Zimmer Periarticular Elbow Locking Plate System

Transcription

1 Zimmer Periarticular Elbow Locking Plate System Surgical Technique The Right Solutions for Fractures Around the Elbow

2 Disclaimer This document is intended exclusively for physicians and is not intended for laypersons. Information on the products and procedures contained in this document is of a general nature and does not represent and does not constitute medical advice or recommendations. Because this information does not purport to constitute any diagnostic or therapeutic statement with regard to any individual medical case, each patient must be examined and advised individually, and this document does not replace the need for such examination and/or advice in whole or in part. Information contained in this document was gathered and compiled by medical experts and qualified Zimmer personnel. The information contained herein is accurate to the best knowledge of Zimmer and of those experts and personnel involved in its compilation. However, Zimmer does not assume any liability for the accuracy, completeness or quality of the information in this document, and Zimmer is not liable for any losses, tangible or intangible, that may be caused by the use of this information.

3 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 1 Table of Contents Zimmer Periarticular Elbow Locking Plate System Surgical Technique Introduction, Indications, Contraindications 2 Bone Void Fillers 2 Required Instrumentation 3 Preoperative Preparation and Surgical Approach 3 Section 1: Distal Humerus Two Plate Technique 90 Degree Plate Placement 4 Determine Posterolateral Plate Length 4 Fracture Reduction and Temporary Fixation 4 Assemble Jig to Posterolateral Plate 5 Position Posterolateral Plate 6 Screw Trajectories and Lengths 7 Insert Distal Screws 8 Assemble Jig to Medial Plate 8 Position Medial Plate 9 Insert Distal Screws 10 Fix Shaft of Posterolateral Plate 10 Fix Shaft of Medial Plate 10 Section 2: Distal Humerus Two Plate Technique 180 Degree Plate Placement 11 Determine Plate Length 11 Assemble Jig to Plate 12 Screw Trajectories and Lengths 13 Position Plate 12 Insert Distal Screws 14 Assemble Jig to Medial Plate 15 Position Medial Plate 16 Section 3: Olecranon Plate Technique 17 Surgical Approach 17 Fracture Reduction 17 Determine Plate Length 17 Assemble Jig to the Olecranon Plate 18 Position the Olecranon Plate 19 Insert Proximal Screws 20 Insert Shaft Screws 20 Wound Closure 20 Postoperative Treatment 20 Implant Removal 20 Zimmer Periarticular Elbow Locking Plates Information 21 Plates for Distal Humerus Two Plates Technique 90 Plate Placement 21 Plates for Distal Humerus Two Plates Technique 180 Plate Placement 22 Plates for Proximal Ulna 23 Periarticular Elbow Locking Plates System 24 Kit and Item Information 24 Graphic Cases 31 General Instrument Case 31 Instrument and Implant Case Tray 1 32 Instrument and Implant Case Tray 2 33 Instrument and Implant Case Tray 3 34 Instrument and Implant Case Base 35 Instrument and Implant Case Screw Caddy 36

4 2 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Introduction The Zimmer Periarticular Locking Plate System combines locking screw technology with periarticular plates to create fixed-angle constructs for use in multifragmentary fractures or where deficient bone stock or poor bone quality is encountered. The fixed-angle plate/ screw device can be used in osteopenic bone and other areas where traditional screw fixation may be compromised. The Periarticular Locking Plates will accommodate standard screws, as well as locking screws with threaded heads that allow the screw to be locked into position to facilitate proper plate/screw placement. When necessary, interfragmentary compression can be achieved with lag screws. The plates contain locking screw holes in the plate head and Universal Locking System (ULS) holes in the shaft. The ULS holes are figure-8 shaped and will accommodate standard or locking screws on either side of the hole. The ULS holes enable the surgeon to: Treat fractures using compression plating techniques with standard cortical or cancellous screws Apply the implant as an internal fixator to bridge highly comminuted zones while providing stable fixation Utilize both standard and locking screws in the same construct Apply bi-directional axial compression within the construct Utilize unicortical locking fixation as necessary Indications The Periarticular Locking Plate System is indicated for temporary internal fixation and stabilization of osteotomies and fractures, including: Comminuted fractures Supracondylar fractures Intra-articular and extra-articular condylar fractures Fractures in osteopenic bone Nonunions Malunions Bone Void Fillers Autograft, allograft, or synthetic bone void fillers are indicated for use in bony voids or gaps created surgically or through traumatic injury, that are not intrinsic to the stability of the bone structure. CopiOs Bone Void Filler* Osteoconductive/Carrier Technology provides a 3-D collagen scaffold that resembles human cancellous bone for guided bone formation. Unique mineral chemistry of dibasic calcium phosphate provides an abundance of localized minerals to promote bone healing. Available in both Sponge and Paste formations. Contraindications Contraindications include: Infection Sternal or spinal fractures or defects * CopiOs is a registered trademark of Zimmer, Inc. or its affiliates. Manufacturer: Kensey Nash Corporation. Distributor: Zimmer, Inc.

5 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 3 Required Instrumentation The following sets may be required for application of the Periarticular Elbow Locking Plates: Surgical Approaches Posterior Approach, Triceps Sparing or Splitting or Posterior Approach, Olecranon Osteotomy Zimmer Periarticular Elbow Locking Implant and Instrument Set Zimmer Periarticular Elbow Locking General Instrument Set Additional Instrumentation The following sets may also be useful: Herbert Bone Screws, 3.0mm diameter Herbert/Whipple Cannulated Bone Screws Herbert Mini Bone Screws Bag Arm holder Bag Preoperative Preparation After assessing the fracture radiographically and preparing a preoperative plan, consider the patient s positioning as supine, lateral and prone positions are all possible. The lateral decubitus position is the most versatile. Resting the arm on a padded bar will allow up to 120 of elbow flexion. Be sure that the fluoroscope can be positioned to visualize the distal humerus and/or proximal ulna in both the lateral and anterior/posterior (A/P) views to ensure adequate reduction of the joint surface, overall alignment of the limb and positioning of the implants.

6 4 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Section 1: Distal Humerus Two Plate Technique 90 Degree Plate Placement Determine Plate Length Choose plate lengths that offer sufficient fixation proximal to the fracture(s). Fracture Reduction and Temporary Fixation It is imperative that accurate reduction of the fracture be obtained prior to and maintained during application of the distal humeral and proximal ulnar locking plates. Reduce the intra-articular fragments using linear bone clamps or Kirschner wires to temporarily hold the reduction. Use lag screws to secure the intra-articular fragments as necessary. To help avoid inserting the lag screws where they will interfere with the plate placement, hold the plate(s) on the bone(s) in its approximate position. Then insert the lag screws as needed. Extra-articular reduction may be accomplished by indirect means (e.g. external fixator, traction, joysticks, bumps, etc.). Distal Posteriolateral Humeral Locking Plate Distal Medial Humeral Locking Plate Distal Medial Humeral Locking Plate (Short) If desired, plate provisionals may be used to determine the appropriate plate length. Do NOT bend the provisional during use. It is intended to be used as a template only, and bending it may cause the provisional to break. Note: To avoid unnecessary stress on the diaphysis of the bone, use medial and posterolateral plates of different lengths. Distal Posteriolateral Humeral Plate Jig Distal Medial Humeral Plate Jig Distal Medial Humeral Plate Jig (Short)

7 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 5 Assemble the Jig to the Posterolateral Plate Hold the Jig on the plate in the appropriate location a feature on the Jig will fit into the first ULS hole in the plate shaft. The Jig is designed to allow the surgeon to thread the cannulas into the plate at the appropriate angles to ensure proper engagement of the cannula with the plate and help prevent cross threading of the cannulas in the plate holes. The Cannula Inserter may used to ensure that the cannulas are fully seated in the plate hole. Once a cannula is threaded into the plate hole through the Jig, a Blue Stop Ring may be used to hold the Jig in place.

8 6 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Position the Posterolateral Plate Place the plate on the bone in the proper position. Use anatomic landmarks and fluoroscopic images as guides. Because the humeral shaft may not be aligned with the distal fragment, the plate head should be used to determine the appropriate placement of the plate. The plate head should conform to the shape of the distal humerus. This will deter -mine the alignment of the shaft. GOLD colored Drill Guide 2.7mm Screws Do NOT fully tighten the screw. This will allow for some adjustment of the plate position prior to final fixation. Note: A screwdriver shaft can be used to loosely insert the screw under power but final seating MUST be accomplished by hand to avoid cross-threading of the screws in the plate or failure of the screw or driver. Tapping is not typically necessary as the flutes of the screws are self-tapping. If the bone is dense, the lateral cortex can be tapped. SILVER color Drill Guide 3.5mm Screws w/2.7mm Head Insert a 3.5mm Cortical Screw with 2.7mm Head, a 2.7mm Conical Screw or a 2.7mm Cortical Screw in the SECOND slot using the appropriate ULS Green/ Gold Drill Guide and Drill Bit.

9 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 7 Screw Trajectories and Lengths Standard Medial Plate Use of the Homerun Screw in hole #2 prevents insertion of a screw in hole #7 2 1 A screw placed in hole #1 must be approximately 10mm in length to avoid interference with screws placed in holes #3 and # H G F E D B C A Use of the Homerun Screw in hole B prevents insertion of 3.5mm screws in holes D and E. It may be possible to use 2.7mm screws in holes C, D, and E. Hole #9 is the Second Slot 9 I Hole I is the Second Slot Posterior Plate

10 8 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Insert the Distal Screws Thread the appropriate cannulas into the plate and use the appropriate drill bit to drill and insert any of the following screws as needed: 3.5mm Locking Screw with 2.7mm Head, 2.7mm Locking Screw, 3.5mm Cortical Screw with 2.7mm head, 2.7mm Conical Screw, 2.7mm Cortical Screw or 4.0mm Cancellous Screw. Use the appropriate depth gauge to measure screw length. Note: A Screw/Cannula/Drill Bit Chart is provided on the lid of the screw caddy for reference. Insert the screws using the 2.5mm Hex Screwdriver or Screwdriver Shaft. Screw length measurement: Metaphyseal Screws the length measurement for screws in the metaphyseal region of the plate is measured line-toline from the base of the screw head to the tip of the screw. Placement of the tip of the Guide Wire will determine placement of the tip of the screw. Note: If lag screw reduction is necessary for any fragment, the lag screw must be inserted before inserting locking screws into that fragment. Check the alignment of the shaft with A/P and lateral fluoroscopic views. Note: In comminuted fractures, it may not always be possible or desirable to achieve anatomic reduction of the fracture. Note: In the distal portion of the plates, pay close attention during drilling and screw insertion. Confirm screw placement and length using image intensification to ensure screws do not enter the joint. Assemble the Jig to the Medial Plate Hold the Jig on the plate in the appropriate location a feature on the Jig will fit into the first ULS hole in the plate shaft. The Jig is designed to allow you to thread the cannulas into the plate at the appropriate angles to ensure proper engagement of the cannula with the plate and help prevent cross threading of the cannulas in the plate holes. Once a cannula is threaded into the plate hole through the Jig, a Blue Stop Ring may be used to hold the Jig in place. Diaphyseal Screws the length measurement for screws in the diaphyseal region of the plate is also measured line-to-line from the base of the screw head to the tip of the screw. In order to achieve full cortical purchase with these screws, it is recommended that 2mm be added to the screw length measurement to allow for the self-tapping flutes to penetrate the far cortex.

11 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 9 Position the Medial Plate Place the plate on the bone in the proper position. Use anatomic landmarks and fluoroscopic images as guides. Because the humeral shaft may not be aligned with the distal fragment, the plate head should be used to determine the appropriate placement of the plate. The plate head should conform to the shape of the distal humerus. This will determine the alignment of the shaft. Insert a 3.5mm Cortical Screw with 2.7mm Head, a 2.7mm Conical Screw or a 2.7mm Cortical Screw in the SECOND slot using the appropriate ULS Green/ Gold Drill Guide and Drill Bit. Note: This portion of the SHORT Distal Medial Humeral Locking Plate should ALWAYS point TOWARD the Olecranon Fossa Note: This portion of the STANDARD Distal Medial Humeral Locking Plate should ALWAYS point TOWARD the Olecranon Fossa

12 10 Zimmer Periarticular Elbow Locking Plate System Surgical Technique GOLD colored Drill Guide 2.7mm Screws SILVER color Drill Guide 3.5mm Screws w/2.7mm Head Do NOT fully tighten the screw. This will allow for some adjustment of the plate position prior to final fixation. NOTE: A screwdriver shaft can be used to loosely insert the screw under power but final seating MUST be accomplished by hand to avoid cross-threading of the screws in the plate or failure of the screw or driver. Tapping is not typically necessary as the flutes of the screws are self-tapping. If the bone is dense, the lateral cortex can be tapped. Insert the Distal Screws Thread the appropriate cannulas into the plate and use the appropriate drill bit to drill and insert any of the following screws as needed: 3.5mm Locking Screw with 2.7mm Head, 2.7mm Locking Screw, 3.5mm Cortical Screw with 2.7mm Head, 2.7mm Conical Screw, 2.7mm Cortical Screw or 4.0mm Cancellous Screw. Drill carefully as interference with screws in the posterolateral plate is possible. In case of interference, stop drilling and use a screw of appropriate length. Use the appropriate depth gauge to measure screw length. Insert the screws using the 2.5mm Hex Screwdriver or Screwdriver Shaft. Diaphyseal Screws the length measurement for screws in the diaphyseal region of the plate is also measured line-to-line from the base of the screw head to the tip of the screw. In order to achieve full cortical purchase with these screws, it is recommended that 2mm be added to the screw length measurement to allow for the self-tapping flutes to penetrate the far cortex. Note: If lag screw reduction is necessary for any fragment, the lag screw must be inserted before inserting locking screws into that fragment. Check the alignment of the shaft with A/P and lateral fluoroscopic views. Note: In comminuted fractures, it may not always be possible or desirable to achieve anatomic reduction of the fracture. Fix the Shaft of the Posterolateral Plate Determine where locking and/or cortical screws will be used in the shaft of the plate. Use the appropriate screws to fix the shaft of the plate to the bone. Note: If lag screw reduction is necessary for any fragment, the lag screw must be inserted before inserting locking screws into that fragment. Fix the Shaft of the Medial Plate Determine where locking and/or cortical screws will be used in the shaft of the plate. Use the appropriate screws to fix the shaft of the plate to the bone. Screw length measurement: Metaphyseal Screws the length measurement for screws in the metaphyseal region of the plate is measured line-toline from the base of the screw head to the tip of the screw. Placement of the tip of the Guide Wire will determine placement of the tip of the screw.

13 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 11 Section 2: Distal Humerus Two Plate Technique 180 Degree Plate Placement Determine Plate Length Choose plate lengths that offer sufficient fixation proximal to the fracture(s). If desired, plate provisionals may be used to determine the appropriate plate length. Do NOT bend the provisional during use. It is intended to be used as a template only, and bending it may cause the provisional to break. Note: To avoid unnecessary stress on the diaphysis of the bone, use medial and lateral plates of different lengths. Distal Lateral Humeral Locking Plate Distal Medial Humeral Locking Plate Distal Medial Humeral Locking Plate (Short) Distal Lateral Humeral Plate Jig Distal Medial Humeral Plate Jig Distal Medial Humeral Plate Jig (Short)

14 12 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Assemble the Jig to the Lateral Plate Hold the Jig on the plate in the appropriate location a feature on the Jig will fit into the first ULS hole or slot in the plate shaft. The Jig is designed to allow you to thread the cannulas into the plate at the appropriate angles to ensure proper engagement of the cannula with the plate and help prevent cross threading of the cannulas in the plate holes. Once a cannula is threaded into the plate hole through the Jig, a Blue Stop Ring may be used to hold the Jig in place. Position the Lateral Plate Place the plate on the bone in the proper position. Use anatomic landmarks and fluoroscopic images as guides. Because the humeral shaft may not be aligned with the distal fragment, the plate head should be used to determine the appropriate placement of the plate. The plate head should conform to the shape of the distal humerus. This will determine the alignment of the shaft. Insert a 3.5mm Cortical Screw with 2.7mm Head, a 2.7mm Conical Screw or a 2.7mm Cortical Screw in the SECOND slot using the appropriate ULS Green/ Gold Drill Guide and Drill Bit.

15 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 13 GOLD colored Drill Guide 2.7mm Screws SILVER colored Drill Guide 3.5mm Screws w/2.7mm Head Do NOT fully tighten the screw. This will allow for some adjustment of the plate position prior to final fixation. NOTE: A screwdriver shaft can be used to loosely insert the screw under power but final seating MUST be accomplished by hand to avoid cross-threading of the screws in the plate or failure of the screw or driver. Tapping is not typically necessary as the flutes of the screws are self-tapping. If the bone is dense, the lateral cortex can be tapped. Screw Trajectories and Lengths 3 Use of the Homerun Screw in hole #2 prevents insertion of a screw in hole #7 2 1 A B A screw placed in hole #1 must be approximately 10mm in length to avoid interference with screws placed in holes #3 and #4 2 1 A B C 2 1 E D 3 4 A B F Standard Medial Plate 5 Hole #9 is the Second Slot F E C D Distal Lateral Plate G H

16 14 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Insert the Distal Screws Thread the appropriate cannulas into the plate and use the appropriate drill bit to drill and insert any of the following screws as needed: 3.5mm Locking Screw with 2.7mm Head, 2.7mm Locking Screw, 2.7mm Conical Screw, 2.7mm Cortical Screw or 4.0mm Cancellous Screw. Use the appropriate depth gauge to measure screw length. Insert the screws using the 2.5mm Hex Screwdriver or Screwdriver Shaft. Screw length measurement: Metaphyseal Screws the length measurement for screws in the metaphyseal region of the plate is measured line-to-line from the base of the screw head to the tip of the screw. Placement of the tip of the Guide Wire will determine placement of the tip of the screw. Diaphyseal Screws the length measurement for screws in the diaphyseal region of the plate is also measured line-to-line from the base of the screw head to the tip of the screw. In order to achieve full cortical purchase with these screws, it is recommended that 2mm be added to the screw length measurement to allow for the self-tapping flutes to penetrate the far cortex. Note: If lag screw reduction is necessary for any fragment, the lag screw must be inserted before inserting locking screws into that fragment. Check the alignment of the shaft with A/P and lateral fluoroscopic views. Note: In comminuted fractures, it may not always be possible or desirable to achieve anatomic reduction of the fracture. Note: In the distal portion of the plates, pay close attention during drilling and screw insertion. Confirm screw placement and length using image intensification to ensure screws do not enter the joint.

17 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 15 Assemble the Jig to the Medial Plate Hold the Jig on the plate in the appropriate location a feature on the Jig will fit into the first ULS hole in the plate shaft. The Jig is designed to allow you to thread the cannulas into the plate at the appropriate angles to ensure proper engagement of the cannula with the plate and help prevent cross threading of the cannulas in the plate holes. Once a cannula is threaded into the plate hole through the Jig, a Blue Stop Ring may be used to hold the Jig in place.

18 16 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Position the Medial Plate Place the plate on the bone in the proper position. Use anatomic landmarks and fluoroscopic images as guides. Because the humeral shaft may not be aligned with the distal fragment, the plate head should be used to determine the appropriate placement of the plate. The plate head should conform to the shape of the distal humerus. This will determine the alignment of the shaft. Note: This portion of the SHORT Distal Medial Humeral Locking Plate should ALWAYS point TOWARD the Olecranon Fossa Note: This portion of the STANDARD Distal Medial Humeral Locking Plate should ALWAYS point TOWARD the Olecranon Fossa Insert a 3.5mm Cortical Screw with 2.7mm Head, a 2.7mm Conical Screw or a 2.7mm Cortical Screw in the SECOND slot using the appropriate ULS Green/ Gold Drill Guide and Drill Bit. Do NOT fully tighten the screw. This will allow for some adjustment of the plate position prior to final fixation. NOTE: A screwdriver shaft can be used to loosely insert the screw under power but final seating MUST be accomplished by hand to avoid cross-threading of the screws in the plate or failure of the screw or driver. Tapping is not typically necessary as the flutes of the screws are self-tapping. If the bone is dense, the lateral cortex can be tapped. Insert the Distal Screws Thread the appropriate cannulas into the plate and use the appropriate drill bit to drill and insert any of the following screws as needed: 3.5mm Locking Screw with 2.7mm Head, 2.7mm Locking Screw, 3.5mm Cortical Screw with 2.7mm Head, 2.7mm Conical Screw, 2.7mm Cortical Screw or 4.0mm Cancellous Screw. Drill carefully as interference with screws in the lateral plate is possible. In case of interference, stop drilling and use a screw of appropriate length. Use the appropriate depth gauge to measure screw length. Insert the screws using the 2.5mm Hex Screwdriver or Screwdriver Shaft.

19 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 17 Section 3: Olecranon Plate Technique Surgical Approach The incision is made on the posterior side of the elbow, and it is typically slightly curved toward the radial side to protect the ulnar nerve. The incision extends from the supracondylar area to a point 4 5 cm distal to the fracture. If necessary, perform an olecranon osteotomy, using the chevron technique, when articular visualization is needed. Fracture Reduction Use direct or indirect reduction techniques to restore the fracture fragments to their normal anatomic position. Take care to ensure that the coronoid is appropriately reduced before fixation. Determine Plate Length Choose plate lengths that offer sufficient fixation proximal to the fracture(s). If desired, plate provisionals may be used to determine the appropriate plate length. Do NOT bend the provisional during use. It is intended to be used as a template only, and bending it may cause the provisional to break. Proximal Ulnar Locking Plate Proximal Ulnar Locking Plate Jig

20 18 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Assemble the Jig to the Olecranon Plate Hold the Jig on the plate in the appropriate location a feature on the Jig will fit into the first slot in the plate shaft. The Jig is designed to allow you to thread the cannulas into the plate at the appropriate angles to ensure proper engagement of the cannula with the plate and help prevent cross threading of the cannulas in the plate holes. Once a cannula is threaded into the plate hole through the Jig, a Blue Stop Ring may be used to hold the Jig in place.

21 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 19 Position the Olecran Plate Place the plate on the bone in the proper position. Use anatomic landmarks and fluoroscopic images as guides. Because the ulnar shaft may not be aligned with the proximal fragment, the plate head should be used to determine the appropriate placement of the plate. The plate head should conform to the shape of the olecranon. This will determine the alignment of the shaft Hole #2 is the Homerun Screw, and it is NON-LOCKING Insert a 3.5mm Cortical Screw with 2.7mm Head, a 2.7mm Conical Screw or a 2.7mm Cortical Screw in the SECOND Slot using the appropriate Double Drill Sleeve Hole #8 is the Second Slot 10 Max length for screw #1 is 26mm To use both screws 3 and 4, the screw shafts must be 2.7mm Homerun 4 6 Do NOT fully tighten the screw. This will allow for some adjustment of the plate position prior to final fixation.

22 20 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Insert the Proximal Screws Thread the appropriate cannulas into the plate and use the appropriate drill bit to drill and insert any of the following screws as needed: 3.5mm Locking Screw with 2.7mm Head, 3.5mm Cortical Screw with 2.7mm Head, 2.7mm Locking Screw, 2.7mm Conical Screw, or 2.7mm Cortical Screw. Use the appropriate depth gauge to measure screw length. Insert the screws using the 2.5mm Hex Screwdriver or Screwdriver Shaft. Insert the Shaft Screws Thread the appropriate cannulas into the plate and use the appropriate drill bit to drill and insert any of the following screws as needed: 3.5mm Locking Screw with 2.7mm Head, 2.7mm Locking Screw, 3.5mm Cortical Screw with 2.7mm Head, 2.7mm Conical Screw, or 2.7mm Cortical Screw. Use the appropriate depth gauge to measure screw length. Insert the screws using the 2.5mm Hex Screwdriver or Screwdriver Shaft. BE SURE THAT ALL SCREWS ARE SECURELY TIGHTENED. Make a final check of the limb alignment and fracture reduction. Then make sure that ALL LOCKING SCREWS ARE SECURELY TIGHTENED by hand before closing. Wound Closure Use the appropriate method for surgical closure of the incisions. Postoperative treatment Postoperative treatment with locking plates does not differ from conventional open reduction internal fixation (ORIF) procedures. Implant Removal To remove locking screws, use the 2.5mm Hex Screwdriver to first unlock all screws from the plate and then remove the screws completely. Please refer to the package insert for product information, including contraindications, warnings, and precautionary information.

23 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 21 Zimmer Periarticular Elbow Locking Plates Information Implants Plates for Distal Humerus Two Plate Technique 90 Plate Placement Distal Posterolateral Humeral Locking Plate, Right, 5 Hole, 98mm Distal Posterolateral Humeral Locking Plate, Right, 7 Hole, 124mm Distal Posterolateral Humeral Locking Plate, Right, 9 Hole, 150mm Distal Posterolateral Humeral Locking Plate, Left, 5 Hole, 98mm Distal Posterolateral Humeral Locking Plate, Left, 7 Hole, 124mm Distal Posterolateral Humeral Locking Plate, Left, 9 Hole, 150mm Distal Posterolateral Humeral Locking Plate, Right, 3 Hole, 72mm, STERILE Distal Posterolateral Humeral Locking Plate, Right, 11 Hole, 176mm, STERILE Distal Posterolateral Humeral Locking Plate, Right, 15 Hole, 228mm, STERILE Distal Posterolateral Humeral Locking Plate, Right, 19 Hole, 280mm, STERILE Distal Posterolateral Humeral Locking Plate, Left, 3 Hole, 72mm, STERILE Distal Posterolateral Humeral Locking Plate, Left, 11 Hole, 176mm, STERILE Distal Posterolateral Humeral Locking Plate, Left, 15 Hole, 228mm, STERILE Distal Posterolateral Humeral Locking Plate, Left, 19 Hole, 280mm, STERILE Distal Medial Humeral Locking Plate, Right, 3 Hole, 78mm Distal Medial Humeral Locking Plate, Right, 5 Hole, 104mm Distal Medial Humeral Locking Plate, Right, 7 Hole, 130mm Distal Medial Humeral Locking Plate, Left, 3 Hole, 78mm Distal Medial Humeral Locking Plate, Left, 5 Hole, 104mm Distal Medial Humeral Locking Plate, Left, 7 Hole, 130mm Distal Medial Humeral Locking Plate, Right, 11 Hole, 182mm, STERILE Distal Medial Humeral Locking Plate, Right, 15 Hole, 234mm, STERILE Distal Medial Humeral Locking Plate, Left, 11 Hole, 182mm, STERILE Distal Medial Humeral Locking Plate, Left, 15 Hole, 234mm, STERILE Distal Medial Humeral Locking Plate, Short, Right, 3 Hole, 74mm Distal Medial Humeral Locking Plate, Short, Right, 5 Hole, 100mm Distal Medial Humeral Locking Plate, Short, Right, 7 Hole, 126mm Distal Medial Humeral Locking Plate, Short, Left, 3 Hole, 74mm Distal Medial Humeral Locking Plate, Short, Left, 5 Hole, 100mm Distal Medial Humeral Locking Plate, Short, Left, 7 Hole, 126mm Distal Medial Humeral Locking Plate, Short, Right, 11 Hole, 178mm, STERILE Distal Medial Humeral Locking Plate, Short, Right, 15 Hole, 230mm, STERILE Distal Medial Humeral Locking Plate, Short, Left, 11 Hole, 178mm, STERILE Distal Medial Humeral Locking Plate, Short, Left, 15 Hole, 230mm, STERILE

24 22 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Implants Plates for Distal Humerus Two Plate Technique 180 Plate Placement Distal Lateral Humeral Locking Plate, Right, 5H, 87mm Distal Lateral Humeral Locking Plate, Right, 7H, 113mm Distal Lateral Humeral Locking Plate, Right, 9H, 139mm Distal Lateral Humeral Locking Plate, Left, 5H, 87mm Distal Lateral Humeral Locking Plate, Left, 7H, 113mm Distal Lateral Humeral Locking Plate, Left, 9H, 139mm Distal Lateral Humeral Locking Plate, Right, 5H, 87mm, Sterile Distal Lateral Humeral Locking Plate, Right, 7H, 113mm, Sterile Distal Lateral Humeral Locking Plate, Right, 9H, 139mm, Sterile Distal Lateral Humeral Locking Plate, Left, 5H, 87mm, Sterile Distal Lateral Humeral Locking Plate, Left, 7H, 113mm, Sterile Distal Lateral Humeral Locking Plate, Left, 9H, 139mm, Sterile Distal Lateral Humeral Locking Plate, Right, 11H, 165mm, Sterile Distal Lateral Humeral Locking Plate, Right, 15H, 217mm, Sterile Distal Lateral Humeral Locking Plate, Left, 11H, 165mm, Sterile Distal Lateral Humeral Locking Plate, Left, 15H, 217mm, Sterile Distal Medial Humeral Locking Plate, Right, 3 Hole, 78mm Distal Medial Humeral Locking Plate, Right, 5 Hole, 104mm Distal Medial Humeral Locking Plate, Right, 7 Hole, 130mm Distal Medial Humeral Locking Plate, Left, 3 Hole, 78mm Distal Medial Humeral Locking Plate, Left, 5 Hole, 104mm Distal Medial Humeral Locking Plate, Left, 7 Hole, 130mm Distal Medial Humeral Locking Plate, Right, 11 Hole, 182mm, STERILE Distal Medial Humeral Locking Plate, Right, 15 Hole, 234mm, STERILE Distal Medial Humeral Locking Plate, Left, 11 Hole, 182mm, STERILE Distal Medial Humeral Locking Plate, Left, 15 Hole, 234mm, STERILE Distal Medial Humeral Locking Plate, Short, Right, 3 Hole, 74mm Distal Medial Humeral Locking Plate, Short, Right, 5 Hole, 100mm Distal Medial Humeral Locking Plate, Short, Right, 7 Hole, 126mm Distal Medial Humeral Locking Plate, Short, Left, 3 Hole, 74mm Distal Medial Humeral Locking Plate, Short, Left, 5 Hole, 100mm Distal Medial Humeral Locking Plate, Short, Left, 7 Hole, 126mm Distal Medial Humeral Locking Plate, Short, Right, 11 Hole, 178mm, STERILE Distal Medial Humeral Locking Plate, Short, Right, 15 Hole, 230mm, STERILE Distal Medial Humeral Locking Plate, Short, Left, 11 Hole, 178mm, STERILE Distal Medial Humeral Locking Plate, Short, Left, 15 Hole, 230mm, STERILE

25 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 23 Implants Plates for Proximal Ulna Proximal Ulna Locking Plate, Right, 3 Hole, 77mm Proximal Ulna Locking Plate, Right, 5 Hole, 103mm Proximal Ulna Locking Plate, Right, 7 Hole, 129mm Proximal Ulna Locking Plate, Right, 9 Hole, 155mm Proximal Ulna Locking Plate, Left, 3 Hole, 77mm Proximal Ulna Locking Plate, Left, 5 Hole, 103mm Proximal Ulna Locking Plate, Left, 7 Hole, 129mm Proximal Ulna Locking Plate, Left, 9 Hole, 155mm Proximal Ulna Locking Plate, Right, 11 Hole, 181mm, STERILE Proximal Ulna Locking Plate, Right, 13 Hole, 207mm, STERILE Proximal Ulna Locking Plate, Right, 15 Hole, 233mm, STERILE Proximal Ulna Locking Plate, Left, 11 Hole, 181mm, STERILE Proximal Ulna Locking Plate, Left, 13 Hole, 207mm, STERILE Proximal Ulna Locking Plate, Left, 15 Hole, 233mm, STERILE

26 24 Zimmer Periarticular Elbow Locking Plate System Surgical Technique Periarticular Elbow Locking Plate System Kit and Item Information REF Description Qty ZS Elbow Locking Plate Set ZS Elbow Locking Plate Set Sterile ZS Elbow Locking Plate Screw Set ZS Elbow Locking Plate Screw Set Sterile KT Elbow Locking Plate General Instrument Set KT Elbow Locking Plate Instrument Set REF Nonsterile REF Sterile Description Qty ZS ZS Periarticular Elbow Locking Plate Set Distal Posterolateral Humeral Locking Plate, Right, 5 Hole, 98mm Distal Posterolateral Humeral Locking Plate, Right, 7 Hole, 124mm Distal Posterolateral Humeral Locking Plate, Right, 9 Hole, 150mm Distal Posterolateral Humeral Locking Plate, Left, 5 Hole, 98mm Distal Posterolateral Humeral Locking Plate, Left, 7 Hole, 124mm Distal Posterolateral Humeral Locking Plate, Left, 9 Hole, 150mm Distal Medial Humeral Locking Plate, Right, 3 Hole, 78mm Distal Medial Humeral Locking Plate, Right, 5 Hole, 104mm Distal Medial Humeral Locking Plate, Right, 7 Hole, 130mm Distal Medial Humeral Locking Plate, Left, 3 Hole, 78mm Distal Medial Humeral Locking Plate, Left, 5 Hole, 104mm Distal Medial Humeral Locking Plate, Left, 7 Hole, 130mm Distal Medial Humeral Locking Plate, Short, Right, 3 Hole, 74mm Distal Medial Humeral Locking Plate, Short, Right, 5 Hole, 100mm Distal Medial Humeral Locking Plate, Short, Right, 7 Hole, 126mm Distal Medial Humeral Locking Plate, Short, Left, 3 Hole, 74mm Distal Medial Humeral Locking Plate, Short, Left, 5 Hole, 100mm Distal Medial Humeral Locking Plate, Short, Left, 7 Hole, 126mm Distal Lateral Humeral Locking Plate, Right, 5 Hole, 87mm Distal Lateral Humeral Locking Plate, Right, 7 Hole, 113mm Distal Lateral Humeral Locking Plate, Left, 5 Hole, 87mm Distal Lateral Humeral Locking Plate, Left, 7 Hole, 113mm Proximal Ulna Locking Plate, Right, 3 Hole, 77mm Proximal Ulna Locking Plate, Right, 5 Hole, 103mm Proximal Ulna Locking Plate, Right, 7 Hole, 129mm Proximal Ulna Locking Plate, Right, 9 Hole, 155mm Proximal Ulna Locking Plate, Left, 3 Hole, 77mm Proximal Ulna Locking Plate, Left, 5 Hole, 103mm Proximal Ulna Locking Plate, Left, 7 Hole, 129mm Proximal Ulna Locking Plate, Left, 9 Hole, 155mm 1

27 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 25 REF Nonsterile REF Sterile Description Qty ZS ZS Periarticular Locking Elbow Screw Set mm Peri Cortical Screw with 2.7mm Head, 10mm Long mm Peri Cortical Screw with 2.7mm Head, 12mm Long mm Peri Cortical Screw with 2.7mm Head, 14mm Long mm Peri Cortical Screw with 2.7mm Head, 16mm Long mm Peri Cortical Screw with 2.7mm Head, 18mm Long mm Peri Cortical Screw with 2.7mm Head, 20mm Long mm Peri Cortical Screw with 2.7mm Head, 22mm Long mm Peri Cortical Screw with 2.7mm Head, 24mm Long mm Peri Cortical Screw with 2.7mm Head, 26mm Long mm Peri Cortical Screw with 2.7mm Head, 28mm Long mm Peri Cortical Screw with 2.7mm Head, 30mm Long mm Peri Cortical Screw with 2.7mm Head, 32mm Long mm Peri Cortical Screw with 2.7mm Head, 34mm Long mm Peri Cortical Screw with 2.7mm Head, 36mm Long mm Peri Cortical Screw with 2.7mm Head, 38mm Long mm Peri Cortical Screw with 2.7mm Head, 40mm Long mm Peri Cortical Screw with 2.7mm Head, 42mm Long mm Peri Cortical Screw with 2.7mm Head, 44mm Long mm Peri Cortical Screw with 2.7mm Head, 46mm Long mm Peri Cortical Screw with 2.7mm Head, 48mm Long mm Peri Cortical Screw with 2.7mm Head, 50mm Long mm Peri Cortical Screw with 2.7mm Head, 52mm Long mm Peri Cortical Screw with 2.7mm Head, 54mm Long mm Peri Cortical Screw with 2.7mm Head, 56mm Long mm Peri Cortical Screw with 2.7mm Head, 58mm Long mm Peri Cortical Screw with 2.7mm Head, 60mm Long mm Peri Cortical Screw with 2.7mm Head, 65mm Long mm Peri Cortical Screw with 2.7mm Head, 70mm Long mm Peri Cortical Screw with 2.7mm Head, 100mm Long mm Peri Cortical Screw with 2.7mm Head, 105mm Long mm Peri Cortical Screw with 2.7mm Head, 110mm Long mm Conical Screw, 14mm Long mm Conical Screw, 16mm Long mm Conical Screw, 18mm Long mm Conical Screw, 20mm Long mm Conical Screw, 22mm Long mm Conical Screw, 24mm Long 2

28 26 Zimmer Periarticular Elbow Locking Plate System Surgical Technique REF Nonsterile REF Sterile Description Qty mm Conical Screw, 26mm Long mm Conical Screw, 28mm Long mm Conical Screw, 30mm Long mm Conical Screw, 32mm Long mm Conical Screw, 34mm Long mm Conical Screw, 36mm Long mm Conical Screw, 38mm Long mm Conical Screw, 40mm Long mm Locking Screw with 2.7mm Head, 10mm Long mm Locking Screw with 2.7mm Head, 12mm Long mm Locking Screw with 2.7mm Head, 14mm Long mm Locking Screw with 2.7mm Head, 16mm Long mm Locking Screw with 2.7mm Head, 18mm Long mm Locking Screw with 2.7mm Head, 20mm Long mm Locking Screw with 2.7mm Head, 22mm Long mm Locking Screw with 2.7mm Head, 24mm Long mm Locking Screw with 2.7mm Head, 26mm Long mm Locking Screw with 2.7mm Head, 28mm Long mm Locking Screw with 2.7mm Head, 30mm Long mm Locking Screw with 2.7mm Head, 32mm Long mm Locking Screw with 2.7mm Head, 34mm Long mm Locking Screw with 2.7mm Head, 36mm Long mm Locking Screw with 2.7mm Head, 38mm Long mm Locking Screw with 2.7mm Head, 40mm Long mm Locking Screw with 2.7mm Head, 42mm Long mm Locking Screw with 2.7mm Head, 44mm Long mm Locking Screw with 2.7mm Head, 46mm Long mm Locking Screw with 2.7mm Head, 48mm Long mm Locking Screw with 2.7mm Head, 50mm Long mm Locking Screw with 2.7mm Head, 55mm Long mm Locking Screw with 2.7mm Head, 60mm Long mm Locking Screw with 2.7mm Head, 65mm Long mm Locking Screw with 2.7mm Head, 70mm Long mm Cortical Self-tapping Screw, 8mm Long mm Cortical Self-tapping Screw, 10mm Long mm Cortical Self-tapping Screw, 12mm Long mm Cortical Self-tapping Screw, 14mm Long mm Cortical Self-tapping Screw, 16mm Long 2

29 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 27 REF Nonsterile REF Sterile Description Qty mm Cortical Self-tapping Screw, 18mm Long mm Cortical Self-tapping Screw, 20mm Long mm Cortical Self-tapping Screw, 22mm Long mm Cortical Self-tapping Screw, 24mm Long mm Cortical Self-tapping Screw, 26mm Long mm Cortical Self-tapping Screw, 28mm Long mm Cortical Self-tapping Screw, 30mm Long mm Cortical Self-tapping Screw, 32mm Long mm Cortical Self-tapping Screw, 34mm Long mm Cortical Self-tapping Screw, 36mm Long mm Cortical Self-tapping Screw, 38mm Long mm Cortical Self-tapping Screw, 40mm Long mm Cortical Self-tapping Screw, 45mm Long mm Cortical Self-tapping Screw, 50mm Long mm Cortical Self-tapping Screw, 55mm Long mm Cortical Self-tapping Screw, 60mm Long mm Cortical Self-tapping Screw, 65mm Long mm Cortical Self-tapping Screw, 70mm Long mm Locking Screw, 10mm Long mm Locking Screw, 12mm Long mm Locking Screw, 14mm Long mm Locking Screw, 16mm Long mm Locking Screw, 18mm Long mm Locking Screw, 20mm Long mm Locking Screw, 22mm Long mm Locking Screw, 24mm Long mm Locking Screw, 26mm Long mm Locking Screw, 28mm Long mm Locking Screw, 30mm Long mm Locking Screw, 32mm Long mm Locking Screw, 34mm Long mm Locking Screw, 36mm Long mm Locking Screw, 38mm Long mm Locking Screw, 40mm Long mm Locking Screw, 42mm Long mm Locking Screw, 44mm Long mm Locking Screw, 46mm Long mm Locking Screw, 48mm Long 2

30 28 Zimmer Periarticular Elbow Locking Plate System Surgical Technique REF Nonsterile REF Sterile Description Qty mm Locking Screw, 50mm Long mm Locking Screw, 55mm Long mm Locking Screw, 60mm Long mm Cancellous Screw, Partially Threaded, 20mm Long mm Cancellous Screw, Partially Threaded, 26mm Long mm Cancellous Screw, Partially Threaded, 30mm Long mm Cancellous Screw, Partially Threaded, 35mm Long mm Cancellous Screw, Partially Threaded, 40mm Long mm Cancellous Screw, Partially Threaded, 45mm Long mm Cancellous Screw, Partially Threaded, 50mm Long mm Cancellous Screw, Partially Threaded, 55mm Long mm Cancellous Screw, Partially Threaded, 60mm Long mm Cancellous Screw, Partially Threaded, 65mm Long mm Cancellous Screw, Partially Threaded, 70mm Long Small Washer, for 2.7mm, 3.5mm, and 4.0mm Screws 2 KT Periarticular Elbow Locking Instrument Set mm D-Drive Cannula for 2.7mm Locking Hole mm D-Drive Cannula for 2.7mm Locking Hole mm D-Drive Cannula Inserter Distal Posterolateral Humeral Locking Plate Jig, Right Distal Posterolateral Humeral Locking Plate Jig, Left Distal Medial Humeral Locking Plate Jig, Right Distal Medial Humeral Locking Plate Jig, Left Distal Medial Humeral Locking Plate Jig, Short, Right Distal Medial Humeral Locking Plate Jig, Short, Left Proximal Ulnar Locking Plate Jig, Right Proximal Ulnar Locking Plate Jig, Left Distal Lateral Humeral Locking Plate Jig, Right Distal Lateral Humeral Locking Plate Jig, Left mm Screwdriver Stop Ring 1 pkg of Cleaning Stylet Cleaning Brush mm Standard Cannula (for 3.5mm locking screw with 2.7mm head) Torque Limiting Attachment mm Standard Tap, QC mm Standard Tap, QC mm Hex QC Standard Screwdriver Bit mm Standard Drill, QC, 175mm long mm Standard Drill, QC, 205mm long 2

31 Zimmer Periarticular Elbow Locking Plate System Surgical Technique 29 Prod. No. Description Qty QC T Handle Cannulated Ratchet Handle, AO Connection mm Hex Standard Screwdriver, QC Small Depth Gauge, Measures up to 60mm Small Depth Gauge, Measures up to 150mm Kwires, 1.25mm diameter, 150mm long, 10 per box 1 box Kwires, 1.6mm diameter, 150mm long, 10 per box 1 box Kwires, 2.0mm diameter, 150mm long, 10 per box 1 box mm Drill, QC, 100mm long mm Drill, QC, 110mm long mm Drill, QC, 205mm long mm Drill, QC, 100mm long mm Drill, QC, 110mm long mm/2.0mm Double Drill Sleeve mm/2.5mm Double Drill Sleeve mm Tap, QC mm Tap, QC Small Holding Sleeve Screw Holding Forceps mm ULS Compression Drill Guide mm ULS Compression Drill Guide for 3.5mm Screw Countersink /2.5 Insert Drill Sleeve Peri Elbow Locking Instrument Base and Tray Case Lid 1 KT Periarticular Elbow Locking General Instrument Set Reduction Forceps, Ratchet, Serrated w/ Points, Narrow, 133mm length Reduction Forceps, Ratchet, Serrated w/ Points, Broad, 133mm length Reduction Forceps, Ratchet, w/ Points, 205mm length Reduction Forceps, Ratchet, Serrated Jaws, 145mm length Reduction Forceps, Speed-Lock, 180mm Length Reduction Forceps, Speed-Lock, with Narrow Serrated Jaws, 245mm Length Bending Iron, Left, 2.7/3.5 Plates Bending Iron, Right, 2.7/3.5 Plates Hohmann Retractor, 8mm width, Short Narrow Tip, 165mm length Hohmann Retractor, 15mm width, 160mm length 2