humerus recovery

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T2Humeral Nailing System

Operative Technique


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T2 Hmeral Nailin Sstem

Contributing Surgeons

Rpert Beicert, M. D.Senior Trauma SurgeonMurnau Trauma CenterMurnauGermany

Rosemar Bcle, M. D.

Orthopaedic Associates, L. L. P.Clinical InstructorUniversity o Texas Medical SchoolHouston, TexasUSA

Prof. Dr. med. Voler Bhren

Chie o Surgical ServicesMedical Director o Murnau Trauma CenterMurnauGermany

Michael D. Mason, D. O.

Assistant Proessor o Orthopaedic SurgeryTuts University School o MedicineNew England Baptist Bone & Joint Institute

Boston, MassachusettsUSA

This publication sets orth detailedrecommended procedures or usingStryker Osteosynthesis devices andinstruments.

It oers guidance that you shouldheed, but, as with any such technicalguide, each surgeon must consider

the particular needs o each patientand make appropriate adjustmentswhen and as required.

A workshop training is required priorto rst surgery.

All non-sterile devices must becleaned and sterilized beore use.Follow the instructions provided inour reprocessing guide (L24002000).Multi-component instruments must

be disassembled or cleaning. Pleasereer to the corresponding assembly/disassembly instructions

See package insert (L22000007) ora complete list o potential adverseeects, contraindications, warningsand precautions. The surgeon mustdiscuss all relevant risks, including thenite lietime o the device, with thepatient, when necessary.

Warning:

All bone screws reerenced inthis document here are notapproved or screw attachment orxation to the posterior elements(pedicles) o the cervical, thoracicor lumbar spine.

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Page

1. Introduction 4

Implant Features 4

Technical Details 5

Instrument Features 62. Reerences 7

3. Indications, Precautions and Contraindications 8

Indications 8

Precautions 8

Relative Contraindications 8

4. Pre-operative Planning 9

5. Locking Options 10

6. Operative Technique Antegrade Technique 12

Patient Positioning and Fracture Reduction 12

Incision 12

Entry Point 13

Unreamed Technique 14

Reamed Technique 14

Nail Selection 16

Nail Insertion 17

Guided Locking Mode (via Target Device) 18

Static Locking Mode 19

Freehand Distal Locking 22

End Cap Insertion 24

Dynamic Locking Mode 24

Apposition /Compression Locking Mode 25

Advanced Locking Mode 27

Nail Removal 28

7. Operative Technique Antegrade Technique 29

Patient Positioning 29

Incision 29

Entry Point 30

Unreamed Technique 30

Reamed Technique 31

Nail Selection 32

Nail Insertion 32

Guided Locking Mode (via Target Device) 35

Static Locking Mode 36

Freehand Proximal Locking 39

End Cap Insertion 40

Dynamic Locking Mode 40

Apposition /Compression Locking Mode 41

Advanced Locking Mode 43

Nail Removal 44

Ordering Inormation Implants 45

Ordering Inormation Instruments 47

Contents

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Introdction

Over the past several decades ante-grade humeral nailinghas becomethe treatment o choice or mosthumeral shat ractures. Retrogradehumeral nailinghas expanded the

use o intramedullary nails.

Studies have shown the ollow-ing benets to be associated withHumeral Nailing :Brie operative time (1)Minimal morbidity (1)Early return to unction o theextremity (2)In 90% o the cases, no external sup-port is needed (1, 2)Closed technique (4)

Low inection rate (2, 5, 6)Very good pain relie in stabilization opathological ractures (2, 4)

Compared to Plate and ScrewOsteosynthesis :Minimal damage to muscle, connec-tive tissue and vasculature (1, 3, 7)Reduced periosteal stripping and con-

comitant sot tissue damage(1)Fewer radial nerve palsies (3, 4)Designed or load sharing instead oload bearing (2)Cosmetically smaller incision

The T2 Humeral Nailing System isone o the rst humeral nailingsystems to oer an option or either anantegrade or a retrograde approach torepair ractures o the humerus.

One Implant, Two Approaches

Stryker Osteosynthesis has created alocking nail system, bring-ing togetherall the capabilities and benets o sep-arate antegrade and retrograde nailingsystems to create a single, integratedsurgical resource or xation o long-

bone ractures.Furthermore, the development othe T2 Humeral Nailing System oersthe competitive advantages o :

Dual nailing approach : Antegradeand Retrograde

Accommodating reamed or

unreamed procedures Static, controlled dynamic and

apposition/compression lockingoptions

Advanced Locking Mode forincreased rotational stability.

Through the development o a com-mon, streamlined and intuitive surgi-

cal approach, both in principle and indetail, the T2 Humeral Nailing Systemoers signicantly increased speedand unctionality or the treatmento ractures as well as simpliying thetraining requirements or all personnelinvolved.

The T2 Humeral Nailing System is therealization o superior biomechanicalintramedullary stabilization.

The system oers the option odierent locking modes : Static, transverse /oblique Dynamic Apposition/compression

Advanced locking

In some indications, a controlledapposition/compression o bone rag-ments can be applied by introducinga compression screw rom the top onail. To urther increase rotationalstability, the nail can be locked aterutilizing the apposition/compressioneature.

The benecial eect o apposition/

compression in treating long-boneractures in cases involving transverseand short oblique ractures that areaxial ly stable is well documented(15, 16, 19).

The compression screw is pushedagainst the proximal PartiallyThreaded Locking Screw (ShatScrew) that has been placed in theoblong hole, drawing either the distalor the proximal segment towards theracture site. In stable ractures, thishas the biomechanical advantage ocreating active circumerential com-

pression to the racture site, transer-ring axial load to the bone, andreducing the unction o the nail as aload bearing device (17).

This ability to transer load back tothe bone can reduce the incidence oimplant ailure secondary to atigue.Typical statical ly locked nails unc-tioning as load bearing devices havereported ailure rates in excess o 20%(18).

Common 4mm cortical screws sim-pliy the surgical procedure. FullyThreaded Locking Screws are avail-able or regular locking procedures.Partially Threaded Locking Screws(Shat Screws) are designed or appli-cation o apposition/compression.

One common Humeral Compression

Screwto close the racture site, andEnd Caps in six sizes are available toprovide an improved t or every indi-cation to allow nail length adaptationater insertion and to prevent boneingrowth.

All implants o the T2 HumeralNailing System are cannulatedand made oType II anodizedtitanium alloy (Ti6AL4V) orenhanced biomechanical and bio-

medical perormance.

See the detailed chart on the next pageor the design specications and sizeoerings.

Implant Features

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Technical Details

Introdction

Bend, 6

CompressionRange*

SLOT

0mm

12

23

28

38

62

30

36

48mm

28

10

0mm

18

Bend, 4

Nails

Diameter 79mmSizes 140320mm

* Compression Range

Total Length o Slot 10mm

Less Screw Diameter () 4mm

Maximum Movement o Screw 6mm

Hmers Advanced

Compression Screw

(Diameter = 6mm)

4.0mm Fll Threaded

Locin Screws

L = 2060mm

4.0mm Partiall Threaded

Locin Screws

(Shat Screws)L = 2060mm

End Caps

Standard +5mm +10mm +15mm +20mm +25mm

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The major advantage o the instru-ment system is a breakthrough in theintegration o the instrument plat-orm which can be used not only orthe complete T2 Nailing System, butwill be the platorm or all utureStryker nail ing systems, thereby reduc-ing complexity and inventory.

The instrument platorm oersadvanced precision and usability, andeatures ergonomically styledtargeting devices.

Instrument FeaturesSymbol coding on the instrumentsindicates the type o procedure, andmust not be mixed.

Smbol

Square = Long instruments

Triangular = Short instruments

Drills

Drills feature color coded rings :

3.5mm = OrangeFor 4.0mm Fully Threaded LockingScrews and or the second cortexwhen using 4.0mm Partially ThreadedLocking Screws (Shat Screws).

4.0mm = GreyFor the rst cortex when using 4.0mmPartially Threaded Locking Screws(Shat Screws).

Introdction

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16. O. Gonschorek, G. O. Homann,V. Bhren, InterlockingCompression Nailing : A reporton 402 Applications, Arch OrthopTrauma Surg (1998)117 : 430437.

17. T. E. Richardson, M. Voor,D. Seligson, Fracture SiteCompression and Motion withThree Types o IntramedullaryFixation o the Femur,In : Osteosynthese International(1998), 6 : 261264.

18. Hutson et al., Mechanical Failureso Intramedullary Tibial NailsApplied without Reaming, In :Clin. Orthop. (1995), 315 : 129137.

19. Bhren V., Kompressionsnagelunglanger Rhrenknochen,Unallchirurg 103,2000, 708720.

20. Mehdi Mousavi, et al., PressureChanges During Reaming withDifferent Parameters and Reamer

Designs, Clinical Orthopaedicsand Related Research, Number 373,pp. 295303, 2000.

1. J. Blum et al., Unreamed HumeralNails Prove Reliable, Sae inMulticentre Study, InternationalEdition Orthopaedics Today,Volume 1 Number 2, March/April1998.

2. B. Redmond et al., InterlockingIntramedullary Nailing oPathological Fractures o the Shato the Humerus, The Journal oBone and Joint Surgery,Vol. 78-A, No. 6, June 1996.

3. P. Rommens et al., Die

Verriegelungsnagelung derHumerusschatraktur. Einekritische Bewertung von 100Fllen, Swiss Surg. Suppl. 2/1996, p. 7

4. P. Rommens et al., RetrogradeVerriegelungsnagelung derHumerusschatraktur, Eineklinische Studie, Unallchirurg,1995, 98 pp. 133138.

5. The Unreamed Nail A Biological

Osteosynthesis o the upper armActa Chir. Belg. 1997 August ; 97(4) :184189.

6. J. Stapert et al., Behandlung vonHumerus-rakturen mit dem TLN(Telescopic Locking Nail),Swiss Surg. Suppl. 2/1996, p.

7. D. Wheeler, M. Colville,Biomechanical Comparison oIntramedullary and PercutaneousPin Fixation or Proximal Humeral

Fracture Fixation, Journal oOrthopaedic Trauma, Vol. 11, No. 5,pp. 363367.

8. ASTM Designation : F13692,Standard Specication or WroughtTitanium 6A I4V ELI Alloy orSurgical Implant Applications.

9. ASTM Designation : F13892,Standard Specication or StainlessSteel Bar and Wire or SurgicalImplants (Special Quality).

10. Leventhal G., Journal o Bone andJoint Surgery, Vol 33A, No 2,April 1951, p475.

11. Bothe RT, Beaton KE, Davenport

HA (1940) Reaction o Boneto Multiple Metallic Implants,Surg. Gynaecol. Obstet. 71, 598.

12. Bardos DI, Titanium andTitanium Alloys, in D. Williams(ed.) Concise encyclopedia omedical and dental materials,Pergamon Press, Oxord, 1990,360365.

13. Solar R. : Corrosion Resistance o

Titanium Surgical Implant Alloys :A Review, in Corrosion andDegradation of Implant Materials,ASTM STP 684, American Societyor Testing and Materials, 1979,pp 259273.

14. AO/ASIF Titanium 6%Aluminum 7% NiobiumImplant Material, AO/ASIFMaterials Technical Commission,First Edition June 1993.

15. Mller ME, et al Manual forInternal Fixation. Springer-VerlagBerlin, 1991.

References

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The T2 Humeral Nail is intendedto provide temporary stabilization

o various types o ractures,malunions and nonunions o thehumerus.The nails are inserted usingan opened or closed techniqueand can be static, dynamic andcompression locked.The subject and predicate devicesare indicated or use in thehumerus.Types o ractures include, butnot limited to ractures o thehumeral shat, non-unions,malalignments, pathologicalhumeral ractures, and impendingpathological ractures.

Indications Precautions

The physicians education, trainingand proessional judgement mustbe relied upon to choose the mostappropriate device and treatment.Conditions presenting an increasedrisk o ailure include:

Any active or suspected latentinection or marked localinfammation in or about theaected area.Compromised vascularity that

would inhibit adequate bloodsupply to the racture or theoperative site.Bone stock compromised bydisease, inection or priorimplantation that can not provideadequate support and/or xationo the devices.Material sensitivity, documentedor suspected.Obesity. An overweight or obesepatient can produce loads on theimplant that can lead to ailure

o the xation o the device or toailure o the device itsel.Patients having inadequate tissuecoverage over the operative site.

Relative Contraindications

Indications, Precations and Contraindications

Implant util ization that wouldinterere with anatomicalstructures or physiologicalperormance.Any mental or neuromuscular

disorder which would createan unacceptable risk o xationailure or complications inpostoperative care.Other medical or surgicalconditions which would precludethe potential benet o surgery.

The T2 System has not been evaluatedor saety and compatibility in the MR

environment.The T2 System has not been testedor heating or migration in the MRenvironment.

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An X-Ray Template (1806-0003) isavailable or pre-operative planning.

Thorough evaluation o pre-operativeradiographs o the aected extremityis critical. Careul radiographic exami-nation can help prevent intra-operativecomplications.

I X-Rays show a very narrowintramedullary canal in the distal parto the humerus, retrograde humeralnailing is not possible.

The proper nail length when inserted

antegrade should extend rom sub-chondral bone proximally, to 1cmabove the olecranon ossa distally.

The retrograde nail length is deter-mined by measuring the distance rom1cm above the olecranon ossa to thecenter o the humeral head.

In either approach, the surgeon shouldconsider the apposition/compressioneature o the T2 Humeral Nail,

knowing that 6mm o active apposi-tion/compression is possible, prior todetermining the nal length o theimplant.

Note:Check with local representativeregarding availability o nail sizes.

Pre-operative Plannin

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Static Mode obliqeStatic Mode transverse

Retrorade

Anterade

Locin Options

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Advanced Locin ModeDnamic Mode Apposition/Compression Mode

Locin Options

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Fi. 2

The patient is placed in a semireclinedbeach chair position or supine ona radiolucent table. Patient position-ing should be checked to ensurethat imaging and access to the entrysite are possible without excessivemanipulation o the aected extremity(Fig. 1). The image intensier is placedat the legside o the patient ; the sur-geon is positioned at the headside.

IncisionA small incision is made in line withthe bers o the deltoid muscle ante-rolateral to the acromion. The deltoid

is split to expose the subdeltoid bursa.Palpate to identiy the anterior andposterior margins o the greatertuberosity and supraspinatus tendon.The supraspinatus tendon is thenincised in line with its bers(Fig. 2).

The real rotation o the proximal rag-ment is checked (inversion or rever-sion), considering that the entry pointis at the tip o the greater tubercle. Ithe proximal ragment is inverted,the entry point is more anterior. I theproximal ragment is in external rota-tion, the entry point is more lateral. Itis recommended to localize the entrypoint under image intensier control,also palpating the bicipital groove,the portal is about 10mm posterior tothe biceps tendon. This will make theentry portal concentric to the medul-lary canal.

Patient Positioning and Fracture Reduction

Operative Techniqe Anterade Techniqe

Fi. 1

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Fi. 3

Fi. 3a

The entry point is made with theCurved, cannulated Awl (1806-0040)(Fig. 3). The 2.5 800mm Ball TipGuide Wire (1806-0083S) is thenintroduced through the awl underimage intensication into the meta-physis, central to the long axis o thehumerus.

Alternatively, the optional Crown Drill(1806-2020) may be used over theK-Wire with Washer (1806-0051S) orentry point preparation. The K-Wirewill help to guide the Crown Drillcentrally (Fig. 3a).

Then, the 3 285mm K-Wire (1806-0050S) is introduced under imageintensication into the meta-physis,central to the long axis o the humer-us.

The cannulated 10mm Rigid Reamer(1806-2010) may be used over theK-Wire and the proximal metaphysisshould be drilled to a depth o at least6cm.

Note:During opening the entry portal

with the Awl, dense cortex mayblock the tip o the Awl. An AwlPlug (1806-0032) can be insertedthrough the Awl to avoid penetra-tion o bone debris into the can-nulation o the Awl shat.

Entry Point


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I an unreamed technique is pre-erred, the nail may be inserted overthe 2.2 800mm Smooth Tip GuideWire (1806-0093S) (Fig. 4).

Unreamed Technique

Fi. 5

Fi. 6

Fi. 4

For reamed techniques, the2.5 800mm Ball Tip Guide Wire(1806-0083S) is inserted across theracture site.The Reduction Rod (1806-0363) maybe used as a racture reduction tool toacilitate Guide Wire insertion acrossthe racture site (Fig. 5).

Reaming is commenced in 0.5mmincrements until cortical contact isappreciated. Final reaming should

be 1mm1.5mm larger than the dia-meter o the nail to be used.

The Guide Wire Pusher can be used tohelp keep the Guide Wire in positionduring reamer shat extraction. Themetal cavity at the end o the handlepushed on the end o the power toolacilitates to hold the Guide Wire inplace when starting to pull the powertool. When close to the Guide Wireend place the Guide Wire Pusher with

its unnel tip to the end o the powertool cannulation. While removing thepower tool the Guide Wire Pusher willkeep the Guide Wire in place(Fig. 6 & 7).

Reamed Technique


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Fi. 8

Fi. 9


Note:8mm Humeral Nails cannot be

inserted over the 3 1000mm BallTip Guide Wire (1806-0085S).The Ball Tip Guide Wire mustbe exchanged or the 3 800mmSmooth Tip Guide Wire (1806-0090S) prior to nail insertion.Use the Tefon Tube (1806-0073S)or the Guide Wire exchange.

When reaming is completed, theTefon Tube (1806-0073S) should beused to exchange the Ball Tip GuideWire (1806-0083S) with the Smooth

Tip Guide Wire (1806-0093S) or nailinsertion (Fig. 8 and 9).

An unreamed technique can beconsidered in cases, where themedullary canal has the appropriatediameter. In these cases, the nail canbe introduced over the 2.2800mmSmooth Tip Guide Wire (1806-0093S).

Note:X-Ray Templates should be used

pre-operatively to determine thecanal size radiographically.The driving end o 7mm nails is8mm.

Fi. 7

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Diameter

The diameter o the selected nailshould be 1mm1.5mm smaller thanthe last reamer used.

Lenth

Nail length may be determined withthe X-Ray Ruler (Fig. 10). The GuideWire Ruler (1806-0022) may beused by placing it on the Guide Wirereading the correct nail length at theend o the Guide Wire on the GuideWire Ruler (Fig. 11 and 12). Conrmthe position o the tip o the GuideWire prior to measurement.

Note:I the racture is suitable orapposition/compression, theimplant selected should be610mm shorter than measuredto help avoid migration o the nailbeyond the insertion site.

Fi. 10

Diameter Length

HolePositions

Transverse Oblique Compression Slot(Oblique or Dynamic)

Length

240mm

Fi. 11

End o Guide Wire Ruleris the measurement reerence

The X-Ray Template should be usedpre-operatively to determine the canalsize radiographically. This inormationmay be utilized in conjunction withthe clinical assessment o canal sizeas determined by the size o the lastreamer used.

Nail Selection

Fi. 12

The Guide Wire Ruler can be easilyolded and unolded.


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Nail Insertion

Fi. 13

Fi. 17

Fi. 14 Fi. 15

Fi. 16

10mm

6mm

2mm

Apposition/Compression

Dynamic

Static


The selected nail is assembled ontothe Target Device (1806-0143) withthe Nail Holding Screw (1806-0163).Tighten the Nail Holding Screwsecurely with the Insertion Wrench(1806-0135) so that it does not loosenduring nail insertion (Fig. 13).

Note:Prior to nail insertion pleasecheck correct alignment byinserting a drill bit through theassembled Tissue Protection andDrill Sleeve placed in the required

holes o the targeting device.

Upon completion o reaming andGuide Wire exchange, the appropriatesize nail is ready or insertion.Advance the nail through the entrypoint past the racture site to theappropriate level.

Gentle rotation o the nail may benecessary to start the nail insertion.The nail should be advanced withmanual pressure. Aggressive use o

the slotted hammer can result inadditional ractures. I the nail doesnot advance easily, a check with imageintensication should be made to seei the nail angle is too steep resultingin the nail impinging on the medialcortex.

The Slotted Hammer (1806-0170)can be used to insert the nail over theGuide Wire.DO NOT hit the Target Device.

Note:A chamer is located on theworking end o the nail todenote the end under X-Ray.Three circumerential groovesare located on the insertionpost at 2mm, 6mm, and 10mmrom the driving end o the nail(Fig. 14-16). Depth of insertionmay be visualized with the aid ofuoroscopy.

The 3 285mm K-Wire may beinserted through the Target Devicewhich identies the junction o thenail and insertion post (Fig. 17).

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Fi. 19

43

4

43

12

Fi. 18.1

Fi. 18.2

Fi. 18.3

Fi. 18.4

Guided Locking Mode(via Target Device)Prior to guided locking via the TargetDevice, the Nail Holding Screw mustbe rmly tightened using the InsertionWrench, to ensure that the nail is incorrect alignment with the TargetDevice.

The Target Device is designed to pro-vide our options or guided locking(Fig. 18.118.4).

In the Static Oblique Locking Mode,the two static holes closest to the

end o the nail may be used or staticoblique (30) locking (Fig. 18.1).1. Static

2. Static

In the Static Transverse Locking Mode,the next static hole and the dynamichole are used or static transverselocking (Fig. 18.2).3. Static

4. Dnamic

In the Controlled Dynamic Mode,and/or Controlled Apposition/Com-pression Mode, the dynamic hole isrequired (Fig. 18.3).4. Dnamic

In the Advanced Locking Mode, thedynamic hole is required. Aterutilizing compression with theAdvanced Compression Screw, thestatic hole is used (Fig. 18.4).4. Dnamic

3. Static

The Short Tissue Protection Sleeve,(1806-0180), together with the ShortDrill Sleeve (1806-0210) and the ShortTrocar (1806-0310), are inserted intothe Target Device by pressing the sae-ty clip (Fig. 19).

The riction lock mechanism isdesigned to keep the sleeve in placeand prevent it rom alling out. It is

designed to also keep the sleeve romsliding during screw measurement.To release the Tissue Protection Sleeve,the saety clip must be pressed again.


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Static Transverse

Locin Mode

In unstable or comminuted ractures,the nail should be used as a standardinterlocking nail. Static locking o thedistal holes will help maintain thelength o the bone and the rotationalstability o the racture.

The Short Tissue Protection Sleeve,together with the Short Dril l Sleeveand the Short Trocar, are positionedthrough the static locking hole on theTarget Device. A small skin incision

is made, and the assembly is pushedthrough until it is in contact with thelateral cortex o the humerus (Fig. 20).

Note:Especially in the proximalhumerus, use image inten-sication to help ensure the TissueProtection Sleeve is fush with thecortex or you could lose 12mm oscrew measurement accuracy.

The Trocar is removed while theTissue Protection Sleeve and the Dril lSleeve remain in position.

For accurate drilling and easy determi-nation o screw length, use the center-tipped, 3.5 230mm calibrated Drill(1806-3540S). The centered Drill isorwarded through the Drill Sleeveand pushed onto the cortex.Ater the rst cortex is drilled to theappropriate level the screw length maybe read directly o o the Drill at the

end o the Drill Sleeve (Fig. 21).

Caution:Make sure the Tissue ProtectionSleeve/Drill Sleeve Assembly is

seated on bone prior to selectingnal screw length.

Static Locking Mode

50mm

Fi. 21

Fi. 20


50mm

19


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Warning:Do not drill through the far cor-tex as this will penetrate the joint.

Note:The position o the end o theDrill as it relates to the far cortexis equal to where the end o thescrew will be. Thereore, i the endof the Drill is 3mm beyond the farcortex, the end o the screw willalso be 3mm beyond.The Screw Gauge, Short, is cali-brated so that with the bend at theend pulled back fush with the ar

cortex, the screw tip will end 3mmbeyond the ar cortex (Fig. 21).

When the Drill Sleeve is removed,thecorrect 4.0mm Locking Screw isinserted through the Tissue ProtectionSleeve using the Screwdriver Shat,Short (1806-0222) with the TeardropHandle (702429, Fig. 22). The screw isnear its proper seating position whenthe groove around the shat o thescrewdriver is approaching the end o

the Tissue Protection Sleeve.

Use image intensication to conrmscrew position through the nail as wellas screw length.

Repeat the locking procedure or theother statically positioned LockingScrew (Fig. 23).

Caution:The coupling o Elastosil handlescontains a mechanism with one

or multiple ball bearings. In caseo applied axial stress on theElastosil handle, those compo-nents are pressed into the sur-rounding cylinder resulting in acomplete blockage o the deviceand possible bending.To avoid intra-operative com-plications and secure long-termunctionality, we mandate thatElastosil handles be used only ortheir intended use.

DO NOT HIT any Elastosil han-dles.

Fi. 23

Fi. 22

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Static Obliqe

Locin Mode

In cases that may be locked in theStatic Oblique Locking Mode, placethe assembly o the Tissue ProtectionSleeve together with the Drill Sleeveand the Trocar through the Obliquestatic hole closest to the driving endo the nail (Fig. 24). Reer to the pro-cedure or Locking Screw insertion.

The second Fully Threaded LockingScrew is inserted through the statichole (Fig. 25) next to the rst hole, and

placed in an oblique manner throughthe oblong hole o the nail (Fig. 26).

Conrm screw position and screwlength with image intensication.

Washer

The Washer, either Rectangular orRound, may be used in cases o osteo-porotic bone to bridge the bone gapand allow or enhanced purchase o

the Locking Screw (Fig. 27).

Fi. 24

Fi. 25

Fi. 26

Fi. 27


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The reehand technique is used toinsert Locking Screws into both theA/P and M/L holes in the nail.Rotational alignment must be checkedprior to distal locking.

Multiple locking techniques and radio-lucent drill devices are available orreehand locking. The critical stepwith any reehand locking technique,proximal or distal, is to visualize aperectly round locking hole with theC-Arm.

Caution:

In order to avoid damage tothe neurovascular structure, alimited open approach should beconsidered.

The center-tipped 3.5 230mmDrill (1806-3540S), or the optional3.5 130mm Dril l (1806-3550S), isheld at an oblique angle to the centero the locking hole (Fig. 28 and 29).Upon X-Ray verication, the Drill isplaced perpendicular to the nail and

drilled through the anterior cortex.Conrm these views in both the A/Pand M/L planes by X-Ray.

Freehand Distal Locking

Fi. 28

Fi. 29


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Ater drilling both cortices, the screwlength may be read directly o othe Screw Scale, Short (1806-0360)at the orange color coded ring on thecenter-tipped Drill (Fig. 30). As withproximal locking (Fig. 21, p. 19), theposition o the end o the drill is equalto the end o the screw as they relate tothe ar cortex.

Routine Locking Screw insertion isemployed with the assembled ShortScrewdriver Shat and the TeardropHandle.

I possible, the distal humerus shouldbe locked with two Fully ThreadedLocking Screws. Additional locking othe M/L hole(s) is possible i the imageintensier can be adjusted (Fig. 31).

Note:Use image intensication toconrm screw position throughthe nail as well as screw length.

Alternatively, the Screw Gauge can be

used to measure the screw length.

35mm

Fi. 30

Fi. 30a

Fi. 31


orange ring

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Fi. 34

End Cap Insertion

Dynamic Locking ModeWhen the racture prole permits,controlled dynamic locking may beutilized or transverse or axially stableractures.

Antegrade dynamization is perormedby statically locking the nail distally.

The guided Partially ThreadedLocking Screw (Shat Screw) is thenplaced in the dynamic position othe oblong hole. This allows the nailto move, and the racture to settlewhile torsional stability is maintained(Fig. 34).

Ater removal o the Target Device, anEnd Cap is used to reduce the poten-tial or bony ingrowth into the proxi-mal threads o the nail.

End Caps are available in six sizes(Fig. 32).

The End Cap is inserted with the ShortScrewdriver Shat assembled on theTeardrop Handle ater intra-operativeradiographs show satisactory re-duction and hardware implantation(Fig. 33). Fully seat the End Cap tominimize the potential or loosening.

Caution:To avoid impingement, careullyselect the length o t he End Cap.

Close the wound using standard tech-nique.

Fi. 33

Standard +5mm +10mm +15mm +20mm +25mm

Fi. 32


24


25/52

Apposition/Compression Locking ModeIn transverse or axially stable racturepatterns, active apposition/compres-sion increases racture stability andenhances racture healing. The ante-grade T2 Humeral Nail provides theoption to treat a humerus racturewith active mechanical apposition/compression prior to leaving theoperating room.

Note:Distal freehand static lockingmust be perormed prior toapplying active, controlled apposi-tion/compression to the racture

site.

I active apposition/compression isrequired, a Partially Threaded LockingScrew (Shat Screw) is inserted via theTarget Device in the dynamic positiono the oblong hole. This will allow ora maximum o 6mm o active, con-trolled apposition/compression. Inorder to insert the Partially ThreadedLocking Screw (Shat Screw), drillboth cortices with the 3.5 230mm

Drill (1806-3540S). Next, the nearcortex ONLY is overdrilled with the4.0 180mm Drill (1806-4000S).

Note:Ater the opposite cortex is drilledwith the 3.5 230mm drill, thecorrect screw length can be readdirectly off of the calibrated Drillat the end of the Drill Sleeve.

Ater the Partially Threaded LockingScrew (Shat Screw) is inserted, the

Nail Holding Screw is removed,leaving the insertion post intact withthe nail (Fig. 35). This will act as aguide or the Compression Screw. TheCompression Screw with the Compres-sion Screwdriver Shat (1806-0263)assembled on the Teardrop Handle isinserted through the insertion post(Fig. 36).

Fi. 35

Fi. 36


25


26/52

Note:It may be easier to insert theCompression Screw prior to ullyseating the nail. Once the nailtip has cleared the racture site,the Guide Wire (i used) is with-drawn. With the proximal portiono the nail not ully seated andextending out o the bone, theAdvanced Compression Screw isinserted. Care should be takenthat the shat o the CompressionScrew does not extend into thearea o the oblong hole.

The Short Tissue Protection Sleeveis removed and the CompressionScrew is gently tightened utilizingthe two-nger technique (Fig. 37). Asthe Compression Screw is advancedagainst the 4.0mm Partial ly ThreadedLocking Screw (Shat Screw), it drawsthe distal racture segment towards theracture site, employing active appo-sition/compression (Fig. 38). Imageintensication will enable the surgeonto visualize active apposition/compres-

sion. Some bending o the transversePartially Threaded Locking Screw(Shat Screw) may be seen.

Note:Apposition/compression must becarried out under X-Ray control.Over-compression may cause thenail or the Partially ThreadedLocking Screw (Shat Screw) toail.When compressing the nail,the implant must be inserted a

sae distance rom the entry pointto accommodate or the 6mm oactive compression. The threegrooves on the insertion post aredesigned to help attain accurateinsertion depth o the implant.


Fi. 37

Fi. 38

26


27/52

Fi. 39

Fi. 40

Fi. 41

Advanced Locking ModeIn order to achieve additional xationand to reduce the load on the PartiallyThreaded Locking Screw (Shat Screw),the design o the T2 Humeral Nailprovides the opportunity to insert aFully Threaded Locking Screw in theother transverse hole at the drivingend o the nail ater apposition/com-pression is uti lized.

Prior to guided locking via the TargetDevice, the Nail Holding Screw mustbe tightened using the InsertionWrench.

Fix the Advanced Compression Screwon the sel-retaining CompressionScrewdriver Shat. Remove the NailHolding Screw leaving the TargetDevice in place (Fig. 39). Advance theCompression Screw through the TargetDevice until the desired amount ocompression is achieved. Visualizedepth o insertion with the aid ofouroscopy (Fig. 40).

Note:

As previously described, it may beeasier to insert the CompressionScrew prior to ully seating thenail.

To reattach the Target Device to thenail, detach the Teardrop Handle romthe Compression Screwdriver Shatand screw the Nail Holding Screw overthe Compression Screwdriver Shatinto its required position.

To insert the second transverse Fully

Threaded Locking Screw, ollow thelocking procedure or static locking(Fig. 41).

Finally, an End Cap should be insert-ed, as shown on page 24.


27


28/52

Nail removal is an elective procedure.I used, rst remove the End Cap withthe Short Screwdriver Shat and theTeardrop Handle (Fig. 42).I Advanced Locking Mode was uti-lized, the most proximal screw isextracted rst, allowing access to thecompression screw. Next, disengagethe Advanced Compression Screwrom the Fully Threaded LockingScrew (Shat Screw) by turning theCompression Screwdriver one ull turnin a counter-clockwise direction(Fig. 43).

Note:There is no need to attempt toremove the Advanced Com-pression Screw rom the nail,which w ith the nail implanted,may be dicult.

The Universal Rod, Short is insertedinto the driving end o the nail beoreall Locking Screws are removed withthe Short Screwdriver Shat and theTeardrop Handle (Fig. 43).

Note:Attaching o the Universal Rodto the nail rst will reduce thepotential or nail migration,then the locking screws may beremoved saely.

The Slotted Hammer is used to extractthe nail in a controlled manner(Fig. 44).

Nail Removal

Fi. 44

Fi. 43

Fi. 42

Advanced CompressionScrew Disengaged


28


29/52

Patient PositioningThe patient is placed on a radiolu-cent table in the prone position orlateral decubitus position. The aectedarm is supported on an arm board orhand table. The shoulder is in 90abduction, the elbow joint fexed alsoin a 90 position. In this position, rac-tures can be reduced in correct rota-tion.

Patient positioning should be checkedto ensure that imaging o the entry siteat the proximal humerus is possible.This allows the elbow to be hyperfexed to accommodate insertion o the

implant parallel to the humerus.

IncisionA posterior approach is used toaccess the distal humerus. Starting at

the tip o the olecranon, a 6cm incisionis made in a proximal direction. Thetriceps tendon is split and muscle tis-sue is bluntly dissected and retracteduntil the upper edge o the olecranonossa is displayed.

The distal insertion point or thenail is one centimeter above the ole-cranon ossa. The Insertion SiteTemplate (703117) may be used to helpdetermine the appropriate insertion

site (Fig. 45). The medullary canal isopened using the Drill 3.5 130mm(1806-3550S) by drilling a set olinear holes (Fig. 46). The holes arethen joined with the Sel-guiding RigidReamer (703125) (Fig. 47).

Note:The drill guide slots o theretrograde Insertion Site Template(703117), must be centered andparallel to the medullary canal(long axis o the humerus).

Fi. 47

Fi. 46

Fi. 45

Operative Techniqe Retrorade Techniqe

29


30/52

Fi. 48

Entry PointFinal insertion site preparation is per-ormed with the Conical Rigid Reamer(703126) to create a longitu-dinal ovalcortical hole at least 3cm in length and1cm in width (Fig. 49).

The cortical bone is removed distallyto the level o the olecranon ossa withthe rigid reamers or small rongeur.

Caution :Although the tip o the nail has a 4degree bend that acilitates distalnail insertion, high compressiveorces during nail insertion can

result in ractures o the distalhumerus i the insertion openingis too short or too steep.

Unreamed TechniqueThe T2 Humeral Nail is cannulated,and may be introduced in an un-reamed ashion over a Smooth TipGuide Wire. This simplies racturereduction and reduces the risk o iatro-genic distal ractures caused by tryingto reduce the racture with the nail.

The 2.2 800mm Smooth Tip Guide

Wire (1806-0093S) is inserted underimage control through the distal rag-ment and into the desired positionwithin the proximal humerus usingthe Guide Wire Handle and Chuck(1806-1095 and 1806-1096) (Fig. 48and 50).

The Reduction Rod (1806-0363) maybe used as a racture reduction toolto acilitate Guide Wire insertion(Fig. 51). The Guide Wire is advanceduntil the tip rests at the center o the

humeral head. The Guide Wire shouldlie in the center o the metaphysis inboth the A/P and Lateral views to helpavoid oset positioning o the nail.The Guide Wire Handle is removedleaving the Guide Wire in place.

Fi. 49

Fi. 50

Fi. 51


30


31/52

Fi. 52

Fi. 53

Fi. 54

Reamed TechniqueFor reamed techniques, the2.5 800mm Ball Tip Guide Wire(1806-0083S) is inserted through theracture site. The Reduction Rod orthe Universal Rod, Short with theoptional Reduction Spoon may beused as a racture reduction tool toacilitate Guide Wire insertion acrossthe racture site (see Fig. 51).

Reaming is commenced in 0.5mmincrements until cortical contact isappreciated. (Fig. 50). The nal reamershould be 1mm1.5mm larger thanthe diameter o the nail to be used.

The Guide Wire Pusher can be used tohelp keep the Guide Wire in positionduring reamer shat extraction. Themetal cavity at the end o the handlepushed on the end o the power toolacilitates to hold the Guide Wire inplace when starting to pull the powertool. When close to the Guide Wireend place the Guide Wire Pusher withits unnel tip to the end o the powertool cannulation. While removing the

power tool the Guide Wire Pusher willkeep the Guide Wire in place (Fig. 53and 54).

Note:The driving end o the 7mm nailis always 8mm.

When reaming is complete, the TefonTube (1806-0073S) should be used toexchange the Ball Tip Guide Wire withthe Smooth Tip Guide Wire or nailinsertion.

Note:Do not insert any T2 HumeralNail over any Ball Tip Guide Wire.

An unreamed technique can beconsidered in cases, where the medul-lary canal has the appropriate dia-meter. In these cases, the nail canbe introduced over the 2.2800mmSmooth Tip Guide Wire (1806-0093S).

Note:X-Ray Templates should be usedpre-operatively to determine thecanal size radiographically.


31


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The X-Ray Template (1806-003) shouldbe used preoperatively to determinecanal size radiographically. This inor-mation may be utilized in conjunctionwith the clinical assessment o canalsize as determined by the size o thelast reamer used.

Diameter

The diameter o the selected nailshould be 1mm smaller than the lastreamer used.

Lenth

Nail length may be determined with

the X-Ray Ruler (1806-0013) (Fig. 55).The Guide Wire Ruler (1806-0022)may be used by placing it on the GuideWire and then reading the correct naillength at the end o the Guide Wireon the Guide Wire Ruler (Fig. 56).Conrm the position o the tip o theGuide Wire prior to measurement.

Note:I the racture is suitable or appo-sition/compression, the implant

selected should be 610mmshorter than measured to helpavoid migration o the nail beyondthe insertion site.

Nail Selection


Nail InsertionThe selected nail is assembled ontothe Target Device (1806-0143) withthe Nail Holding Screw (1806-0163).Tighten the Nail Holding Screw withthe Insertion Wrench (1806-0135)securely so that it does not loosenduring nail insertion (Fig. 57).

Fi. 57

Fi. 55

Fi. 56

The Guide Wire Ruler can be easilyolded and unolded.

32


33/52

Note:Prior to nail insertion pleasecheck correct alignment byinserting a drill bit through theassembled Tissue Protection andDrill Sleeve placed in the required

holes o the targeting device.

Upon completion o reaming andGuide Wire exchange, the appropriatesize nail is ready or insertion and isadvanced through the entry point pastthe racture site to the appropriatelevel.

Gentle rotation o the nail may benecessary to start nail insertion. Thenail should be advanced with manualpressure (Fig. 58). Aggressive useo the slotted hammer can result inadditional ractures. I the nail doesnot advance easily, a check with imageintensication should be made to see ithe nail angle is too steep and the nailis impinging on the anterior cortex. Inthis case, it may be necessary to ur-ther widen the insertion opening.

Note:A chamer is located on the driv-ing end o the nail to denote theend under X-Ray. Three circum-erential grooves are located onthe insertion post at 2mm, 6mm,and 10mm rom the driving endof the nail (Fig. 59). Depth ofinsertion may be visualized withthe aid o fuoroscopy.

The 3 285mm K-Wire may be

inserted through the Target Devicewhich identies the junction o thenail and insertion post.

Insertion o the nail into the racturezone should be monitored underimage intensication.

The nail can be inserted over theSmooth Tip Guide Wire by gentleimpaction on the Nail Holding Screw/Insertion Wrench assembly (Fig. 60)

or the Nail Holding Screw/Strike Plateassembly (Fig. 61).

Fi. 60

Fi. 58

Fi. 59


33


34/52

Repositioning may be carried out

either by hand or by attaching theUniversal Rod, Short to the NailHolding Screw. The slotted hammermay be used to reposition the nailsmoothly (Fig. 62). DO NOT hit onthe Target Device.

When locking the retrograde nail inthe Static Mode, the nail is counter-sunk a minimum o 6mm below thesurace. When the implant is insertedin the Dynamic Mode, with activeapposition/compression, or in the

Advanced Locking Mode, the recom-mended insertion depth is 10mm.

Note :Remove the Guide Wire prior todrilling and inserting the LockingScrews.

Fi. 61

Fi. 62


34


35/52

43

4

43

12

Fi. 63.1

Fi. 63.2

Fi. 63.3

Fi. 63.4

Guided Locking Mode(via Target Device)

Prior to guided locking via the TargetDevice, the Nail Holding Screw mustbe rmly tightened using the InsertionWrench, to ensure that the nailis in correct alignment with the TargetDevice.

The Target Device is designed to pro-vide our options or guided locking(Fig. 63.163.4).

In Static Oblique Locking Mode, thetwo static holes closest to the end othe nail may be used or static oblique(30) locking (Fig. 63.1).1. Static

2. Static

In Static Transverse Locking Mode,the next static hole and the dynamichole are used or static transverselocking (Fig. 63.2).3. Static

4. Dnamic

In controlled Dynamic Mode, and/or controlled Apposition/CompressionMode, the dynamic hole is required(Fig. 63.3).4. Dnamic

In Advanced Locking Mode, thedynamic hole is required. Aterutilizing compression with theAdvanced Compression Screw, thestatic hole is used (Fig. 63.4).4. Dnamic

3. Static

The Tissue Protection Sleeve, Short(1806-0180) together with the DrillSleeve, Short (1806-0210) and theTrocar, Short (1806-0310) are insertedinto the Target Device by pressingthe saety clip (Fig. 64). The rictionlock mechanism is designed to keepthe sleeve in place and prevent it romalling out. It is designed to also keepthe sleeve rom sliding during screwmeasurement. To release the Tissue

Protection Sleeve, the saety clip mustbe pressed again (Fig. 65).

Fi. 64 & 65


35


36/52

Static Transverse Locin Mode

In unstable or comminuted ractures,the nail should be used as a standardinterlocking nail. Static locking willhelp maintain the length o the nailand the rotational stability o the rac-ture.

The Short Tissue Protection Sleevetogether with the Short Dril l Sleeveand the Short Trocar are positionedthrough the static locking hole on theTarget Device. A small skin incisionis made and the assembly is pushed

through, until it is in contact with theposterior cortex o the humerus.

Note:Especially in the proximalhumerus, use image inten-sication to help ensure the TissueProtection sleeve is fush with thecortex or you could lose 12mm oscrew measurement accuracy.

The Trocar is removed, while the

Tissue Protection Sleeve and the Dril lSleeve remain in position.

For accurate drilling and easy de-termination o screw length, use thecenter-tipped 3.5 230mm calibratedDrill (1806-3540S). The Drill is or-warded through the Drill Sleeve andpushed onto the cortex.

Caution:Make sure the Tissue ProtectionSleeve/Drill Sleeve Assembly is

seated on bone prior to selectingnal screw length.

Ater drilling both cortices, the screwlength may be read directly o o thecalibrated Drill at the end o the DrillSleeve (Fig. 66 and 67).

Note :The position o the end o theDrill as it relates to the far cortex

is equal to where the end o the

screw will be. Thereore, i the endof the Drill is 3mm beyond the farcortex, the end o the screw willalso be 3mm beyond.

Static Locking Mode

Fi. 66


50mm

Fi. 67

50mm

36


37/52

Note:The Screw Gauge, Short, is cali-brated so that with the bend at theend pulled back fush with the arcortex, the screw tip will end 3mmbeyond the ar cortex (Fig. 67)

When the Drill Sleeve is removed, thecorrect 4mm Locking Screw is insertedthrough the Tissue Protection Sleeveusing the Short Screwdriver Shat(1806-0222) with the Teardrop Handle(702429). The screw is driven throughboth cortices and is near its properseating position when the center o the

groove around the shat o the screw-driver is approaching the end o theTissue Protection Sleeve (Fig. 68).

Use image intensication to conrmscrew position through the nail as wellas screw length. Repeat the lockingprocedure or the other statically posi-tioned Locking Screw (Fig. 69).

Note:Only the Static Transverse

Locking Option allows the nail tobe easily compressed in a second-ary procedure. The static LockingScrew closest to the driving endo the nail may be removed andthe Compression Screw can beinserted into the nail.

Caution:The coupling o Elastosil handlescontains a mechanism with oneor multiple ball bearings. In caseo applied axial stress on the

Elastosil handle, those compo-nents are pressed into the sur-rounding cylinder resulting in acomplete blockage o the deviceand possible bending.To avoid intra-operative com-plications and secure long-termunctionality, we mandate thatElastosil handles be used only ortheir intended use. DO NOT HIT

any Elastosil handles.

Fi. 68

Fi. 69


37


38/52

Static Obliqe Locin Mode

For the Static Oblique Locking Mode,place the assembly o Tissue ProtectionSleeve together with the Drill Sleeveand the Trocar through the Static holeclosest to the driving end o the nail.Reer to the procedure described orLocking Screw insertion(Fig. 70).

The second Fully Threaded LockingScrew is inserted through the Statichole next to the rst hole and placed inan oblique manner through the oblong

hole o the nail (Fig.71).

Conrm screw position and lengthwith image intensication.

Washer

I the nail insertion opening is toolong, or i osteoporotic bone is encoun-tered, it may not be possible to achievebicortical purchase or the most dis-

tal Fully Threaded Locking Screw. AWasher, either Rectangular or Round,may be used to bridge the bone gapand allow or enhanced purchase othe Locking Screw (Fig. 72).


Fi. 70

Fi. 71

Fi. 72

38


39/52

Freehand Proximal LockingThe reehand technique is used toinsert Locking Screws into both theA/P and M/L holes in the nail.Rotational alignment must be checkedprior to locking the nail statically.

Multiple locking techniques andradiolucent drill devices are availableor reehand locking. The critical stepwith any reehand locking technique,proximal or distal, is to visualize aperectly round locking hole with theC-Arm.

The center-tipped 3.5 230mm

Drill (1806-3540S), or the optional3.5 130mm Dril l (1806-3550S), isheld at an oblique angle to the centero the locking hole (Fig. 73). UponX-Ray verication, the Drill is placedperpendicular to the nail and drilledthrough the anterior cortex. Conrmthese views in both the A/P and M/Lplanes by X-Ray.

Ater drilling both cortices, the screwlength may be read directly o o the

Screw Scale, Short (1806-0360) at theorange color coded ring on the center-tipped Drill (Fig. 74). As with distallocking (Fig. 67, p. 27), the position othe end o the drill is equal to the endo the screw as they relate to the arcortex.

Routine Locking Screw insertion isemployed with the assembled ShortScrewdriver Shat and the TeardropHandle.

I possible, the proximal humerusshould be locked with two FullyThreaded Locking Screws (Fig. 75).

Note :Use image intensication to con-rm screw position within thenail as well as screw length.

Alternatively, the Screw Gauge can beused to measure the screw length.

Fi. 75

35mm

Fi. 74

Fi. 73


Orange ring

39


40/52

Fi. 78

End Cap InsertionAter removal o the Target Device, anEnd Cap is used to reduce the poten-tial or bony ingrowth into the proxi-mal threads o the nail.

End Caps are available in six sizes(Fig. 76).

The End Cap is inserted with the ShortScrewdriver Shat assembled on theTeardrop Handle ater intra-operativeradiographs show satisactory reduc-tion and hardware implantation(Fig. 77). Fully seat the End Cap tominimize the potential or loosening.

Caution:To avoid impingement, careullyselect the length o t he End Cap.

Close the wound using standard tech-nique.

Dynamic Locking ModeControlled dynamic locking may beutilized or transverse or axially stableractures.

Retrograde dynamization is perormedby statically locking the nail proxi-mally.

The guided Locking Screw is thenplaced in the dynamic position o theoblong hole. This allows the nail tomove, and the racture to set tle while

torsional stability is maintained(Fig. 78).

Fi. 77

Standa rd +5mm +10mm +15mm +20mm +25mm

Fi. 76


40


41/52

In transverse or axially stable racturepatterns, active apposition/compres-sion increases racture stability andenhances racture healing. Theretrograde T2 Humeral Nail providesthe option to treat a humerus racturewith active mechanical apposition/compression prior to leaving theoperating room.

Note :Proximal reehand static lockingmust be perormed prior to apply-ing active, controlled apposition/compression to the racture site.

I active apposition/compression isrequired, a Partially Threaded LockingScrew (Shat Screw) is inserted via theTarget Device in the dynamic positiono the oblong hole. This will allow ora maximum o 6mm o active, con-trolled apposition/compression. Inorder to insert the Partially ThreadedLocking Screw (Shat Screw), drillboth cortices with the 3.5 230mmDrill (1806-3540S). Next, the near

cortex ONLY is overdrilled with the4.0 180mm Drill (1806-4000S).

Note :Ater the opposite cortex is drilled

with the 3.5 230mm Drill, thecorrect screw length can be readdirectly off of the calibrated Drillat the end of the Drill Sleeve.It may be easier to insert theCompression Screw prior to ullyseating the nail. Once the nailtip has cleared the racture site,

the Guide Wire (i used) is with-drawn. With the proximal portiono the nail not ully seated andextending out o the bone, theAdvanced Compression Screw isinserted.Care should be taken that theshat o the Compression Screwdoes not extend into the area othe oblong hole.

Apposition/Compression Locking Mode

Fi. 79


41


42/52


43/52

In order to achieve additional xationand to reduce the load on the PartiallyThreaded Locking Screw (ShatScrew), the design o the T2 HumeralNail provides the opportunity to insertan additional Fully Threaded LockingScrew in the other transverse hole atthe driving end o the nail aterapposition/compression is utilized.

Prior to guided locking via the TargetDevice, the Nail Holding Screw mustbe tightened using the InsertionWrench.

The Compression Screw is insertedwith the Compression ScrewdriverShat. Fix the Compression Screw onthe Compression Screwdriver Shat.Remove the Nail Holding Screwleaving the Target Device in place(Fig. 82). Advance the CompressionScrew through the Target Device untilthe desired amount o compression isachieved. Visualize depth o insertionwith the aid o fouroscopy (Fig. 83).

Note:As previously described, it may beeasier to insert the CompressionScrew prior to ully seating thenail.

To reattach the Target Device to thenail, detach the Compression ScrewDriver and screw the Nail HoldingScrew into its required position. Toreattach the Target Device to the nail,detach the Teardrop Handle rom theCompression Screwdriver Shat and

screw the Nail Holding Screw over theCompression Screwdriver Shat intoits required position.

To insert the second transverse FullyThreaded Locking Screw, ollow thelocking procedure or static locking(Fig. 84 and 85).

Advanced Locking Mode

Fi. 82

Fi. 83

Fi. 84

Fi. 85


43


44/52

Nail removal is an elective procedure.I they were used, the End Cap andCompression Screw are removed withthe Short Screwdriver Shat and theTeardrop Handle. I Advanced LockingMode was utilized, the most distalscrew is extracted rst, thus allowingaccess to the compression screw.

The Universal Rod, Short is insertedinto the driving end o the nail beoreall Locking Screws are removed withthe Short Screwdriver Shat and theTeardrop Handle (Fig. 86).

Note :Attaching the Universal Rodto the nail rst, will reduce thepotential or nail migration,then the Locking Screws may beremoved saely.

The Slotted Hammer is used to extractthe nail in a controlled manner(Fig. 87).

Nail Removal

Fi. 87

Fi. 86


44


45/52

7.0

7.07.07.07.07.07.07.07.07.07.07.07.07.07.07.07.0

8.08.08.08.08.08.08.08.08.08.08.08.08.08.08.08.08.0

9.09.09.09.09.09.09.09.09.09.09.09.09.09.09.0

9.09.0

140

160180190200210220230240250260270280290300310320

140160180190200210220230240250260270280290300310320

140160180190200210220230240250260270280290300

310320

1830-0714S

1830-0716S1830-0718S1830-0719S1830-0720S1830-0721S1830-0722S1830-0723S1830-0724S1830-0725S1830-0726S1830-0727S1830-0728S1830-0729S1830-0730S1830-0731S1830-0732S

1830-0814S1830-0816S1830-0818S1830-0819S1830-0820S1830-0821S1830-0822S1830-0823S1830-0824S1830-0825S1830-0826S1830-0827S1830-0828S1830-0829S1830-0830S1830-0831S1830-0832S

1830-0914S1830-0916S1830-0918S1830-0919S1830-0920S1830-0921S1830-0922S1830-0923S1830-0924S1830-0925S1830-0926S1830-0927S1830-0928S1830-0929S1830-0930S

1830-0931S1830-0932S

REF Diameter Lengthmm mm

T2 HuMERAL LOCkINg NAIL

Orderin Information Implants

45


46/52

Implants in sterile packaging.

Note:Check with local representativeregarding availability o sizes.

+ Outside o the U. S., Locking Screws may be

ordered non-sterile without the S at the end o

the corresponding Catalogue Number.

4.0

4.04.04.04.04.04.04.04.04.04.04.04.04.04.04.04.0

20

22242526283032343536384045505560

1896-4020S

1896-4022S1896-4024S1896-4025S1896-4026S1896-4028S1896-4030S1896-4032S1896-4034S1896-4035S1896-4036S1896-4038S1896-4040S1896-4045S1896-4050S1896-4055S1896-4060S


4MM FuLLy THREADED LOCkINg SCREWS+

(Shat Screws)

4.04.04.04.0

4.04.04.04.04.04.04.04.04.04.04.04.04.0

20222425

26283032343536384045505560

1891-4020S1891-4022S1891-4024S1891-4025S

1891-4026S1891-4028S1891-4030S1891-4032S1891-4034S1891-4035S1891-4036S1891-4038S1891-4040S1891-4045S1891-4050S1891-4055S1891-4060S


4MM PARTIALLy THREADED LOCkINg SCREWS+

Washer, roundWasher, square

1830-0008S1830-0009S

REF Description

WASHERS

6.01830-0001S

REF Diametermm

ADVANCED COMPRESSION SCREW, HuMERuS

+10mm

Standard

+25mm+20mm

+5mm

+15mm

6.0

6.06.06.06.06.0

0

+5+10+15+20+25

1830-0003S

1830-0005S1830-0010S1830-0015S1830-0020S1830-0025S


END CAPS

Orderin Information Implants

46


47/5247

Orderin Information Instrments

REF Description

T2 Basic Short

702429 Teardrop Handle, AOCoupling

1806-0022 Guide Wire Ruler

1806-0032 Awl Plug

1806-0041 Awl

1806-0113 Universal Rod, Short

1806-0130 Wrench 8mm/10mm

1806-0135 Insertion Wrench, 10mm

1806-0150 Strike Plate

1806-0170 Slotted Hammer

1806-0180 Tissue Protection Sleeve, Short

1806-0203 Screwdriver, Sel-Holding,Extra Short (3.5)

1806-0210 Dril l Sleeve, Short

1806-0222 Screwdriver Shat AO

1806-0238 Screwdriver, Sel-Holding,Short (3.5)

1806-0310 Trocar, Short

1806-0330 Screw Gauge, Short

1806-0353 Extrac tion Rod, Conical

1806-0360 Screw Scale, Short

1806-0363 Reduction Rod

1806-0390 Depth Gauge

1806-0410 Rigid Reamer Sleeve 10mm

1806-0411 Rigid Reamer Trocar 10mm

1806-1095 Guide Wire Handle

1806-1096 Guide Wire HandleChuck

1806-2020 Crown Dril l

1806-9905 T2 Basic Short Instrument Tray

REF Description

T2 Humerus

703117 Insert ion Site Template

703125 Selguiding Rigid Reamer

703126 Conical Rigid Reamer

1806-0013 X-Ray Ruler

1806-0050 K-Wire 3285mm

1806-0051 K-Wire with Washer

1806-0073 Telon Tube

1806-0143 Target Device

1806-0163 Nail Holding Screw

1806-0263 Screwdriver Sat , Compression

(2.5)

1806-3540* Dril l 3.5230mm, AO

1806-3550* Dril l 3.5130mm, AO

1806-4000* Dril l 4.0180mm, AO

1806-9930 T2 Humerus Instrument Tray

* Instruments designated Outside o the U. S. may

not be ordered or t he U. S. market.

Caution:8mm Nails require 4mm FullyThreaded Screws or locking atthe non-driving end.


48/5248


1806-0003

1806-0045

1806-0083

1806-0093

1806-0083S

1806-0093S

1806-0130

1806-0175

1806-3540S

1806-3550

1806-3550S

1806-4000S

1806-9013

1806-9972

1806-9982

X-Ray Template, Humerus

Awl, 10mm Straight

Guide Wire, Ball Tip, 2.5 800mm

Guide Wire, Smooth Tip, 2.2 800mm

Guide Wire, Ball Tip, 2.5 800mm, Sterile (U.S.)

Guide Wire, Smooth Tip, 2.2 800mm, Sterile (U.S.)

Wrench, 8mm/10mm

Sliding Hammer

Dril l 3.5 230mm, AO, sterile (U.S.)

Dril l 3.5 130mm, AO, (outside o U. S.)

Dril l 3.5 130mm, AO, steril e (U.S.)

Dril l 4 180mm, AO, Sterile (U.S.)

Humerus Screw Tray

T2 PHN Drill Rack

Silicon Mat

* Instruments designated Outside o the U.S.

may not be ordered or t he U.S. market.

REF Description

Optional Instruments


49/52

Complete range o modular andixed-head reamers to matchsurgeon preerence and optimizeO. R. eiciency, presented in ullysterilizable cases.

Studies1 have demonstrated thatthe pressures developed withinthe medullary cavity through the

introduction o unreamed IMnails canbe ar greater than those developedduring reaming but this dependsvery much upon the design o thereamer.

Ater a three year development study2involving several universities, theactors that determine the pressuresand temperatures developed duringreaming were clearly established.These actors were applied to the de-

velopment o advanced reamers thatdemonstrate signiicantly better per-ormance than the best o previousdesigns3.

1 Jan Paul M. Frolke, et al. ;

Intramedullary Pressure in Reamed Femoral

Nailing with Two Dierent Reamer Designs.,

Eur. J. o Trauma, 2001 #5

2 Medhi Moussavi, et al.;

Pressure Changes During Reaming with Dierent

Parameters and Reamer Designs,

Clinical Orthopaedics and Related ResearchNumber 373, pp. 295-303, 2000

3 Andreas Speitling;

Intramedullary Reamers, commented slides o

internal test report, Sep 1999

Large clearance rate resulting rom reduced number

o reamer blades coupled with reduced length o

reamer head to allow or eective relie o pressure

and ecient removal o material3.

Cutting fute geometry optimized to lower pressure

generation3.

Forward- and side-cutting ace combination produces

ecient material removal and rapid clearance3.

Double-wound shat transmits torque eectively and

with high reliability. Low-riction surace nish aids

rapid debris clearance3.

Smaller, 6 and 8mm shat diameters are designed to

reduce IM pressure.Tpical Standard

Reamer 14mm

Clearance area :

32% of cross section

Bict

Reamer 14mm

Clearance area :

59% o cross section


Bict

Bixcut

49


50/52

REF Description Diametermm

BIxCuT MODuLAR HEAD


BIxCuT FIxED HEAD AO FITTINg**

REF Description Lengthmm

BIxCuT SHAFTS (STERILE)1,2,3, 4

REF Description

SHAFT ACCESSORIES

REF Description

BIxCuT TRAyS EMPTy


REF Description

OPTIONAL INSTRuMENTS

0227-0060 Hand Reamer 6 mmw/Mod Trinkle connection

0227-0070 Hand Reamer 7 mmw/Mod Trinkle connection

0227-0080 Hand Reamer 8 mmw/Mod Trinkle connection0227-0090 Hand Reamer 9 mm

w/Mod Trinkle connection1806-6520 Curved Reduction Rod 8.5 mm

w/Mod Trinkle connection1806-6500 T-Handle w/Mod Trinkle connection

0226-3090

0226-3095

0226-3100

0226-3105

0226-3110

0226-3115

0226-3120

0226-3125

0226-3130

0226-3135

0226-3140

0226-3145

0226-3150

0226-3155

0226-3160

0226-3165

0226-3170

0226-3175

0226-3180

0226-41850226-4190

0226-4195

0226-4200

0226-4205

0226-4210

0226-4215

0226-4220

0226-4225

0226-4230

0226-4235

0226-4240

0226-4245

0226-4250

0226-4255

0226-4260

0226-4265

0226-4270

0226-4275

0226-4280

Bixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut Head

Bixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut HeadBixcut Head

9.09.510.010.511.011.512.012.513.013.514.014.515.015.516.016.517.017.518.0

18.519.019.520.020.521.021.522.022.523.023.524.024.525.025.526.026.527.027.528.0

0227-8240S Mod. Trinkle 2840227-3000S Mod. Trinkle 4480227-8510S Mod. Trinkle 5100227-8885S Mod. Trinkle 8850226-8240S AO 2840226-3000S AO 448

0225-6000 Tray, Modular Head

(up to size 22.0mm)0225-6001 Tray, Modular Head

(up to size 28.0mm)0225-8000 Tray, Fixed Head

(up to size 18.0mm)0225-6040 Mini Trauma Tray

(or modular heads 9-18)0225-6050 Mini Revision Tray

(or modular heads 9-28)

0225-50600225-50650225-50700225-60750225-60800225-60850225-60900225-60950225-61000225-61050225-61100225-81150225-81200225-81250225-81300225-81350225-81400225-81450225-8150

0225-81550225-81600225-81650225-81700225-81750225-8180

6.0*6.5*7.0*7.58.08.59.09.510.010.511.011.512.012.513.013.514.014.515.0

15.516.016.517.017.518.0

400400400480480480480480480480480480480480480480480480480

480480480480480480

3212-0-210 Grommet (pack o 25)3212-0-220 Grommet inserter/extrac tor0225-6010 Grommet Case

Note:

Bixcut Fixed Head Modied Trinkle ttingavailable in same diameters andlength as the AO Fitting (REF No: 0227-xxxx)

* Use with 2.2mm 800mm Smooth Tip and 2.5mm 800mm Bal l Tip Guide Wires only.** Use with Stryker Power Equipment.

1. Non-Sterile shats supplied without grommet. Use new grommet or each surgery. See ShatAccessories.

2. Sterile shats supplied with grommet pre-assembled.

3. For Non-Sterile leave S o the REF Number when ordering (510 and 885mm available only sterile

Modiied Trinkle Fitting).

4. Non-Sterile, AO Fitting Shats in 510 and 885mm are available as build to order items:

CM810921 AO Fitting Shat, length 510mm

CM810923 AO Fitting Shat, length 885mm.

50


51/52

Notes

51


52/52

Stryker Trauma GmbHPro.-Kntscher-Strae 1-5D-24232 SchnkirchenGermany

www.osteosynthesis.stryker.com

This document is intended solely or the use o healthcare proessionals. A surgeon must always rely on his or her ownproessional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stry-ker does not dispense medical advice and recommends that surgeons be trained in the use o any particular product beoreusing it in surgery. The inormation presented in thi s brochure is intended to demonstrate a Stryker product. Always reerto the package insert, product label and/or user instructions including the instructions or Cleaning and Sterilization (iapplicable) beore using any Stryker products. Products may not be available in all markets. Product ava ilability is subject

h l di l i h i di id l k Pl S k i i

humerus recovery

Documents