rib Support into the space between theperiosteum and the rib.

Rotate the rib support into the correct position. For themedial construct, seat as medial as possible to the transverseprocess.

3.5Select proper Closing Half-Ring size

Based on the patient’s anatomy, select the appropriate Clos-ing Half-Ring (standard or large). The large Closing Half-Ringis used to encircle large areas of fused ribs or two ribs.

388.488

388.489

388.494

Primary Procedure

3.6Insert Closing Half-Ring

Using the Holding Forceps for Closing Half-Ring, insert theClosing Half-Ring into the intercostal space above the con-tralateral side of the rib.

Rotate the Half-Ring distally to mate with the Cranial RibSupport.

The Closing Half-Ring and Cranial Rib Support now shouldbe aligned.

Note: If the Cranial Rib Support and Closing Half-Ring arenot aligned, prepare the Pliers for Closing Half-Ring and RibSupport (Cradle Assembly Forceps). Affix the Clip for ClosingHalf-Ring and the Clip for Rib Support to the Pliers for Clos-ing Half-Ring and Rib Support.

Align the Cranial Rib Support to the Closing Half-Ring usingthe Cradle Assembly Forceps.


3.7Insert Lock for Rib Support

Load a blue lock into the Inserter for Rib Support Lock.

Insert the lock into the aligned holes of the Cranial Rib Sup-port and the Closing Half-Ring. With a hammer, gently tapinserter to seat the lock.

The Lock Crimper or the lateral Lock Inserter should be usedto ensure that the lock is fully seated.

The implants now encircle the rib.

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Fused ribs and scoliosis

After superior and inferior points of attachment have beenchosen, perform an opening wedge thoracostomy throughthe fused ribs at the apex of the thoracic deformity from thetip of the transverse process to the costochondral junction.Cut a transverse osteotomy from the transverse process tothe sternum, in the line of the normal rib.

4Distract chest wall if necessary


Standard Vein Retractor

U22-64010 Retractor, longitudinal, single, with ratchet lock and two joints

388.486 Foot for Rib Retractor No. U22-64010

399.100 Bone Spreader, speed lock, width 8 mm, length 210 mm

399.130 Bone Spreader, speed lock, width 12 mm, length 270 mm

Assemble the Feet for Rib Retractor to the Retractor. Distractribs using the Rib Retractor assembly as needed. BoneSpreaders in conjunction with Vein Retractors can also beused to gently distract the chest wall at the site of an open-ing wedge thoracostomy.

Additional resection of medial fused ribs may be required ifdistraction is difficult.

Only resect visible bone adjacent to the spine. Be aware ofanomalous arteries due to the abnormal anatomy.

Primary Procedure

Separate the fusion mass into multiple longitudinal sectionsof the approximate width of normal ribs in the patient. Ensure the continuity between the anterior and posterior at-tachments of the newly separated ribs.


5Select appropriate Extension Bar


Standard Ruler

388.870 Trial Rood

Measure the distance between the cranial rib and either thethoracolumbar junction or the chosen caudal rib to deter-mine the appropriate Extension Bar size. – Measure to the thoracolumbar junction when planning a

rib-to-ilium or rib-to-lumbar lamina construct. – Measure to the caudal rib when using a rib-to-rib con-

struct.

The measurement in centimeters will correspond to the cor-rect Extension Bar size. For example, if the distance is determined to be 7 cm, use an Extension Bar marked with a7. Implants are identified from 4–13 in 1 cm increments.

6Determine appropriate matching implants andassemble construct

For rib-to-lumbar lamina and rib-to-ilium constructs seepage 28ff.

For rib-to-rib constructs see page 35ff.

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Primary ProcedureA Lumbar extension

Lumbar extension– Lamina Hook for rib-to-lumbar lamina constructs– Ala Hook for rib-to-ilium constructs


Standard Lamina Feeler

Standard Rod Cutter

Standard Hammer

314.070 2.5 mm Hex Screwdriver

314.270 3.5 mm Hex Screwdriver

388.410 Spreader Forceps

388.441 Holding Forceps for USS Paediatric Rods � 5.0 mm









388.495 Hook Holding Forceps for VEPTR

388.870 Trial Rod

388.910 USS Bending Iron, left

388.911 USS Paediatric Bending Iron for Rods � 5.0 mm, left

388.920 USS Bending Iron, right

388.922 USS Paediatric Bending Iron for Rods � 5.0 mm, right

388.940 Rod Pusher for USS Rods � 6.0 mm

388.960 Bending Pliers with Rolls for USS Rods

498.910 Fixation Ring for Rods � 6 mm


A 6.1Select the appropriate lumbar extension

Lumbar extension sizes correspond with the same size Exten-sion Bar. For example, if the selected Extension Bar is a size 7,the correct Lumbar Extension Rod will also be a size 7.

A 6.2Determine contour and cut to length, if necessary

Use the Trial Rod to determine the contour of the rod portionof the lumbar extension. Do not bend the T-section of thelumbar extension which mates with the Extension Bar. Usingthe Bending Pliers, contour the rod portion only to match theanatomy. As an alternative, the USS Bending Irons can beused for contouring.

If necessary, cut the rod portion of the Lumbar Extension Rodto the correct length using the Rod Cutter. The length of therod portion of the lumbar extension should be at least equalto the distance between the thoracolumbar junction and theplanned caudal implant. When using a Lamina Hook or AlaHook, additional length of 1.5 cm should be left to allow fordistraction.

A 6.3Insert caudal Closure for Extension Bar

Prior to insertion, connect the Extension Bar with the lumbarextension by sliding the Lumbar Extension Rod into the Ex-tension Bar. Align the most caudal hole in the Extension Barwith the most caudal hole in the Lumbar Extension Rod. Theimplants should overlap completely to maximize future ex-pansion capacity.

Place a golden Closure for Extension Bar in this position us-ing the Inserter for Rib Support Lock. With a hammer, firmlytap Inserter to seat the lock. The Lock Crimper or the lateralLock Inserter have to be used to ensure that the Closure isfully seated.

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A 6.4Insert caudal implants

Lamina Hook (Use for rib-to-lumbar lamina construct)Make a four centimeter longitudinal paraspinal skin incisionon the concave side of the curve at the lumbar interspacethat was selected preoperatively. Retract the paraspinal mus-cles laterally. Do not disturb the facet joints.

Use a Lamina Feeler to separate the ligamentum flavum uni-laterally from the underside of the lamina to ensure goodbony contact with the Lamina Hook and to leave the inter-spinous ligament intact. Resect enough ligamentum flavumfor the hook to pass.

Choose the appropriate Lamina Hook (right or left). Thehook will be placed downwards and the set screw must belateral.

Use the Hook Holding Forceps to place the hook in the de-sired location on the lumbar vertebra. The hook can be fur-ther secured by using a heavy, non-absorbable suture aroundthe posterior spinous process.



Ala Hook (Use for rib-to-ilium construct)Make a four centimetre longitudinal incision just lateral tothe posterior cranial iliac spine. Identify the posterior thirdand middle third of the iliac crest. Make a one centimetretransverse incision in the mid substance of the apophysiswith equal layers of cartilage above and below the incision.Insert the periosteal elevator through the apophyseal incisionto widen it into a tunnel and thread it along the medial corti-cal surface of the iliac crest. The tip of the periosteal elevatorshould be just lateral to the Sacro-iliac joint.

Choose the appropriate Ala Hook (45° or 90°, left or right).The correct Ala Hook should have the upper end lying medialto the downward pointed end.

Attach the Extension Connector to the Ala Hook using the2.5 mm Hex Screwdriver. Ensure the 5.0 mm opening in theExtension Connector is mated with the Ala Hook.

Use the 5.0 mm Bending Irons (388.911 and 388.922) tocontour the Ala Hook to fit the ilium. Insert the Ala Hook,pointed end downward, into the apophyseal tunnel usingthe Holding Forceps for USS Paediatric Rods � 5.0 mm(388.441) over the top of the iliac crest and lateral to theSacro-iliac joint.

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A 6.5Align the lumbar extension to the caudal implant

Lamina Hook (Use for rib-to-lumbar lamina construct)Thread a large clamp or scissors carefully from the proximalincision through the paraspinal muscles to emerge in thelumbar incision. Attach No. 20 chest tube to the clamp andthread it from the lumbar incision to emerge in the proximalincision. Thread the end of the lumbar hybrid extension intothe chest tube end and use it to guide the lumbar extensionsafely into the lumbar incision. Take care to remain withinthe paraspinous muscles.

Use Rod Holding Forceps to insert the rod portion of thelumbar extension assembly to reach the hook.

Ala Hook (Use for rib-to-ilium construct)Thread a large clamp carefully from the proximal incisionthrough the paraspinal muscles to emerge into the opposingside of the Extension Connector. Attach No. 20 chest tube tothe clamp and thread it into the proximal incision. Thread theend of the lumbar hybrid extension into the chest tube endand use it to guide the lumbar extension safely into the Ex-tension Connector. Take care to remain within the paraspinalmuscles.

Tighten the set screws in the connector using the 2.5 mmHex Screwdriver.


A 6.6Align Extension Bar to Cranial Rib Support

Use the Holding Forceps for Extension Bar and Holding For-ceps for Rib Support to slide the cranial end of the ExtensionBar over the Cranial Rib Support.

Alternatively the Iron for Extension Bar and the Iron for RibSupport can be used to align the two implants. The Positioner for Rib Support can also facilitate alignment.

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A 6.7Insert Closure for Extension Bar

Insert a golden Closure for Extension Bar using the Inserterfor Rib Support Lock to fix the Extension Bar to the CranialRib Support. With a hammer, tap the Inserter to seat thelock.

Check to ensure all locks are fully seated using the LockCrimper or lateral Lock Inserter.

A 6.8If using a lamina hook, distract if necessary and tighten

Using the 2.5 mm Hex Screwdriver place a Fixation Ring forRod cranial to the hook onto the rod portion of the lumbarextension and tighten.

Using the Spreader Forceps gently distract to further seat thehook. Use the 3.5 mm Hex Screwdriver to tighten thesetscrew in the hook.

Remove the Fixation Ring for Rods following distraction us-ing the 2.5 mm Hex Screwdriver.


Primary ProcedureB Rib-to-rib


Standard Hammer

388.453 or Holding Forceps for 388.465 Closing Half-Ring, for VEPTR









388.472 Distractor for Extension Bar


388.488 Clip for Rib Support for No. 388.494

388.489 Clip for Closing Half-Ring for No. 388.494


388.494 Pliers for Closing Half-Ring and Rib Support

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B 6.1Choose the appropriate caudal rib

The proper rib for attachment of the rib-to-rib device shouldbe transverse and of adequate width. Do not choose anoblique rib, such as rib 11 or 12.

B 6.2Select the appropriate Caudal Rib Support

Caudal Rib Support sizes correspond with the same size Ex-tension Bar. For example, if the selected Extension Bar isa size 7, the correct Caudal Rib Support will also be a size 7.

Primary ProcedureB Rib-to-rib

B 6.3Insert the caudal implants

Using the Holding Forceps for Rib Support seat the CaudalRib Support into the space between the periosteum and therib. Rotate it into the correct position around the rib.

Based on the patient’s anatomy, select the appropriate Clos-ing Half-Ring (standard or large).

Using the Holding Forceps for Closing Half-Ring, seat theClosing Half-Ring over the contralateral side of the rib.

Align the Caudal Rib Support and Closing Half-Ring usingthe Pliers for Closing Half-Ring and Rib Support. Load a blueLock for Rib Support into the Inserter for Rib Support Lock.Insert the lock into the aligned holes of the Caudal Rib Sup-port and the Closing Half-Ring. With a hammer tap Inserterto seat the lock. Check to ensure the lock is fully seated usigthe Lock Crimper or the lateral Lock Inserter. The implantsnow encircle the rib.

Note: A 220 mm Extension Bar requires the use of a220 mm Caudal Rib Support. A 70 mm Extension Barrequires the use of a 70 mm Caudal Rib Support.


B 6.4Assemble the construct

Use the Holding Forceps for Extension Bar to slide the se-lected Extension Bar over the Caudal Rib Support.

Slide the Extension Bar onto the Cranial Rib Support. TheIron for Extension Bar and Iron for Rib Support can be usedto align the two implants. The Positioner for Rib Support canalso help with alignment.

Place a golden Closure for Extension Bar in the cranial end ofthe Extension Bar using the Inserter for Rib Support Lock.With a hammer tap the Inserter to seat the lock. The LockCrimper or the lateral Lock Inserter have to be used to en-sure that the Closure is fully seated.

Use the Rib Distraction Pliers, Distractor for Extension Bar orthe Spreader for Rib Support to distract the device until thecaudal hole in the Extension Bar is aligned with a hole in theCaudal Rib Support. Both the Cranial and Caudal Rib Sup-ports should be seated against the ribs.

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B 6.5Lock the construct

Using the Inserter for Rib Support Lock place a golden Clo-sure for Extension bar in the caudal end of the Extension Barto lock the assembly in place. check to ensure both locks arefully seated using the Lock Crimper of Lock Inserter.

Note: If the patient is older than 18 months and of adequatebody size, a second device (rib-to-rib construct) may beadded posterolaterally in the mid-axillary line to further ex-pand the constricted hemitorax.

Expansion Procedure

1Patient positioning

Place the patient in a lateral decubitus or prone position.

2Exposure

Identify the approximate location of the caudal Closure forExtension Bar through palpation and/or radiographic marker.Make a transverse or longitudinal incision over the closure.

3Remove the lock


388.452 Lock Removal Pliers, for VEPTR

388.462 Lock Removal Device, for VEPTR

Remove the golden Closure for Extension Bar using the LockRemoval Pliers or the Lock Removal Device.


4Distraction



388.472 Distractor for Extension Bar, curved


388.457 Distraction Pin for VEPTR, temporary

498.910 Fixation Ring for Rods � 6 mm

Use the Rib Distraction Pliers or the Distractor for ExtensionBar in conjunction with a Fixation Ring for Rods to gently dis-tract the implanted device until the device is adequatelylengthened. Use the Temporary Distraction Pins as placehold-ers to assist distraction.

5Final locking


Standard Hammer




Insert a new golden Closure for Extension Bar using the In-serter for Rib Support Lock to fix the Extension Bar in its distracted position. With a hammer tap the Inserter to seatthe Closure.

Check to ensure the closure is fully seated using the LockCrimper or the lateral Lock Inserter.

Synthes 39

Replacement Procedure

To replace the Extension Bar, Caudal Rib Support or LumbarExtension Rod make three transverse incisions, one at themid-portion of the implanted construct and others along thedistal and proximal portions. A portion of the previous thora-cotomy incision may be used.

Unlock the device by removing the golden Closure(s) for Ex-tension Bars using the Lock Removal Pliers.

Remove the required components and insert the new com-ponents through the fibrous canal surrounding the old de-vices.

Install new Closure(s) for Extension Bars.

Refer to detailed instructions within this Surgical techniqueto install specific components.


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Documents

Technique Guide - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · 4 Synthes VEPTR Technique Guide ... inadvertent rubbing or bumping of