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Surgical Technique
Transforaminal Posterior Atraumatic Lumbar Cage System
T-PAL
Image intensifier control
This description alone does not provide sufficient background for direct use of DePuy Synthes products. Instruction by a surgeon experienced in handling these products is highly recommended.
Processing, Reprocessing, Care and MaintenanceFor general guidelines, function control and dismantling of multi-part instruments, as well as processing guidelines for implants, please contact your local sales representative or refer to:http://emea.depuysynthes.com/hcp/reprocessing-care-maintenanceFor general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, as well as processing of Synthes non-sterile implants, please consult the Important Information leaflet (SE_023827) or refer to: http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance
T-PAL Surgical Technique DePuy Synthes 1
Table of Contents
Introduction T-PAL 2
AO Spine Principles 4
Indications and Contraindications 5
Surgical Technique Preoperative Planning and Preparation 6
Patient Positioning 7
Access and Exposure 8 – Minimally invasive transforaminal approach 8 – Open transforaminal approach 10
Discectomy 11
Disc Space Preparation 12
Trial for Implant Size 13
Implant Preparation 23
PEEK Implant Insertion 26
Titanium Implant Insertion 30
Posterior Support 34
Implant Removal 35
Product Information Implants 37
Instruments 39
Sets 43
Applicator Instructions 45
Function control 48
Filling Material 49
Bibliography 50
2 DePuy Synthes T-PAL Surgical Technique
• Rails on top of the implant, designed to guide and turn the cage between the vertebral bodies into the desired position
• Three x-ray markers help to visualize the implant under radiographic control
T-PAL. Transforaminal Posterior Atraumatic Lumbar Cage System.
Implant with guiding rails
MaterialAvailable in two materials; PEEK (with Titanium alloy marker pins [TAN]); Titanium alloy (TAN)
Two anterior radiographic marker pinsEnable visualization of the anterior implant positionThe B1.4 pins are located approximately 2 mm from the anterior edge of the implant
One proximal radiographic marker pinEnable visualization of implant tip position while insertion
Connection cylinderPermits the pivoting mechanism in combination with the applicator
Axial windowAccommodates autogenous bone graft or bone graft substitute to allow fusion to occur through the cage
Rails on the surfaceDesigned to guide and turn the cage into the desired position
Pyramidal teethDesigned to provide resistance to implant migration
Self-distracting noseAllows for ease of insertion
Lordotic angle5° to restore the natural spine lordotic curve (except for the 7 mm height)
AP trial marker Lateral trial marker
T-PAL Surgical Technique DePuy Synthes 3
• Trial implants can be placed at the same position, where after the implant will be placed
• Designed for guided insertion because of the pivoting applicator and the rails on the surface of the implants and trials
• Designed for secure insertion because of permanent connection to the implants and trials during insertion process
• OR technique based on one key instrument: the applicator
• Designed for minimally invasive surgical technique
Guided insertion technique• One key instrument for insertion
of implant and trials• Applicator is designed to allow
a controlled and guided insertion based on the pivoting option
• Security button designed to prevent implant disengagement
• Applicator is designed for minimally invasive surgeries
One surgery, one instrument
coronalaxial
sagittal
1 DePuy Synthes T-PAL Surgical Technique
The four principles to be considered as the foundation for proper spine patient management underpin the design and delivery of the Curriculum: Stability – Alignment – Biology – Function.1,2
StabilityStabilization to achieve a specifi c therapeutic out-come
BiologyEtiology, pathogenesis, neural protection, and tissue healing
AlignmentBalancing the spine in three dimensions
FunctionPreservations and resto-ration of function to pre-vent disability
AO Spine Principles
Copyright © 2012 by AOSpine
1 Aebi et al (1998)2 Aebi et al (2007)
T-PAL Surgical Technique DePuy Synthes 5
Indications and Contraindications
Intended useThe T-PAL implant is intended to replace lumbar inter-vertebral discs and to fuse the adjacent vertebral bodies together at vertebral levels L1–S1. The T-PAL implant is designed for a transforaminal approach.
IndicationsIndications are lumbar and lumbosacral pathologies in which segmental spondylodesis is indicated, for example:• Degenerative disc diseases and spinal instabilities• Revision procedures for post-discectomy syndrome• Pseudarthrosis or failed spondylodesis• Degenerative spondylolisthesis• Isthmic spondylolisthesis
Contraindications• Vertebral body fractures• Spinal tumours• Major spinal instabilities• Primary spinal deformities• Osteoporosis
Warning: T-PAL must be applied in combination with posterior fixation.
6 DePuy Synthes T-PAL Surgical Technique
Preparation
Set
01.812.001 Set T-PAL
Optional sets
01.809.011 Dilation Instrument Set
01.615.004 Insight Tubes Setor01.615.002 Insight Retractor Set,
Standard Configuration
01.612.110 Set for MIS Support System
01.605.903 Set for Minimally Invasive Posterior Instruments
Have all necessary imaging studies readily available to plan implant placement and visualize individual patient anatomy.
Have all sets readily available prior to surgery.
Preoperative Planning and Preparation
T-PAL Surgical Technique DePuy Synthes 7
Position the patient
Position the patient in a restored physiological lordosis and decompress the abdomen to reduce venous stasis.
Patient Positioning
8 DePuy Synthes T-PAL Surgical Technique
1. Approach
Optional sets
01.809.011 Dilation Instrument Set
01.615.004 Insight Tubes Setor01.615.002 Insight Retractor Set,
Standard Configuration
01.612.110 MIS Support System Set
Locate the correct operative level with fluoroscopic views. Push the Kirschner wire into the desired facet joint. Separate the posterior soft tissue by inserting the smallest diameter dilator over the Kirschner wire. Repeat with next larger diameter dilator until required dilation is achieved. Use fluoroscopy to determine the location of dilator.
Access and Exposure Minimally invasive transforaminal approach
2a. Retraction with insight tubes
Instrument set
01.615.004 Insight Tubes Set
Optional sets
01.612.110 MIS Support System Set
01.809.011 Dilation Instrument Set
Determine the appropriate tube length from the depth indicators on the dilators.
Slide the tube over the dilators until it contacts the facet joint.
Use the flex arm to stabilize the tube to the OR table. Remove the dilators and the Kirschner wire.
T-PAL Surgical Technique DePuy Synthes 9
2b. Retraction with insight retractor
Instrument set
01.615.002 Insight Retractor Set, Standard Configuration
Optional Sets
01.809.011 Dilation Instrument Set
01.612.110 MIS Support System Set
Determine the appropriate retractor lengths of the cranial/caudal and medial/lateral blades from the depth indicators on the dilators.
Slide the retractor with the cranial/caudal blades over the dilators until the blades contact the facet joints. Distract the blades and introduce the second retractor with the medial/lateral blades.
Use the flex arm to stabilize the retractor to the OR table. Remove the dilators and the Kirschner wire.
3. Cut transforaminal window
Instruments
03.605.508 Osteotome, straight, black
03.605.520 Laminectomy Punch, 40°, 4.0 mm, black
Prepare a window for the transforaminal approach using the osteotome to remove the inferior facet of the cranial vertebra and the superior facet of the caudal vertebra.
With the punch, additional bone or osteophytes can be removed.
11 DePuy Synthes T-PAL Surgical Technique
1. Retraction with an open transforaminal approach
Instrument
03.812.040 Lamina Spreader for T-PAL
Make a standard open incision, retract the muscle layer to view the desired segment.
Distract the segment if desired. Position the lamina spreader for T-PAL at the base of the spinous processes. Distract carefully until required distraction is achieved.
Distraction opens the posterior disc space and promotes exposure both for decompression and delivery of the implant.
2. Cut transforaminal window
Instruments
03.605.508 Osteotome, straight, black
03.605.520 Laminectomy Punch, 40°, 4.0 mm, black
Prepare a window for the transforaminal approach using the osteotome to remove the inferior facet of the cranial vertebra and the superior facet of the caudal vertebra.
With the laminectomy punch, additional bone or osteophytes can be removed.
Access and Exposure
Open transforaminal approach
T-PAL Surgical Technique DePuy Synthes 11
Instruments
03.605.507 Rasp, dual-sided, bayoneted, black
03.605.510 Ring Curette, straight, bayoneted, black
03.605.514 Rongeur, curved, 4.0 mm, black
03.605.520 Laminectomy Punch, 40°, 4.0 mm, black
03.605.527 Rongeur, straight, 4.0 mm, black
03.605.529 Curette, rectangular, angled, right, bayoneted, black
03.605.530 Curette, rectangular, angled, left, bayoneted, black
03.803.054 Curette, rectangular, bayoneted, black
389.767– Shaver for Intervertebral Discs, 389.777 size 7–17 mm
394.951 T-Handle with Quick Coupling
Through an incision above the pedicle, access the fora-men and remove disc material, using any of the follow-ing instruments: box and ring curettes, rongeurs as well as disc shavers.
The annulus must be preserved to provide additional support for the T-PAL implant and prevent migration of bone graft and bone graft substitute into the spinal canal.
The shavers can initially be used to ream out disc m aterial or for final removal of the disc material and cartilaginous tissue.
For removal of the tissue in the far lateral disc space, use the left/right angled curettes and the curved rongeur.
Warning: Provide enough lateral exposure to the disc to reduce dural retraction.
Discectomy
12 DePuy Synthes T-PAL Surgical Technique
1. Prepare endplates
Instrument
03.605.511 Rasp, dual-sided, angled, bayoneted, black
When the discectomy is completed, use the rasp to re-move the superficial cartilaginous layers of the endplates to expose the bleeding bone.
Warning: Excessive removal of the subchondral bone may weaken the vertebral endplate. The entire removal of the endplate may result in subsidence and a loss of segmental stability.
Disc Space Preparation
2. Pack disc space
Instrument
03.605.532 Impactor, curved, standard, bayoneted, black
Before the T-PAL cage is implanted, the anterior and far lateral disc space should be filled with bone graft or bone graft substitute.
Note: For more information about the filling mate-rial chronOS see page 49.
1
2
3
T-PAL Surgical Technique DePuy Synthes 13
Trial for Implant Size
1. Assemble applicator and connect non detachable trial implant
Instruments
03.812.001 Applicator Outer Shaft
03.812.307– T-PAL Small Trial Implant, size 7–17 mm, 03.812.317 non detachable
03.812.507– T-PAL Large Trial Implant, size 7–17 mm, 03.812.517 non detachable
03.812.004 Applicator Knob
The applicator must be assembled before insertion of the trial.
Attach the applicator knob to the proximal end of the applicator outer shaft by turning the knob counterclock-wise until it stops (1).
Select an appropriately size trial implant. Insert the trial implant shaft into the applicator outer shaft making sure that the arrow on the outer shaft is aligned with the dis-tal opening of the trial implant shaft (2). The trial implant shaft should now be trapped inside the applicator outer shaft (3).
Turn the applicator knob clockwise to secure the trial im-plant. During this attaching procedure the security ring moves upwards, so that the green color band is visible. Continue to turn the knob until it is tightened.
Warning: Ensure the arrows on the end of the applicator align with those on the trial implant. The con-tact surfaces between the trial and the applicator should have no gap (3).
Note: For disassembly pull the security ring down, turn the applicator knob counterclockwise until it stops. Push the small button on the applicator knob and simultaneously pull the trial implant shaft out of the applicator outer shaft. Turn the applicator knob clockwise. For detailed disassembly instruc-tions please refer to page 47.
Warning: Please read fi rst the applicator instruc-tions on page 45–46.
1
2
3
11 DePuy Synthes T-PAL Surgical Technique
Trial for Implant Size
Optional: Assemble applicator and connect detachable trial implant
Instruments
03.812.001 Applicator Outer Shaft
03.812.003 Applicator Inner Shaft
03.812.004 Applicator Knob
The applicator must be assembled before insertion of the trial.
Attach the applicator knob to the proximal end of the applicator outer shaft by turning the knob counterclock-wise until it stops (1).
Insert the applicator inner shaft into the applicator outer shaft making sure that the arrow on the outer shaft is aligned with the distal opening of the inner shaft (2). The applicator inner shaft should now be trapped inside the outer shaft (3).
Note: For disassembly pull the security ring down, turn the applicator knob counterclockwise until it stops. Push the small button on the applicator knob and simultaneously pull the inner shaft out of the outer shaft. Turn the applicator knob clockwise. For detailed disassembly instructions please refer to page 47.
Warning: Please read first the applicator instruc-tions on page 45–46.
1 2
3
T-PAL Surgical Technique DePuy Synthes 15
Connect detachable trial implant to the applicator
Instruments
03.812.007– T-PAL Small Trial Implant, size 7–17 mm03.812.017
03.812.207– T-PAL Large Trial Implant, size 7–17 mm03.812.217
Connect an appropriately sized trial implant to the appli-cator. Pull the security ring down and simultaneously turn the knob at the proximal end of the applicator counterclockwise. The applicator jaws open (1). Place the jaws over the proximal end of the trial implant making sure to align the arrows on the end of the applicator with those on the trial implant (2).
Turn the applicator knob clockwise to close the jaws. During this closing procedure the security ring moves upwards, so that the green color band is visible (3). Continue to turn the knob until it is tightened (2).
Note: When the applicator knob remains tightened, the trial implant can not pivot or detach.
Warning: Ensure the arrows on the end of the appli-cator align with those on the trial implant. The con-tact surfaces between the trial implant and the applicator should have no gap (2).
10–15°
1
2
3
16 DePuy Synthes T-PAL Surgical Technique
Trial for Implant Size
2. Insert trial implant
Optional instrument
SFW691R Prodisc-L Combined Hammer
Recheck the firm connection of trial implant to applica-tor. Insert the trial implant into the disc space, ensuring that the orientation of the trial implant is correct. The trial implant tip should be orientated medial. Maintain 10–15° between the applicator handle and the sagittal plane during trial implant insertion (1).Controlled and light hammering on the applicator may be required to advance the trial implant into the interver-tebral disc space. Use fluoroscopy to confirm position and fit of the trial implant. The tip should be positioned near the anterior edge of the adjacent vertebral bodies (2).
Notes:• Firm connection of trial implant to applicator can
be checked manually by applying pressure on the lateral side of the trial implant with the thumb. Trial implant should not pivot.
• Use soft tissue retractor 389.857–389.859 to protect soft tissue.
• Use fluoroscopy during the insertion to confirm anterior positioning of the trial implant.
Warnings: • The trial tip indicates approximate final anterior
position of trial implant (3).• Maintain 10–15° between the applicator handle
and the sagittal plane during trial implant insertion.
10–15°
10–15°
2
1
T-PAL Surgical Technique DePuy Synthes 17
3. Position trial implant
Optional Instrument
SFW691R Prodisc-L Combined Hammer
Turn the applicator knob counterclockwise until it stops (1)
Note: Ensure applicator knob is turned counter-clockwise until it stops to avoid trial or applicator outershaft deformation.
Controlled and light hammering on the applicator may be required to pivot the trial implant into final position (2).Use fluoroscopy during the pivoting procedure and confirm fit and position of the trial implant. Each trial has a medial/lateral and an anterior/posterior opening for position control. If the trial implant appears too small or too tight, try the next larger or smaller size height until the most secure fit is achieved.
Note: Ensure that the trial implant is positioned where the implant will be placed.
Warnings:• Maintain 10–15° between the applicator handle
and the sagittal plane during trial implant insertion.
• Do not detach the trial implant in the disc space.
10–15°
1 2
18 DePuy Synthes T-PAL Surgical Technique
Optional: Position trial implant
If trial implant does not pivot automatically, turn the applicator handle medially to initiate pivoting upon impaction (1). After pivoting is initiated the applicator handle must be turned back to an angle of 10–15° from the sagittal plane to pivot the trial implant into final position (2).
Warning: Maintain 10–15° between the applicator handle and the sagittal plane for final trial implant insertion.
Trial for Implant Size
1 2
T-PAL Surgical Technique DePuy Synthes 19
4. Remove non detachable trial implant
Instruments
03.809.972 Oracle Slide Hammer
Optional instrument
SFW691R Prodisc-L Combined Hammer
Warning: The applicator must be in the pivoting position to remove the trial implant.
Slide the slide hammer onto the end of the applicator knob with quick coupling (1). While holding the handle with one hand, apply an upward force to the slide hammer with the other hand. Repeat this procedure until the trial implant is removed (2).
Optionally the combination hammer may also be used to remove the trial implant.
Remove the slide hammer from the handle by pushing on the end of the slide hammer.
43
5
21 DePuy Synthes T-PAL Surgical Technique
Trial for Implant Size
To detach the trial implant from the applicator pull the security ring down simultaneously turn the knob coun-terclockwise until it stops (3). Push the small button on the applicator knob and remove the trial implant (4).
Insert the applicator inner shaft into the applicator outer shaft making sure that the arrow on the outer shaft is aligned with the distal opening of the inner shaft (5). The applicator inner shaft should now be trapped inside the outer shaft. The applicator is now ready to accept the implant.
Note: If the security ring cannot be pulled down, turn the knob clockwise a quarter turn. The ring can now be pulled down.
1 2
T-PAL Surgical Technique DePuy Synthes 21
Optional: Remove detachable trial implant
Instrument
03.809.972 Oracle Slide Hammer
Optional instrument
SFW691R Prodisc-L Combined Hammer
Warning: The applicator must be in the pivoting position to remove the trial implant.
Slide the slide hammer onto the end of the applicator knob with quick coupling (1). While holding the handle with one hand, apply an upward force to the slide hammer with the other hand. Repeat this procedure until the trial implant is removed (2).
Optionally the combination hammer may also be used to remove the trial implant.
Remove the slide hammer from the handle by pushing on the end of the slide hammer.
43
22 DePuy Synthes T-PAL Surgical Technique
Trial for Implant Size
To detach the trial implant, pull the security ring down and simultaneously turn the applicator knob counter-clockwise until it stops (3). The trial implant can now be removed from the applicator (4).
Note: If the security ring cannot be pulled down, turn the knob clockwise a quarter turn. The ring can now be pulled down.
T-PAL Surgical Technique DePuy Synthes 23
Implant Preparation
1. Select Implant
Implants and Instruments
08.812.007S– T-PAL Small, Cage, height 7–17 mm, 08.812.017S PEEK, sterile
08.812.207S– T-PAL Large, Cage, height 7–17 mm, 08.812.217S PEEK, sterile
04.812.007S– T-PAL Small, Cage, height 7–17 mm, 04.812.017S Titanium, sterile
04.812.207S– T-PAL Large, Cage, height 7–17 mm, 04.812.217S Titanium, sterile
03.812.044 Packing Block for T-PAL
Select the T-PAL implant that corresponds to the height and size measured using the trial implant in the previous steps.
Insert the selected implant into the appropriate packing block place.
1
2
3
21 DePuy Synthes T-PAL Surgical Technique
2. Pack implant with bone graft
Instrument
03.812.043 Cancellous Bone Impactor for T-PAL
Turn the packing block on its side and use the cancellous bone impactor to firmly pack the filling material into the implant cavities (1).
Make sure the implant is well placed in the packing block to avoid implant damage while bone graft filling (2).
It is important to fill the implant until the filling material protrudes from its perforations in order to ensure optimal contact with the vertebral endplates (3).
For more information about the filling volumes, see page 37 in this surgical technique.
Note: For more information about the filling mate-rial chronOS see page 49.
Implant Preparation
1
3
2
T-PAL Surgical Technique DePuy Synthes 25
3. Connect implant to the applicator
Instruments
03.812.001 Applicator Outer Shaft
03.812.003 Applicator Inner Shaft
03.812.004 Applicator Knob
To connect the implant to the applicator turn the pack-ing block upwards again. Pull the security ring down and simultaneously turn the knob at the proximal end of the applicator counterclockwise. The applicator jaws open (1). Place the jaws over the proximal end of the implant making sure to align the arrows on the end of the appli-cator with those on the implant (2).
Turn the applicator knob clockwise to close the jaws. During this closing procedure the security ring moves upwards, so that the green color band is visible. Con-tinue to turn the knob until it is tightened (3).
Note: When the applicator knob is tightened, the implant can not pivot or detach.
Warning: Ensure the arrows on the end of the appli-cator align with those on the implant. The contact surfaces between the implant and the applicator should have no gap (2).
10–15°
1
2
3
26 DePuy Synthes T-PAL Surgical Technique
1. Insert implant
Optional Instrument
SFW691R Prodisc-L Combined Hammer
Recheck the firm connection of implant to applicator. Insert the implant into the disc space, ensuring that the orientation of the implant is correct. The implant tip should be orientated medial. Maintain 10–15° between the applicator handle and the sagittal plane during implant insertion (1). Controlled and light hammering on the applicator may be required to advance the implant into the inter-vertebral disc space.Use fluoroscopy to confirm position and fit of the implant.The tip should be positioned near the anterior edge of the adjacent vertebral bodies (2).
Notes: • Firm connection of implant to applicator can be
checked manually by applying pressure on the lateral side of the implant with the thumb. Implant should not pivot.
• Use soft tissue retractor 389.857–389.859 to reduce soft tissue damage/injury.
• Use fluoroscopy during the insertion to confirm anterior position of the implant.
• The anterior marker pins of the implant are located approximately 2 mm from the edge of the implant.
Warnings: • The implant tip marker pin indicates approximate
final anterior position of implant (3).• Maintain 10–15° between the applicator handle
and the sagittal plane during implant insertion.
PEEK Implant Insertion
10–15°
10–15°1
2
T-PAL Surgical Technique DePuy Synthes 27
2. Position implant
Optional Instrument
SFW691R Prodisc-L Combined Hammer
Turn the applicator knob counterclockwise until it stops (1).
Note: Ensure applicator knob is turned counter-clockwise until it stops to avoid deformation of the applicator outershaft.
Controlled and light hammering on the applicator may be required to pivot the implant into final position (2). Use fluoroscopy during the pivoting procedure and confirm fit and position of the implant. With a medial/lateral fluoroscopic image of the cage in the final position, the two anterior pins of the implant should appear as one line.
In an anterior/posterior fluoroscopic image, the two anterior pins should be equidistant to the pedicles. The tip pin indicates the lateral edge of the implant.
Note: If bone graft or bone graft substitutes are placed into the disc space after trialing, the implant may not reach the same position as the trial.
Warning: Maintain 10–15° between the applicator handle and the sagittal plane during implant insertion.
10–15°
1 2
28 DePuy Synthes T-PAL Surgical Technique
Optional: Position implant
If implant does not pivot automatically, turn the applica-tor handle medially to initiate pivoting upon impaction (1). After pivoting is initiated the applicator handle must be turned back to an angle of 10–15° from the sagittal plane to pivot the implant into final position (2).
Warning: Maintain 10–15° between the applicator handle and the sagittal plane for final implant insertion.
PEEK Implant Insertion
T-PAL Surgical Technique DePuy Synthes 29
3. Detach implant
To detach the implant, pull the security ring down and simultaneously turn the applicator knob counterclock-wise until it stops. The applicator can now be removed from the implant.
Use fluoroscopy to verify final position of the implant. With a medial/lateral fluoroscopic image, the two anterior pins of the implant should appear as one line and the tip marker as a dot.
Note: If the security ring cannot be pulled down, turn the knob clockwise a quarter turn. The ring can now be pulled down.
Note: If the applicator does not disengage from the implant turn the applicator handle laterally to free the instrument.
10–15°
2
3
31 DePuy Synthes T-PAL Surgical Technique
Titanium Implant Insertion
1. Insert implant
Optional instrument
SFW691R Prodisc-L Combined Hammer
Recheck the firm connection of implant to applicator. Insert the implant into the disc space, ensuring that the orientation of the implant is correct. The implant tip should be orientated medial. Maintain 10–15° between the applicator handle and the sagittal plane during im-plant insertion (1). Controlled and light hammering on the applicator may be required to advance the implant into the interverte-bral disc space.Use fluoroscopy to confirm position and fit of the implant. The tip should be positioned near the anterior edge of the adjacent vertebral bodies (2).
Notes:• Firm connection of implant to applicator can be
checked manually by applying pressure on the lat-eral side of the implant with the thumb. Implant should not pivot.
• Use soft tissue retractor 389.857–389.859 to protect soft tissue.
• Use fluoroscopy during the insertion to confirm anterior position of the implant.
Warnings: • The implant tip indicates approximate final
anterior position of implant (3).• Maintain 10–15° between the applicator handle
and the sagittal plane during implant insertion.
10–15°
10–15°
1
2
T-PAL Surgical Technique DePuy Synthes 31
2. Position implant
Optional instrument
SFW691R Prodisc-L Combined Hammer
Turn the applicator knob counterclockwise until it stops (1).
Note: Ensure applicator knob is turned counter-clockwise until it stops to avoid deformation of the applicator outershaft.
Controlled and light hammering on the applicator may be required to pivot the implant into final position (2). Use fluoroscopy during the pivoting procedure and con-firm fit and position of the implant. Each implant has a medial/lateral and an anterior/posterior opening for posi-tion control.
Note: If bone graft or bone graft substitutes are placed into the disc space after trialing, the implant may not reach the same position as the trial.
Warning: Maintain 10–15° between the applicator handle and the sagittal plane during implant insertion.
10–15°
1 2
32 DePuy Synthes T-PAL Surgical Technique
Optional: Position implant
If implant does not pivot automatically, turn the applicator handle medially to initiate pivoting upon impaction (1). After pivoting is initiated the applicator handle must be turned back to an angle of 10–15° from the sagittal plane to pivot the implant into final position (2).
Warning: Maintain 10–15° between the applicator handle and the sagittal plane for final implant insertion.
Titanium Implant Insertion
T-PAL Surgical Technique DePuy Synthes 33
3. Detach implant
To detach the implant, pull the security ring down and simultaneously turn the applicator knob counterclock-wise until it stops. The applicator can now be removed from the implant.
Use fluoroscopy to verify final position of the implant. With a medial/lateral fluoroscopic image, lateral opening of the titanium T-PAL implant should be visible.
Note: If the security ring cannot be pulled down, turn the knob clockwise a quarter turn. The ring can now be pulled down.
Note: If the applicator does not disengage from the implant turn the applicator handle laterally to free the instrument.
31 DePuy Synthes T-PAL Surgical Technique
1. Pack disc space
Instrument
03.605.532 Impactor, curved, standard, bayoneted, black
After the T-PAL cage is implanted, fill the posterior disc space and the lateral disc space with bone graft or bone graft substitute to create desired conditions for fusion.
Note: For more information about the filling mate-rial chronOS see page 49.
Posterior Support
2. Supplemental fixation
The T-PAL cage is intended to be used in combination with posterior fixation (e.g. Click’X).
T-PAL Surgical Technique DePuy Synthes 35
Implant Removal
Implant removal with the applicator
Instruments
03.812.001 Applicator Outer Shaft
03.812.003 Applicator Inner Shaft
03.812.004 Applicator Knob
Ensure that the applicator is in the fully open position. Locate the implant and close the applicator by turning the knob clockwise until the security ring is moving upwards. There should be no gap between the applica-tor knob and the security ring. To ensure that the knob is in contact with the security ring, turn the knob coun-terclockwise until it stops, in this position the implant can pivot but not detach from the ap plicator. The im-plant can now be removed. The slap hammer may be required to facilitate removal.
Note: Distraction of the segment may facilitate implant removal. However, if possible, do not distract before ensuring a firm connection between the implant and the applicator.
Warning: The applicator must be in the pivoting position to remove the implant.
36 DePuy Synthes T-PAL Surgical Technique
Implant Removal
Implant removal with the removal tool
Instrument
03.812.005 Removal Tool for T-PAL
Optional instrument
03.809.972 Oracle Slide Hammer
Ensure that the removal tool for T-PAL is in the fully open position. Locate the implant and squeeze the han-dle firmly. Advance the speed nut to lock the handle. The implant can now be removed. The slap hammer may be required to facilitate removal.
Note: When the removal tool handle is squeezed, the implant can pivot but not detach from the removal tool.
Note: Distraction of the segment may facilitate implant removal. However, if possible, do not distract before ensuring a firm connection between the implant and the removal tool.
T-PAL Surgical Technique DePuy Synthes 37
Graft volume
The table below shows the approximate graft volume that T-PAL implants will hold, depending on the foot-print and heights.
Anterior
Posterior
Implants
Total depthSmall implants14 mmLarge implants16 mm
Insertion depthSmall implants 10 mmLarge implants 12 mm
LengthSmall implants 28 mmLarge implants 31 mm
* 7 mm height = 0°
T-PAL Implant, 5° angle*, small footprint 10 × 28 mm
Heights Filling volume PEEK Implants Titanium Implants
7 mm 0.4 cc 08.812.007S 04.812.007S
8 mm 0.4 cc 08.812.008S 04.812.008S
9 mm 0.5 cc 08.812.009S 04.812.009S
10 mm 0.6 cc 08.812.010S 04.812.010S
11 mm 0.7 cc 08.812.011S 04.812.011S
12 mm 0.8 cc 08.812.012S 04.812.012S
13 mm 0.9 cc 08.812.013S 04.812.013S
15 mm 1.0 cc 08.812.015S 04.812.015S
17 mm 1.3 cc 08.812.017S 04.812.017S
T-PAL Implant, 5° angle*, large footprint 12 × 31 mm
Heights Filling volume PEEK Implants Titanium Implants
7 mm 0.6 cc 08.812.207S 04.812.207S
8 mm 0.7 cc 08.812.208S 04.812.208S
9 mm 0.8 cc 08.812.209S 04.812.209S
10 mm 0.9 cc 08.812.210S 04.812.210S
11 mm 1.1 cc 08.812.211S 04.812.211S
12 mm 1.2 cc 08.812.212S 04.812.212S
13 mm 1.4 cc 08.812.213S 04.812.213S
15 mm 1.7 cc 08.812.215S 04.812.215S
17 mm 2.0 cc 08.812.217S 04.812.217S
38 DePuy Synthes T-PAL Surgical Technique
Height
Height Posterior Height
* 7 mm height = 0°
T-PAL Implant, 5° angle*, small footprint 10 × 28 mm
Heights Posterior height PEEK Implants Titanium Implants
7 mm 7.0 mm 08.812.007S 04.812.007S
8 mm 7.2 mm 08.812.008S 04.812.008S
9 mm 8.2 mm 08.812.009S 04.812.009S
10 mm 9.2 mm 08.812.010S 04.812.010S
11 mm 10.2 mm 08.812.011S 04.812.011S
12 mm 11.2 mm 08.812.012S 04.812.012S
13 mm 12.2 mm 08.812.013S 04.812.013S
15 mm 14.2 mm 08.812.015S 04.812.015S
17 mm 16.2 mm 08.812.017S 04.812.017S
T-PAL Implant, 5° angle*, large footprint 12 × 31 mm
Heights Posterior height PEEK Implants Titanium Implants
7 mm 7.0 mm 08.812.207S 04.812.207S
8 mm 7.0 mm 08.812.208S 04.812.208S
9 mm 8.0 mm 08.812.209S 04.812.209S
10 mm 9.0 mm 08.812.210S 04.812.210S
11 mm 10.0 mm 08.812.211S 04.812.211S
12 mm 11.0 mm 08.812.212S 04.812.212S
13 mm 12.0 mm 08.812.213S 04.812.213S
15 mm 14.0 mm 08.812.215S 04.812.215S
17 mm 16.0 mm 08.812.217S 04.812.217S
Implants
T-PAL Surgical Technique DePuy Synthes 39
03.812.001 Applicator Outer Shaft
03.812.003 Applicator Inner Shaft
03.812.004 Applicator Knob
03.812.005 Removal Tool for T-PAL
03.812.043 Cancellous Bone Impactor for T-PAL
Instruments
03.812.307– T-PAL Small Trial Implant size 7–17 mm, 03.812.317 non detachable
03.812.507– T-PAL Large Trial Implant, size 7–17 mm, 03.812.517 non detachable
11 DePuy Synthes T-PAL Surgical Technique
03.809.972 Oracle Slide Hammer
SFW691R Prodisc-L Combined Hammer
03.812.044 Packing Block for T-PAL
03.605.514 Rongeur, curved, 4.0 mm, black
03.605.520 Laminectomy Punch, 40°, 4.0 mm, black
03.605.527 Rongeur, straight, 4.0 mm, black
Instruments
T-PAL Surgical Technique DePuy Synthes 11
03.605.529 Curette, rectangular, angled, right, bayoneted, black
03.605.530 Curette, rectangular, angled, left, bayoneted, black
03.803.054 Curette, rectangular, bayoneted, black
03.605.532 Impactor, curved, standard, bayoneted, black
03.605.508 Osteotome, straight, black
03.605.507 Rasp, dual-sided, bayoneted, black
03.605.510 Ring Curette, straight, bayoneted, black
03.605.511 Rasp, dual-sided, angled, bayoneted, black
12 DePuy Synthes T-PAL Surgical Technique
389.857 – Soft Tissue Retractor, width 6, 8, 10 mm389.859
389.767– Shaver for Intervertebral Discs, 389.777 size 7–17 mm
394.951 T-Handle with Quick Coupling
03.812.040 Lamina Spreader for T-PAL
03.812.007– T-PAL Small Trial Implant, size 7–17 mm03.812.017
03.812.207– T-PAL Large Trial Implant, size 7–17 mm03.812.217
Optional Instruments
Instruments
T-PAL Surgical Technique DePuy Synthes 13
Sets
Vario Case
68.812.001 Vario Case for T-PAL
Instruments
03.812.001 Applicator Outer Shaft
03.812.003 Applicator Inner Shaft
03.812.004 Applicator Knob
03.812.005 Removal Tool for T-PAL
03.812.307– T-PAL Small Trial Implant, size 7–17 mm, 03.812.317 non detachable
03.812.507– T-PAL Large Trial Implant, size 7–17 mm, 03.812.517 non detachable
03.812.043 Cancellous Bone Impactor for T-PAL
03.812.044 Packing Block for T-PAL
03.809.972 Oracle Slide Hammer
SFW691R Prodisc-L Combined Hammer
11 DePuy Synthes T-PAL Surgical Technique
Vario Case
68.812.002 Disc Removal Set for T-PAL
Instruments
03.605.507 Rasp, dual-sided, bayoneted, black
03.605.508 Osteotome, straight, black
03.605.510 Ring Curette, straight, bayoneted, black
03.605.511 Rasp, dual-sided, angled, bayoneted, black
03.605.514 Rongeur, curved, 4.0 mm, black
03.605.520 Laminectomy Punch, 40°, 4.0 mm, black
03.605.527 Rongeur, straight, 4.0 mm, black
03.605.529 Curette, rectangular, angled, right, bayoneted, black
03.605.530 Curette, rectangular, angled, left, bayoneted, black
03.803.054 Curette, rectangular, bayoneted, black
03.605.532 Impactor, curved, standard, bayoneted, black
03.812.040 Lamina Spreader for T-PAL
389.857– Soft Tissue Retractor,389.859 width 6, 8 and 10 mm
389.767– Shaver for Intervertebral Discs, 389.777 size 7–17 mm
394.951 T-Handle with Quick Coupling
Sets
T-PAL Surgical Technique DePuy Synthes 15
Attach positionPull the security ring down and simultaneously turn the knob counterclockwise. No gap between the handle, security ring and the applicator knob should be present. The green color band should not be visible.
The implant or trial can be attached.
Insertion positionTurn the applicator knob clockwise to close the jaws. During this closing procedure the security ring moves upwards, so that the green color band is visible. Continue to turn the knob until it is tightened.
In the insertion position; the implant or trial is fixed. The implant or trial can not pivot or detach.
Applicator Instructions
16 DePuy Synthes T-PAL Surgical Technique
Pivoting positionTurn the applicator knob counterclockwise until it stops. The applicator knob and the security ring will now be in contact.
In this position the implant or trial can pivot 80°. Implant or trial cannot detach from applicator.
Detach positionPull the security ring down and simultaneously turn the knob counterclockwise. No gap between the handle, security ring and the Applicator knob should be present. The green color band should not be visible.
The implant or trial can be detached.
Note: If the security ring cannot be pulled down, turn the knob clockwise a quarter turn. The ring can now be pulled down.
Applicator Instructions
1
2
12
1
T-PAL Surgical Technique DePuy Synthes 17
2
1
3
Applicator Outer ShaftInner ShaftKnobT-PAL Small Trial Implant, size 7–17 mm, non detachableT-PAL Large Trial Implant, size 7–17 mm, non detachable
03.812.00103.812.00303.812.004
03.812.307–31703.812.507–517
4
18 DePuy Synthes T-PAL Surgical Technique
Possible damage• Overlaying deformation at the
edge of the groove
Prevention• none
Recommendation• Exchange instrument
Function Control
03.812.003 Applicator Inner Shaft
T-PAL Surgical Technique DePuy Synthes 19
Filling Material
chronOS is a bone graft substitute consisting of pure b-tricalcium phosphate. Its compressive strength is simi-lar to that of cancellous bone once it has been incorpo-rated and remodeled.1 Based on literature, the use of b-tricalcium phosphate in the spinal column is a valuable alternative to allografts and autografts, even when larger amounts are required.2
Resorbable It is being replaced in the human body by host bone in 6 to 18 months; depending on the indication and the patient’s conditions.2,3–5
Synthetic Having a synthetic origin, chronOS offers the advantage of uniform quality and unlimited availability.3
Osteoconductive Interconnected macropores of defined size (100–500 μm) facilitate bone formation throughout the entire implant. Interconnected micropores (<10 μm) allow supply of nutrients.1,6
Osteoinductive with bone marrow The patient’s blood, blood platelet concentrate or bone marrow aspirate enhances the properties of chronOS required for fusion.4,5
chronOS Granules
Art. no. B (mm) cc
710.000S 0.5–0.7 0.5
710.001S 0.7–1.4 0.5
710.002S 0.7–1.4 1
710.003S 0.7–1.4 2.5
710.011S 1.4–2.8 2.5
710.014S 1.4–2.8 5
710.019S 1.4–2.8 10
710.021S 1.4–2.8 20
710.024S 2.8–5.6 2.5
710.025S 2.8–5.6 5
710.026S 2.8–5.6 10
710.027S 2.8–5.6 20
1 Gazdag et al. 1995 ² Muschik et al. 2001 ³ Stoll et al. 2004 4 Becker et al. 2006 5 Wheeler et al. 2005 6 Lu et al. 1999
chronOS – synthetic b-tricalcium phosphate cancellous bone substitute
51 DePuy Synthes T-PAL Surgical Technique
Bibliography
Aebi M, Arlet V, Webb JK, (2007): AOSPINE Manual(2 vols), Stuttgart, New York: Thieme.
Aebi M, Thalgott JS, Webb JK (1998): AO ASIF Principlesin Spine Surgery. Berlin: Springer.
Becker S, Maissen O, Ponomarev I, Stoll T, Rahn B, Wilke I (2006) Osteopromotion by a b-Tricalcium Phosphate/Bone Marrow Hybrid Implant for Use in Spine Surgery. Spine 31 (1): 11-17 Gazdag AR, Lane JM, Glaser D, Forster RA (1995) Alter-natives to autogenous bone graft: efficacy and indica-tions. J Am Acad Orthop Surg 3: 1-8. Lu J. X. , et al. Role of interconnections in porous bio ceramics on bone recolonization in vitro and in vivo. J Mater Sci Mater Med. 1999; 10(2): 111–120. Muschik M, Ludwig R, Halbhubner S, Bursche K, Stoll T (2001) Beta-tricalcium phosphate as a bone substitute for dorsal spinal fusion in adolescent idiopathic scoliosis: preliminary results of a prospective clinical study. Eur Spine J. 10 (2):178–84. Stoll T, Maissen O, Meury T, Becker S (2004) New as-pects in osteoinduction. Mat.-wiss. u. Werk stofftech 35: 198–202 Wheeler D. L., et al. Grafting of Massive Tibial Subchon-dral Bone Defects in a Caprine Module Using beta-Trical-cium Phosphate versus Autograft. J Orthop Trauma 2005; 19(2): 85–91.
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