USS II ILIO-SACRAL - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · 6 DePuy Synthes USS II Ilio-Sacral Surgical Technique Iliac connectors,

SURGICAL TECHNIQUE

Modular System for Stable Fixation in the Sacrum and Illium

USS II ILIO-SACRAL

Instruments and implants approved by the AO Foundation.This publication is not intended for distribution in the USA.

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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

http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance

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USS II Ilio-Sacral Surgical Technique DePuy Synthes 1

TABLE OF CONTENTS

INTRODUCTION USS II Ilio-Sacral 2

AO Spine Principles 4

Indications and Contraindications 5

PRODUCT INFORMATION Implants 6

Instruments 8

SURGICAL TECHNIQUE Iliac Fixation with Iliac Connector 10

S2 Fixation with S2 Connector 19 – Insertion S2 connector left/right 22 – Insertion S2 connector for rod end 24

Remobilisation of the Polyaxial Connection 26 for Implant Removal

BIBLIOGRAPHY 27

21

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2 DePuy Synthes USS II Ilio-Sacral Surgical Technique

USS II ILIO-SACRAL

USS II Ilio-Sacral is intended for an addi-tional rod fixation in the ilium and in S2. It is an add-on to USS II Polyaxial and combined with the USS systems enables a construct from the thoracolumbar spine to the pelvis.

There are different connectors available for the linkage to the ilium and to the S2 pedicle. All connectors are combined with the USS II Polyaxial bone screws.

USS II Ilio-Sacral

• Add-on to USS II Polyaxial• Uses the same bone screws

(extra long up to 140 mm)• Low profile

USS II nut

Fixed length iliac connector (1)Telescopic iliac connector (2)

Clamp for fixed length/telescopic iliac connector

Collet

Dual-core cancellous bone screws

S2 connector, left/right S2 connector, for rod end

Pelvic connectors

Pelvic rod

Secure working over sticks, for both USS II Ilio-Sacral and USS II Polyaxial.

S2 fixation

coronalaxial

sagittal


Copyright © 2012 by AOSpine

The four principles to be considered as the foundation for proper spine patient management underpin the design and delivery of the Curriculum: Stability – Align-ment – Biology – Function.1,2

FunctionPreservations and restora-tion of function to prevent disability

StabilityStabilization to achieve a specifi c therapeutic out-come

AlignmentBalancing the spine in three dimensions

BiologyEtiology, pathogenesis, neural protection, and tissue healing

AO SPINE PRINCIPLES

1 Aebi et al (1998)2 Aebi et al (2007)


INDICATIONS AND CONTRAINDICATIONS

Notes:• The iliac connectors provide additional stabiliza-

tion for an S1 screw fixation. It is recommended to always combine an iliac connector with an S1 screw.

• For degenerative diseases, it is recommended to use an S2 fixation where possible in addition to the S1 screw.

IndicationsUSS II Ilio-Sacral is indicated for fixation of long posterior rod constructs in the ilium and in S2, both in combina-tion with an S1 fixation.

S1 fixation combined with iliac fixation:• Severe scoliosis (e.g. neuromuscular)

S1 fixation combined with S2 fixation:• Degenerative diseases (e.g. spondylolisthesis)

Contraindications• Fractures and tumours with insufficient anterior support• USS II Ilio-Sacral should not be used where no fixation

in S1 is possible.


Iliac connectors, fixed length

04.621.112–145* Iliac connectors in fixed lengths from 12 to 45 mm (in 3 mm steps)

04.621.275* Clamp for iliac connector with fixed length

Iliac connector, telescopic

04.621.171* Iliac connector, telescopic, neutral, length 17–27 mm

04.621.270* Clamp for telescopic iliac connector

S2 connectors

04.621.260/261* S2 connector, left/right, for rods ⌀ 6.0 mm

04.621.262* S2 connector for rod end, for rods ⌀ 6 mm

Collet for iliac connector and S2 connector

04.621.190* Collet for iliac connector and S2 connector, for all sizes

IMPLANTS

* All implants are also available sterile packed. Add suffix “S” to article number.


USS II nut

499.294* USS II nut

USS II Polyaxial cancellous bone screws with dual core

Art. Nos. ⌀ Lengths Colour

04.607.232–239* 6.2 mm 30–65 mm light blue

04.607.252–269* 7.0 mm 30–140 mm turquoise

04.607.272–289* 8.0 mm 30–140 mm blue

Optionally USS II Polyaxial pedicle screws can be used.

Pelvic connectors*

04.300.000* L-connector

04.300.001* Claw-connector

04.300.002* T-connector, small

04.300.003* T-connector, large

Pelvic rods*

04.306.010 Pelvic rod, left

04.306.012 Pelvic rod, right

* Implants are also available sterile packed. Add suffix “S” to article number.


The USS General Instruments (187.200) are recom-mended for use as basic instrument set.

USS II Polyaxial instruments needed for USS II Ilio-Sacral

03.607.001 Screwdriver, bihexagonal 3.0 mm, with T-Handle

03.607.003 USS II Polyaxial Holding Sleeve for No. 03.607.001

03.607.002 Screwdriver Shaft for USS II Polyaxial cancellous bone screws with lengths M70 mm

388.622 Handle for Screw Holder or 03.607.006 USS II Polyaxial Handle for Screw Holder

03.607.055

03.607.000 USS II Polyaxial Reamer

INSTRUMENTS


03.607.005 USS II Polyaxial Screw Holder

388.584 Socket Wrench for twelve point nut, with L-Handle

USS II Ilio-Sacral instruments

03.621.011 Clamp Holder (for clamps 04.621.270 and 275)

03.621.031–33 Templates for Iliac Connectors (short, medium, long)

03.621.012 Socket Wrench, cannulated, with Straight Handle for USS-II Nut

Additional instruments

319.011 Depth Gauge for Pedicle Screws, measuring range up to 110 mm

388.143 Socket Wrench 5.0 mm, with T-Handle

314.070 Screwdriver, hexagonal, small, 2.5 mm, with Groove


1Instrument spine down to S1

Instrument the spine with a rod construct down to S1 according to the surgical technique of the implant sys-tem used (e.g. USS II Polyaxial). In S1, it is recommended to use a USS II Polyaxial cancellous bone screw for easy rod introduction.

Note: Leave at least 3 cm excess rod caudally to the S1 screw for later placement of the iliac connector.

AlternativeInstead of applying the iliac connectors to the rod as the last step in the surgery, it is also possible to insert all screws and iliac connectors first, and then apply the rod.

2Determine size of iliac connector

Required instruments

03.621.031–33 Templates (short, medium, long)

Use the templates to determine the proper implant size. Either the telescopic or the fixed-length iliac connector may be used.

Notes:• Fixed length connector: The distances indicated on

the template correspond to the implant size (mm).• Telescopic connector: The distance varies between

17 and 27 mm.

ILIAC FIXATION WITH ILIAC CONNECTOR


3Attach clamp

Required instrument

03.621.011 Clamp Holder

Pick up the corresponding clamp for the telescopic or fixed-length connector from the tray using the Clamp Holder.

Note: The Clamp Holder is approx. twice as long as the USS II Polyaxial Screw Holder.

Attach the clamp to the rod from the midline. If neces-sary, remove excessive bone below the rod to create enough space for the clamp.

Clamp for fixed-length iliac connector

Clamp for telescopic iliac connector

Note: To prevent possible tissue irritation remove enough bone on the ilium so that the iliac connector will be seated below the original iliac crest.


4Place iliac connector and create screw entry point

Required instrument


Drop the iliac connector over the Clamp Holder. With the implant in place, verify that the correct implant size has been chosen.

Use a pedicle probe to drill the screw hole in the center of the opening of the iliac connector. This ensures that the screw will be placed at the correct distance to the rod.

After drilling the screw hole, remove the iliac connector.

Alternative screw placement in the ilium: The screw may be placed from the inner side of the iliac crest in order to reduce the extent of soft tissue exposure.

Iliac Fixation with Iliac Connector


5Insert bone screw



03.607.003 USS II Polyaxial Holding Sleeve

Optional instruments

03.607.002 Screwdriver Shaft for screws M70 mm

03.607.006 USS II Polyaxial Handle

Pick up the appropriate screw from the screw rack using the Screwdriver and the Holding Sleeve. Insert the screw into the prepared ilium until the screw is well seated.

Note: For cancellous bone screws with a length of 70 mm or longer, use the Screwdriver Shaft 03.607.002 attached to the USS II Polyaxial Handle.


6Expose screw head




Place the Reamer guided by the Screwdriver over the screw head. Ream away excessive bone by moving the reamer back and forth until the red mark on the screw-driver shaft becomes visible.

Note: If more bone that may block the connector has to be removed, use a chisel or gauge pliers.



7Click on the collet



03.607.006 USS II Polyaxial Handle(388.622) (Handle for Screw Holder)

Use the USS II Polyaxial Screw Holder to pick up a collet from the tray. Optionally, attach the Handle for a better hold.

Click on the collet and orient the notch on the collet in direction of the screw angulation to achieve larger an-gles. Afterwards release the Handle leaving the Screw Holder attached to the collet.

Note: Make sure that no tissue is stuck between the screw head and the collet.


8Insert iliac connector



Attach the clamp to the rod from the midline.

Slide the iliac connector over both the Clamp Holder and the Screw Holder.


1

2


9Lock iliac connector


03.621.012 Socket Wrench, cannulated, with Straight Handle for USS-II Nut



Pick up a nut using the Socket Wrench with Straight Handle (black), place it over the collet of the iliac screw and tighten it slightly. (1)

Notes:• Always first place a nut on the collet (iliac screw)

and then one on the clamp (rod).• Pre-tighten the nut on the iliac screw at least

2 revolutions. This is how the iliac connector is firmly attached to the bone screw while the poly-axiality is still maintained. Pull on the Screw Holder to check if the collet has been attached correctly.

Secondly, apply a nut on the clamp, and tighten it slightly. (2)

For final tightening, change the Socket Wrench with black handle to the one with L-Handle. Use the Socket Wrench with T-Handle as counter-torque.


Optional: Lock the clamp of the connector with the Spreader Forceps


388.410 Spreader Forceps

388.615 Support for Rod Introduction Pliers (Clip for Persuader)

In some cases, the iliac connector may not be properly seated on the rod, and the nut cannot be tightened. In this case, use the technique described below.

With the Socket Wrench with L-Handle in place, attach the Clip for Persuader at the distal end of the Clamp Holder. Press the Spreader Forceps. This will pull up the clamp. At the same time, turn the Socket Wrench until the nut engages.



1Instrument spine down to S1

Place the pedicle screws according to the surgical tech-nique of the system used (e.g. USS II Polyaxial)

2Prepare hole for the S2 pedicle screw


388.540 Pedicle probe ⌀ 3.8 mm with Canevasit Handle

388.539 Pedicle probe ⌀ 4.8 mm with Canevasit Handle

Open the pedicle using a pedicle probe.

S2 FIXATION WITH S2 CONNECTOR


3Insert S2 screw



03.607.003 USS II Polyaxial Holding Sleeve

Pick up the appropriate screw from the screw rack using the Screwdriver and the Holding Sleeve. Insert the screw into the prepared pedicle until the screw is well seated. Ideally, the screw is placed bicortically.

4Expose screw head




Place the Reamer guided by the Screwdriver over the screw head. Ream away excessive bone by moving the reamer back and forth until the red mark on the screw-driver shaft becomes visible.

S2 Fixation with S2 Connector


5Click on the collet



388.622 Handle for Screw Holder

(03.607.006) (USS II Polyaxial Handle)

Use the USS II Polyaxial Screw Holder to pick up a collet from the tray. Optionally, attach the Handle for a better hold.

Click on the collet and orient the notch on the collet in direction of the screw angulation to achieve larger an-gles. Afterwards release the Handle leaving the Screw Holder attached to the collet.

Notes:• Make sure that no tissue is stuck between the

screw head and the collet.• Alternatively a USS II Polyaxial 3-D head may be

clicked on the screw instead of using the S2 connector.


Insertion S2 connector left/right

6aInsert S2 connector (left or right)




Slide the connector over the Screw Holder onto the collet.

Pick up a nut using the Socket Wrench with L-Handle, and place it over the collet of the S2 screw.

Pre-tighten the nut on the S2 screw at least two revolu-tions. This is how the S2 connector is firmly attached to the bone screw while the polyaxiality is still maintained. Check for a secure seat by pulling on the Screw Holder.



7aInsert rod and lock nuts






Insert the rod into the connector.

Connect the rod to the remaining screws according to the surgical technique of the implant system used (e.g. USS II Polyaxial).

Use the Screwdriver to lock the set screw on the S2 connector.

Use the Socket Wrench with T-Handle as counter-torque for final tightening.


Insertion S2 connector for rod end

6bInsert connector for rod end

Required instrument

314.070 Screwdriver, hexagonal, small, 2.5 mm, with Groove

Insert contoured rod into the connector and lock the set screw with the 2.5 mm Screwdriver. Slide the connector over the Screw Holder onto the collet.

Pick up a nut using the Socket Wrench with L-Handle and place it over the collet of the S2 screw. Pre-tighten the nut on the S2 screw at least two revolu-tions. This is how the S2 connector is firmly attached to the bone screw while the polyaxiality is still maintained. Check for a secure seat by pulling on the Screw Holder.



7bConnect rod to remaining screws and lock nuts





Connect the rod to the remaining screws according to the surgical technique of the implant system used (e.g. USS II Polyaxial).

Use the Socket Wrench with T-Handle as counter-torque for final tightening.





03.607.006 USS II Polyaxial Handle

After removing the nuts, move the collet back and forth using the Screw Holder. The collet will come loose.

REMOBILISATION OF THE POLYAXIAL CONNECTION FOR IMPLANT REMOVAL


Aebi M, Thalgott JS, Webb JK (1998): AO ASIF Principles in Spine Surgery. Berlin: Springer.

Aebi M, Arlet V, Webb JK (2007): AOSPINE Manual (2 vols), Stuttgart, New York: Thieme.

BIBLIOGRAPHY

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Synthes GmbHEimattstrasse 34436 OberdorfSwitzerlandTel: +41 61 965 61 11Fax: +41 61 965 66 00www.depuysynthes.com ©

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Not all products are currently available in all markets.

This publication is not intended for distribution in the USA.

All surgical techniques are available as PDF files at www.depuysynthes.com/ifu

Documents

USS II ILIO-SACRAL - synthes.vo.llnwd.netsynthes.vo.llnwd.net/o16/LLNWMB8/INT Mobile/Synthes International... · 6 DePuy Synthes USS II Ilio-Sacral Surgical Technique Iliac connectors,