1 SurgicAL TecHNiqUE STEP by step Elbow System 2.0, 2.8 APTUS Elbow
2 2 Elbow System 2.0, 2.8
3 Elbow System 2.0, Elbow System 2.0, 2.8 Contents 4-5 Features, Technique 6-13 Introduction and Indications 6 introduction 6 Product materials 6 indications 6 contraindications 6 Color coding 7-8 Radial Head Plates 9-11 Olecranon Plates Distal Humerus Plates General Instrument Application Bending 17 Drilling 18 Thread preparation Surgical technique lag screws 21 Determination of depth 22 Screw pick-up Aiming Device Step-by-Step Instructions Radial Head Plates Olecranon Tension Plate Olecranon Neutralization Plates 34 Proximal Ulna Neutralization Plate Distal Humerus Plates Correct application of the TriLock locking technology Medartis, APTUS, MODUS, TriLock, HexaDrive and SpeedTip are registered trademarks of Medartis AG, 4057 Basel, Switzerland
4 4 Elbow System 2.0, 2.8 Features, Technique Combination is the Solution CAD model with elbow plates 2 Detail - radial head plate 3 Radial head plate with screws 4 Olecranon tension plate on bone model 5 Finite elements representation of a Medartis plate For further information on the plate range, see the APTUS Ordering Catalog at
5 Elbow System 2.0, Multidirectional (±15 ) and angular stable TriLock locking technology Anatomic plate designs HexaDrive interface with excellent self-holding properties Technology Multidirectional (±15 ) and angular stable TriLock locking system o Spherical three-point wedge-locking o Friction locking through radial bracing of the screw head in the plate without additional tensioning components TriLock screws can be re-locked in the same plate hole under individual angles up to three times Minimal screw head protrusion thanks to internal locking contour TriLock screws can be re-locked up to three times Variable angle of ±15 No cold welding between plate and screws Intra-operative fine tuning capabilities Plate Features Anatomically pre-contoured plate design Low overall profile height Rounded edges and polished surfaces for maximum soft tissue protection Plates may be bent for a wide range of applications Excellent self-holding properties screw Features HexaDrive the optimal self-retaining mechanism between screw and screwdriver for increased torque transmission Precision cut thread profile for improved sharpness and self-tapping properties Contact surface for screw retention Contact surface for torque transmission
6 6 Elbow System 2.0, 2.8 Introduction and Indications INTRODUCtion Indications Multidirectional and angular stable treatment for the elbow The APTUS Elbow products provide an optimal selection for the treatment of fractures, osteotomies and pseudarthroses. The anatomic plate designs result in a highly precise fit. The unique TriLock technology allows stabilization and bridging of unstable zones in accordance with the fixateur interne principle. Multidirectional screw positioning helps to fixate angular stable bone fragments, allowing for perfect anatomical reconstruction. As a result of the enhanced self-retaining HexaDrive screw holding properties, the screws are securely held by the screwdriver. The combination of intuitive sophisticated instrumentation results in an extremely user friendly system. Product Materials All APTUS implants are made from pure titanium (ASTM F67, ISO ) or from titanium alloy (ASTM F136, ISO ). All of the titanium materials used are biocompatible, corrosion-resistant and non-toxic in a biological environment. K-wires consist of stainless steel (ASTM F 138); Instruments consist of stainless steel, PEEK or aluminum. Management of proximal radius fractures and osteotomies Management of fractures and osteotomies of the proximal ulna Management of fractures, osteotomies and non-unions of the distal humerus Contraindications Pre-existing or suspected infections at or near the implantation site Known allergies and/or hypersensitivity to foreign bodies Inferior or insufficient bone quality to securely anchor the implant Patients who are incapacitated and/or uncooperative during the treatment phase The treatment of at-risk groups is inadvisable Color Coding System Color Code APTUS 2.0 blue APTUS 2.8 orange Plates and Screws Special implant plates and screws have their own color: Blue implant plates: TriLock plates (locking) Gold implant screws: Cortical screws (fixation) Blue implant screws: TriLock screws (locking)
7 Elbow System 2.0, Radial Head Plates The radial head plates can be used for fractures and osteotomies of the proximal radius, in which internal fixation with plates is indicated. The plates should be placed in the so-called Safe Zone whenever the fracture pattern allows it (c. picture). Safe Zone View on the articulation of the radial head from proximal. Right radius in neutral position. The radial head plates exist in two versions, the rim plate A and the buttress plate A The radial head buttress plate has the advantage to spare the annular ligament and enables the buttressing of a fracture with comminution in the neck region. Radial Head Rim Plate For the stabilization of complex comminuted fractures The radial head rim plate lies in part under the annular ligament, but gives the possibility to treat complex fracture patterns of radial head by internal fixation. In particular, the orientation of the plate screw holes of the rim plate make it possible to place bicortically subchondral screws in the most proximal screw range that are parallel to the humeroradial joint surface. This enables an optimal angular stable bridging of a zone of comminution. Radial Head Buttress Plate For an optimal sparing of the annular ligament
8 8 Elbow System 2.0, 2.8 Plate Features Minimal plate thickness Chamfered plate contour to minimize soft tissue irritation Anatomic plate design TriLock multidirectional (±15 ) and angular stable screw locking is possible in each plate hole All plate holes can be utilized with either locking or non-locking screws Consistent screw size (Ø 2.0 mm) Titanium Grade 4 for optimal stability Holes for supplemental 1.2 mm K-wire fixation Clinical Benefits Anatomic design to minimize soft tissue irritation and ensure stable fixation Anatomically optimized plate designs Fixation of multiple fragments Low plate profile minimizes soft tissue irritation particularly in the case of the annular ligament Multiple locking options Multidirectional and angular stable TriLock technology provides a variable cone of ±15 for optimal fixation of all fragments Angular stability of screw fixation minimizes risk of postoperative loss of reduction Screw configuration can be adapted to the fracture pattern due to numerous plate holes
9 Elbow System 2.0, Olecranon Plates We distinguish in the following two fracture and plate types: A. Fractures with inter-fragmentary support Olecranon Tension Plate B. Fractures without inter-fragmentary support Neutralization Plates The Olecranon Tension Plate is intended to replace the classical tension band wiring, is very thin entailing limited hardware prominence and can only withstand tension forces. Olecranon Tension Plate The Neutralization Plates integrate increased bending stiffness and are suitable for angular stable bridging of comminuted fracture zones. The Medartis neutralization plates are placed as a pair laterally and medially to the dorsal rim of the proximal ulna, which is the favorable position from the biomechanical standpoint. Medartis offers two types of neutralization plates to address various fracture patterns: B.1 Proximal fractures of the proximal ulna Olecranon Neutralization Plates Olecranon Neutralization Plates B.2 Distal fractures of the proximal ulna Proximal Ulna Neutralization Plates (PUNP) In the case of the neutralization plates, at least two screws should be placed in each fragment for both plates. Proximal Ulna Neutralization Plates
10 10 Elbow System 2.0, 2.8 The Olecranon Neutralization Plates are to be used if the fracture pattern is so proximal that the proximal part of the plates must surround the tip of the olecranon, entering the insertion of the triceps tendon. The Proximal Ulna Neutralization Plates can be used if the fracture pattern is distal enough that the proximal part of the plates do not have to go around the olecranon tip, thus sparing the insertion of the triceps tendon. In the case of the three fracture patterns, the following articles have to be used: 1. Olecranon Tension Plate 1x A Olecranon Neutralization Plates 1x A x A Proximal Ulna Neutralization Plates 2x A A A A A Because the Olecranon Neutralization Plates become to lie around the tip of the olecranon, they are already pre-contoured. Additionally, the most proximal hole is laterally angulated, on the right side for A and on the left side for A This angulation assures that the most proximal holes do not abut one another behind the olecranon and that the two small incisions in the insertion of the triceps tendon can be parallel to the muscle fibres. The two plates should therefore be optimally placed as it is shown in the figure on the right if possible. The olecranon plates have several holes for temporary fixation with K-wires of diameter 1.6 mm.
11 Elbow System 2.0, Plate Features TriLock multidirectional (±15 ) and angular stable locking Neutralization plates are placed laterally to the ulna (biomechanical advantage leads to smaller plates) Uniform screw size (Ø 2.8 mm) Plate thickness 0.5 mm (tension plate) and 1.6 mm (neutralization plates) made of Titanium grade 4 for high stability Anatomical plate design and easy contourability Clinical Advantagess Tension Plate More stable fixation with tension plate compared to classical tension band wiring even in borderline cases No K-wire migration No irritating wire knots Neutralization Plates Less soft tissue irritation due to very low profile plates Plates can be covered by muscle tissue
12 12 Elbow System 2.0, Distal Humeral Plates Three plate types are designed for internal fixation of distal humeral fractures with the following plate positions: 1. Medial position 2. Lateral position 3. Posterolateral position All plates are available in two lengths and in a left and a right version, have a compression hole and several holes for temporary fixation with K-wires of diameter 1.8 mm. Medial Lateral Posterolateral The plates can be used as a pair in the case of bicolumnar fractures, either in a 90 (perpendicular) or in a 180 (parallel) configuration as is illustrated in the figure. 90 Configuration 180 Configuration The aiming device A-2096 facilitates the placement of the screws in the region of the articulation, in particular in the cases of long screws between the epicondyles, because the exit point of the screws is precisely fixed before drilling. Please refer to page 19 for the handling.
13 Elbow System 2.0, Plate Features Multidirectional angular stability ±15 (TriLock) Optimized anatomical plate shapes Contourable for best fit to individual anatomy 3 plate types for 90 - and 180 -configuration Low plate profile Tapered plate thickness at the plate ends (ca. 1.6 mm), maximum plate thickness in the fracture zone (ca. 3 mm) Chamfered plate borders Oblong hole and compression hole in every plate Unique system size 2.8 K-wire holes Ø 1.8 mm Lateral plates with twist for posterior position on the proximal side (cf. figure on the right above) Medial plates with recess to protect the the ulnar nerve (cf. figure on the right below) Posterolateral plates with pre-angled distal holes and flap Aiming device for the placement of long screws in the distal periarticular bone Clinical Advantages Stable fixation due to locking technology Anatomical plate shapes facilitate anatomical reduction 90 - as well as 180 -configuration possibles 4 long screws can be placed in the distal subchondral bone between the epicondyles and locked within the plates Minimal soft tissue irritation due to anatomical plate design, especially around the epicondyles Stress risers in the bone avoided due to decreasing thickness of the proximal plate ends Sparing of the ulnar nerve due to a recess in the medial plates Less soft tissue detachment and easier screw placement thanks to posterior position of the proximal part of the lateral plates distal fragments of the capitulum can be easily reached due to the pre-angulation of the distal screw holes of the posterolateral plates Flap of the posterolateral plates enable the connection of the long subchondral screws to the plate Atraumatic screw tips prevent soft tissue irritation when inserting screws bicortically Unique system size and easy-to-handle instruments facilitate surgery
14 14 Elbow System 2.0, 2.8 General Instrument Application Bending If required, TriLock radial head plates can be bent with the plate bending pliers A-2040 or A TriLock olecranon plates and the lateral flap of the posterolateral distal humerus plates can be bent only with the plate bending pliers A These plate bending pliers have two different pins to protect the locking holes of flat and curved plates during the bending process. A Plate Bending Pliers, with Vario Pin A Plate Bending Pliers, with Pins
15 Elbow System 2.0, A-2040 The labeled side of the plate must always face upward ( UP ) when inserting the plate into the bending pliers. A-2047 When bending a flat plate (olecranon plate) or the flap of the posterolateral plates, the plate bending pliers must be held so that the letters F FLAT PLATE THIS SIDE UP are legible from above. When bending a curved plate (radial head plate), the letters C CURVED PLATE THIS SIDE UP must be legible from above. This ensures that the plate holes are not damaged. While bending, the plate must always be held at 2 adjacent holes to prevent contour deformation of the intermediate plate hole.
16 16 Elbow System 2.0, 2.8 Do not bend the plate by more than 30. Bending the plate further may deform the plate holes and may cause the plate to break postoperatively. Note: Repeated bending of the plate in opposite directions may cause the plate to break postoperatively. Always use the provided plate bending pliers to avoid damaging the plate holes. Damaged plate holes prevent correct and secure seating of the screw in the plate and increase the risk of system failure. A-2090 With the help of the bending irons A-2090, the distal humerus plates can be bent or twisted out of to the plate plane or they can be twisted. A-2090 Plate Bending Irons Elbow The medial and lateral distal humerus plates are to be bent in the open slits med and lat, resp., out of the plate plane and to be twisted in the closed slits med and lat, resp. The posterolateral distal humerus plates are both to be bent and twisted in the open slit post-lat.
17 Elbow System 2.0, Drilling Color-coded twist drills are available for every APTUS system size. All twist drills are color-coded via a ring system. System size 2.0 = blue, 2.8 = orange. There are two different types of twist drills available for every system size: one for core holes (one colored ring) and one for gliding holes (two colored rings) (lag screw technique, cf. page 19). Core Hole Drills = one colored ring Gliding Hole Drills = two colored rings The drill must always be guided through the drill guide A-2620/A-2820 to prevent damaging the plate hole and to protect surrounding tissue from direct contact with the drill. A /2.3 Drill Guide A Drill Guide The drill guide also serves to limit the drilling angle (±15 ). After positioning the plate, insert the drill guide into the plate hole and the twist drill into the drill guide. Note: For locking plates ensure that the screw holes are predrilled with a pivoting angle of up to ±15. For this purpose, the drill guides show a limit stop of ±15. A pre-drilled pivoting angle of < ±15 guarantees that the TriLock screws lock correctly into the plate.
18 18 Elbow System 2.0, 2.8 Thread Preparation with the Tap All Medartis screws are self-tapping. In the case of very hard bone, especially in the shaft region of the distal humerus, it can be indicated to reduce the insertion torque of the 2.8 mm screws by using the 2.8 tap A A Tap An unusually high resistance during the drilling of the core hole and / or an unusually high insertiion torque of the screw can be signs of a particularly hard bone requiring prior tapping. A-2070 (A-2073) Handle with AO coupling (canulated) After drilling a core hole with a 2.8 core hole drill (1 orange ring), create a thread in the hole by using the 2.8 tap A-3839 together with the handle A-2070 (or A-2073). Then insert the screw with the corresponding screw driver (Screw driver blade A-2013 with handle A-2070 (or A-2073)).
19 Elbow System 2.0, Lag screw techniques Two lag screw techniques can be used, depending on the implant. A) Lag screw technique using cortical screws The procedure for the lag screw technique using cortical screws (A-5400.xx or A-5800.xx) is as follows: 1. Drilling the gliding hole Use the gliding hole drill (two colored rings) to drill the gliding hole through the end of drill guide A-2620 (2.0 mm) or A-2820 (2.8 mm) labeled LAG. 2. Drilling the core hole Place the other end of the drill guide A-2620 (2.0 mm) or A-2820 (2.8 mm) into the drilled gliding hole and use the twist drill for core holes (one colored ring) to drill the core hole. 3. Compressing the fracture Compress the fracture with the screw of the corresponding size. 4. Optional steps before compression If required, use the countersink A-3835 to create a recess in the bone for the screw head. We recommend: Use the handle A-2070 instead of a power drive.
20 20 Elbow System 2.0, 2.8 B) Lag screw technique using lag screws For lag screws A-5830.xx (2.8 mm) with partially threaded shafts/necks, it is sufficient to drill a core hole using the drill guide A-2820 and the core hole drill A-3832 or A-3837 (one orange ring) and to insert the screw. 1. Drilling the core hole Place the end of the drill guide (one colored marking) onto the bone and use the core hole drill (one colored ring) to drill the core hole. 2. Compressing the fracture Compress the fracture by the use of a lag screw. 3. Optional steps before compression If required, use the countersink A-3835 to create a recess in the bone for the screw head. We recommend: Use the handle A-2070 instead of a power drive. Washer If the cortical bone is soft, the washer A can be used for 2.8 mm cortical or lag screws in order to distribute the lag forces over a larger surface of the bone around the screw hole.
21 Elbow System 2.0, Determination of Depth The depth gauge A-2032 is used to determine the optimal screw length for monocortical or bicortical screw fixation in the case of 2.0 mm screws. A /2.3 Depth Gauge The depth gauge A-2836 is used to determine the optimal screw length for monocortical or bicortical screw fixation in the case of 2.8 mm screws. A Depth Gauge To determine the screw length, place the tip of the depth gauge into the implant plate or directly onto the bone. The caliper of the depth gauge has a hooked tip that is either inserted to the bottom of the hole or is used to catch the far cortex of the bone to determine the correct screw length, whereby the needle remains in place and only the slider is moved. A scale on the depth gauge shows the ideal screw length for the measured drill hole.
22 22 Elbow System 2.0, 2.8 Screw Pick-uP The screwdriver A-2610 with the driver size HD6 is to be used for the screws of size 2.0 mm. The handle A-2070 together with the screw driver blade A-2013 of the driver size HD7 is to be used for the screws of size 2.8 mm. A /2.3 Screwdriver, self-holding, HD6 Both A-2610 and A-2013 feature the patented HexaDrive self-holding system. A-2013 / A /2.8 Screwdriver Blade, self-holding, HD7, with handle To remove the screws from the implant container, vertically insert the appropriately color-coded screwdriver into the screw head of the desired screw with axial pressure and lift the screw out of the container. Note: The screw will not hold without axial pressure! Vertically extract the screw from the compartment. The screw is held securely by the blade. If self-retention between screwdriver and screw cannot be achieved despite being picked up correctly, usually the screw has already been picked up. This often leads to a permanent deformation of the self-retaining area of the HexaDrive inside the screw head. Check the screw length and diameter with the scale of the measuring module. The screw is measured including its head.
23 Elbow System 2.0, Target tip Drill Guide with drill stop Aiming Device A-2096 for Distal Humerus Plates The aiming device A-2096 facilitates the placement of the screws in the region of the articulation, in particular in the case of long screws between the epicondyles, because the exit point of the screws is precisely fixed before drilling. The device is designed in a way that the drilling stops when the drill bit A-3837 arrives at the target tip at the second cortex of the bone. The length of the bicortical screw hole can be read on the scale of the axle of the aiming device. Trigger handle Release handle Position the target tip of the aiming device at the place where the screw should exit (on the left in the picture). The drill guide (on the right in the picture) of the aiming device can be positioned in the plate hole in which the screw should be placed by gripping the trigger handle. This reduces the distance between the target tip and the drill guide until both are in contact with the bone or the plate, respectively. The device also exerts a slight compression on the fracture. By gripping the trigger handle, the distance between the target tip and the drill guide is reduced. Trigger Handle By pushing the Release button, the distance is increased. Release handle The drill bit A-3837 is inserted into the drill guide of the aiming device and the hole can be drilled. The drill bit is stopped just before it reaches the target tip. Note: The drill guide is connected to the aiming device via a left-hand thread. Drill Guide with drill stop When the device is in position, the screw length can be read on the scale on the axle. Read value Axle with scale
24 24 Elbow System 2.0, 2.8 Assembly of the Aiming Device The aiming device A-2096 consists of the components A and the components are stored individually in the container module in order to assure an optimal sterilization. Numbers of the components A Frame with handle A Drill Stop A Trigger with Target Tip A Drill Guide 2.8 Step 1 Insert the drill guide 2.8 A into the frame with handle A Note: Left-handed thread!
25 Elbow System 2.0, Step 2 Insert the axle with drill stop A into the frame with handle A Note: Slightly lift the handle Release while inserting the A Step 3 Insert the trigger with target tip A into the frame with handle A Note: The axle with drill stop must be totally inserted before the trigger with target tip A A slight click should be heard at the end of insertion.
26 26 Elbow System 2.0, 2.8 Step-by-Step Instructions Radial Head Plates Choose the radial head rim plate A or the radial head buttress plate A depending on the fracture pattern (cf. page 7). Please refer to pages for more details concerning the use of the instruments employed in the following. Reduce the fracture and apply the plate temporarily in order to evaluate the necessity of bending of the plate. Position the plate whenever possible in the Safe Zone (cf. page 7). If necessary, bend the plates with the bending pliers A-2040 or A Especially in the case of the buttress plate A , the bending of the plate bars in the neck region (cf. figure) can optimize the plate position more or less distally from the joint surface depending on the fracture pattern and the individual anatomy. Fix the plate temporarily with K-wires of diameter 1.2 or 1.25 mm. Shorten the K-wires with cutting pliers if they hinder the following steps. Place a first cortical screw in the shaft region. This screw pulls the plate against the bone in order to establish a close contact. For this, drill a core hole with the help of the drill guide A-2620 and the core hole drill bit A-3434 through the corresponding plate hole.
27 Elbow System 2.0, Determine the screw length with the help of the depth gauge A Pick up a cortical screw A-5400.xx of the determined length with the help of the screw driver A-2610 and insert it into the drilled hole. Correspondingly, fill the remaining plate holes with locking (A-5450.xx) or non-locking (A-5400.xx) screws wherever the fracture pattern requires it. Place at least three screws in the shaft and the head part of the plate in order to achieve a sufficient stability. A distribution of the screws into the head utilizing both proximal screw rows increases the stability of the fixation. The choice of locking screws generally result in a in a higher construct stability, especially in the case of comminution or compromised bone quality. A non-locking screw enables to pull a fragment against the plate. It is important due to the natural convergence of the screws in the plate around the round radial head to take advantage of the multi-directionality (±15 ) of the locking and non-locking screws (gold) in order to avoid screw collisions.
28 28 Elbow System 2.0, 2.8 Olecranon Tension Plate Fixation Principle The Olecranon Tension Plate can be used in the case of simple fractures or osteotomies with good inter-fragmentary support. The fixation principle of the Tension Plate is derived from classical tension band wiring. The primary fixation is achieved by two parallel, fracture crossing, lag screws connected to the Tension Plate through the proximal plate holes - that take the place of the K-wires in tension band wiring. These two lag screws are protected against the forces of the triceps by the Tension Plate that takes the role of the cerclage wire and compensates the tension forces of the triceps. The lag screws enable a precise final reduction and compression of the fracture gap. The two oblong holes of the plate serve to tighten the thin bars of the plate, which is important that the plate can accomplish its function. The remaining two screw holes serve for a secure fixation of the plate distally. Step-by-Step Instructions Please refer to pages for more details concerning the use of the instruments employed in the following. Reduce the fracture/osteotomy with positioning forceps and fix the fracture temporarily with a K-wire in axial direction. This K-wire will also help later as a mechanical guide when the fracture/osteotomy is compressed with the help of the first lag screw. Contour the plate by hand so that the two proximal holes fit around the tip of the olecranon and that the distal holes come to lie on both sides laterally to the dorsal rim of the proximal ulna.
29 Elbow System 2.0, Make two small incisions into the triceps tendon on the olecranon in order to be able to place the two proximal holes in direct contact with the bone of the proximal fragment. These incisions should be parallel to the muscle fibres. Make sure that the plate lies tightly and symmetrically on the dorsal rim of the proximal ulna. Temporarily fix the plate with two K-wires (ø=1.6 mm) through the K-wire holes. This ensures that the plate remains centered on the dorsal edge of the ulna while inserting the long lag screws in the next steps. Drill a fracture crossing core hole (drill bit with 1 orange ring) through the first proximal plate hole using the drill guide for soft tissue protection. The direction of this screw hole should be subchondral to the trochlear notch of the ulna (similar to the direction of the K-wires in classical tension band wiring) so as to enable the placement of the two parallel fracturecrossing screws. These screws should be bicortical. Measure the length of the screw using the depth gauge A Insert a lag screw (A-5830.xx) of the measured length through this hole without tightening it. Repeat the procedure with the second proximal hole and a second lag screw. Remove the two K-wires from the plate. Close the fracture gap by carefully tightening the two fracturecrossing lag screws and exert a slight compression on the fracture so as to complete the reduction.
30 30 Elbow System 2.0, 2.8 Insure by contouring the plate with your fingers that the plate lies tightly on the posterior part of the proximal ulna. Drill a core hole (drill bit with 1 orange ring) through the longer of the two oblong holes. This core hole should lie slightly more distally to the middle of the oblong hole. Measure the length of the screw using the depth gauge A-2031 and insert a cortical screw (A-5800.xx) of appropriate length in this hole. Do not tighten the screw yet. To tighten the plate longitudinal plate bars, hook the pointed reduction forceps A-7003 in the distal part of the same oblong hole and engage the forceps crosswise on the other side of the dorsal rim of the ulna. Tighten the reduction forceps until the longitudinal plate bar lies flat on the ulna. Then tighten the screw in the oblong hole. Drill a core hole through the neighbouring plate hole and insert a cortical or locking screw. A locking screw will provide more stability. Tighten it. Repeat these steps on the other side of the plate, completing the fixation of the plate. The small incisions in the triceps can be closed over the proximal plate holes by a small suture on each side.
31 Elbow System 2.0, OleCranon Neutralization Plates Fixation Principle The Olecranon Neutralization Plates are intended for fractures being so proximal that the plates must come to lie around the tip of the olecranon in order to enable the placement of enough screws in the proximal fragment. For this reason, the plates are already pre-contoured in order to fit around the tip of the olecranon. Additionally, the most proximal hole is laterally angulated, on the right side for A and on the left side for A This angulation assures that the most proximal holes do not touch behind the olecranon and that the two small incisions in the insertion of the triceps tendon can be parallel to the muscle fibres. The two plates should therefore be placed as shown in the figure on the right if possible. Step-by-Step instructions Reduce the fracture. Temporary fixation of the plate K-wires of 1.6 mm possible. Identify the optimal plate positions and make two incisions into the triceps tendon on the olecranon in order to be able to place the proximal part of the two plates on the proximal fragment. The plates should lie laterally to the dorsal rim of the proximal ulna and surround the olecranon tip without touching each other. Open the muscle insertions on the distal fragment in order to be able to place the plates laterally on both sides of the ulna. The position of the plates should be lateral to the dorsal rim of the proximal ulna, not too dorsal in order to spare the dorsal rim and not too ventral in order to avoid an excessive detachment of muscles and the contact with the ulnar and radial nerves
32 32 Elbow System 2.0, 2.8 Bend the plates with the bending pliers A-2047 in order to fit the anatomy of the patient s bone. Temporarily fix each plate using a cortical screw A-5800.xx in the oblong hole. This pulls the contoured plate against the bone. For this, drill a hole through the oblong hole with the help of the drill guide A-2820 and the core hole drill bit A Determine the optimal screw length using the depth gauge A Pick up a cortical screw (A-5800.xx) of the determined length with the screw driver blade A-2013 and the handle A-2070 (or A-2073) and insert it into the drilled hole.
33 Elbow System 2.0, Fill the remaining plate holes with locking (A-5850.xx) or nonlocking (A-5800.xx) screws wherever indicated by the fracture pattern. For each plate, set at least two locking screws distally and proximally to the fracture so as to ensure a sufficient stability. Take care that the screws in the proximal part are short enough to not protrude into the joint surface. The other screws can be placed bicortically for increased stability. In the case of a fracture of the coronoid process with involvement of the medial collateral ligament, one or two screws depending on the fragment size can potentially be placed into the tuberculum subliminum from the plate on the radial side of the ulna (cf. figure on the right). If possible, close the incisions of the muscle insertions by sutures in order to restore the function of the muscle and to cover the plates with muscle tissue.
34 34 Elbow System 2.0, 2.8 Proximal ulna neutralization plate Fixation principle The Proximal Ulna Neutralization Plates are intended for fractures that lie distally enough that enough screws can be placed in the proximal fragment without the necessity to go around the tip of the olecranon with the plates. The plates are therefore straight because they can be contoured easily with the help of the bending pliers A-2047 to the lateral bow of the proximal ulna. Step-by-Step instructions In analogy to the preceding section
35 Elbow System 2.0, Distal Humeral Plates Reduce the fracture. All plates can be temporarily fixed with 1.8 mm K-wires on the bone and a compression hole can be used to exert compression on the fracture (cf. page 39). Please refer to pages for more details concerning the use of the instruments employed in the following. In both cases of 90 or 180 configuration, place a medial plate on the medial side of the distal humerus. The plate can be fixed temporarily on the bone with 1.8 mm K-wire. If necessary, contour the plate with the bending irons A-2090 in order to achieve an optimal fit to the individual anatomy of the patient. In the case of a 90 configuration, place a posterolateral plate on the posterior side of the lateral column of the distal humerus. If necessary, contour the flap of the plate with the help of the bending pliers A-2047 so that it fits the lateral epicondyle. This flap can also be removed using cutting pliers. The bending irons must be held that the inscription F corresponds to the upper side of the plate (cf. figure on the right).
36 36 Elbow System 2.0, 2.8 In the case of a 180 configuration, place a lateral plate on the lateral side of the distal humerus. The lateral plate is designed to lie truly laterally on the lateral epicondyle, but has a twist that brings it proximally in the shaft region on the posterior side of the humerus. If necessary, adapt the plate to the individual anatomy by using the bending irons. In all plates, the use of the oblong hole enables the temporary fixation of the plate on the bone and makes still possible a subsequent adjustment of the plate position in axial direction. For this, drill a core hole through the oblong hole using the drill bit A-3832 (1 orange circle) and the drill guide A Determine the screw length by measuring the depth of the hole using the depth gauge A Insert a non-locking cortical screw (gold) of the determined length into the drilled hole with the help of the screw driver. If necessary, the plate position can be adapted longitudinally after removal of the K-wires in the plate by temporarily loosening this screw.
37 Elbow System 2.0, Place cortical or locking screws, depending on the fracture pattern, into the plate screw holes where appropriate following the previous instructions. If the fragment is to be reduced against the plate, a cortical screw is necessary. Otherwise, a locking screw is recommended to achieve greater stability of the fixation. Take advantage of the multi-directionality of the locking and non-locking screws in order to fix the different fragments against the plate where appropriate and to avoid screw collisions, especially in the case of bicortical screw placement. It is generally advantageous to direct two subchondral screws from each epicondyle to the other side. Try to direct the screw exit points in direction of the bone next to the joint surfaces of the trochlea or the capitulum, respectively. To facilitate the placement of these long screws, an aiming device can be used. The sharp metallic point (on the left in the figure can be set on the exit point and the drill sleeve on the entrance point (on the right side in the figure). A slight compression can then be exerted on the fracture with the instrument. The drill bit A-3837 is guided by the drill sleeve and thus the direction of the hole predetermined.
38 38 Elbow System 2.0, 2.8 Angulated distal screw holes of the posterolateral plates The two most distal screw holes of the posterolateral plates are angulated for the following reasons: - even very small distal fragments of the capitulum can be reached and fixed against the plate - the passage of the long subchrondral screws from the flap in direction of the opposite epicondyle is made possible
39 Elbow System 2.0, Use of the compression hole Each distal humeral plate has a compression hole (second most proximal plate hole). It can be used if compression is to be exerted on the fracture. Insure that the fragments distal to the fracture line are securely fixed against the plate. Drill a core hole (drill bit with one orange circle) in the small part of the eccentric compression hole and select a cortical screw of appropriate length with the depth gauge. Insert this cortical screw into the drilled hole without tightening it. Remove all temporary K-wires and screws in the proximal part of the plate and untighten the screw in the oblong hole, then tighten the screw in the compression hole. During the tightening of the screw in the compression hole, the screw head glides from the small part into the large part of the eccentric hole, which moves the plate in proximal direction and exerts compression on the fracture.
40 40 Elbow System 2.0, 2.8 Correct Application of the TriLock Locking Technology The screw is inserted through the plate hole into a pre-drilled canal in the bone. An increase of the tightening torque will be felt as soon as the screw head gets in contact with the plate surface. This indicates the start of the Insertion Phase as the screw head starts entering the locking zone of the plate (section A in the diagram). Afterwards, a drop of the tightening torque occurs (section B in the diagram). Finally the actual locking is initiated (section C in the diagram) as a friction connection is established between screw and plate when tightening firmly. The torque applied during fastening of the screw is decisive for the quality of the locking as described in section C of the diagram. Rotational Angle α Locking Torque M Lock Torque M Insertion Torque M In Insertion Phase A Release B Locking C
41 Elbow System 2.0, Correct locking (±15 ) of the TriLock screws in the plate Visual inspection of the screw head projection provides an indicator of correct locking. Correct locking has occurred only when the screw head has locked flush with the plate surface (figures 1+3). However, if the screw head can still be seen or felt (figures 2+4), the screw head has not completely entered the plate and reached the locking position. In this case the screw has to be retightened to obtain full penetration and proper locking. Do not overtighten the screw, otherwise the locking function cannot be guaranteed anymore. Correct: LOCKED Incorrect: UNLOCKED Figure 1 Figure 2 Correct: LOCKED Incorrect: UNLOCKED Figure 3 Figure 4
42 42 Elbow System 2.0, 2.8
43 Elbow System 2.0,
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