Expert ALFN. Adolescent Lateral Femoral Nail.

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1 Expert ALFN. Adolescent Lateral Femoral Nail. Surgical Technique EXPERT Nailing System This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation.

2 Image intensifier control Warning This description alone does not provide sufficient background for direct use of DePuy Synthes products. Instruction by a surgeon experienced in handling these products is highly recommended. Processing, Reprocessing, Care and Maintenance For general guidelines, function control and dismantling of multi-part instruments, as well as processing guidelines for implants, please contact your local sales representative or refer to: For general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, as well as processing of Synthes non-sterile implants, please consult the Important Information leaflet (SE_023827) or refer to:

3 Table of Contents Introduction Expert ALFN 2 AO Principles 4 Indications 5 Clinical Cases 6 Surgical Technique Preoperative Planning 10 Opening the Femur 13 Inserting the Nail 18 Locking Options 23 Proximal Locking Standard 25 Recon (Optional) 29 Distal Locking 34 End Cap Insertion 39 Implant Removal 41 Product Information Implants 47 Instruments 51 Comparison Table 62 Handling Information 64 Set List 66 Modular Cases 66 Vario Cases 70 Optional: Angular Stable Locking System (ASLS) 74 MRI Information 76 Expert ALFN Surgical Technique DePuy Synthes 1

4 Expert ALFN Adolescent Lateral Femoral Nail System Nail features Design accommodates a lateral entry site through the greater trochanter Anatomic nail design based on a femoral canal study* Titanium cannulated nail for reamed or unreamed techniques Lengths from 240 mm to 400 mm, in 20 mm increments Designed for use in patients where Titanium Elastic Nails are not large enough and the Expert Lateral Femoral Nail for adults is too large 8.2 mm, 9.0 mm, and 10.0 mm diameter nails with 11.0 mm diameter proximal ends Improved instrumentation Easy-to-use instrumentation facilitates the surgical procedure Ball-tip reaming rod can be removed through the nail and the insertion instruments, eliminating the need for an exchange tube Tailored to the needs of the clinic available as: an upgrade set for adolescents to Expert Lateral Femoral System for adults or a standard Instrument Set for Expert Adolescent Lateral Femoral Nail End caps Prevent ingrowth of tissue and facilitate nail extraction Self-retaining, T40 Stardrive recess for easy pickup and insertion of the end cap Cannulated for insertion over a guide wire 0 mm end cap sits flush with the nail 5 mm, 10 mm, and 15 mm end caps extend nail height if the nail is overinserted * Ehmke L, Polzin B, Roth C, Bottlang M (2006) Femoral Nailing Through the Trochanter: The Reamer Pathway Indicates A Helical Shape. Journal of Orthopedic Trauma Vol. 20 (Number 10): DePuy Synthes Expert ALFN Surgical Technique

5 Standard locking screws Double-lead thread for ease of insertion Thread closer to screw head provides better bone purchase in the near cortex and improved stability Titanium alloy* for improved mechanical and fatigue properties Self-tapping blunt tip Self-retaining T25 Stardrive recess allows improved torque transmission, increased resistance to stripping relative to a hex recess, and secure locking screw pickup 4.0 mm diameter 5.0 mm hip screws Lengths from 50 mm to 125 mm in 5 mm increments Self-retaining T25 Stardrive recess Titanium alloy* * Titanium 6% aluminum 7% niobium alloy Expert ALFN Surgical Technique DePuy Synthes 3

6 AO Principles In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation. 1,2 Anatomic reduction Fracture reduction and fixation to restore anatomical relationships. 1 2 Stable fixation Fracture fixation providing absolute or relative stability, as required by the patient, the injury, and the personality of the fracture. Early, active mobilization Early and safe mobilization and rehabilitation of the injured part and the patient as a whole. 4 3 Preservation of blood supply Preservation of the blood supply to soft tissues and bone by gentle reduction techniques and careful handling. 1 Müller ME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal Fixation. 3rd ed. Berlin Heidelberg New York: Springer Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme DePuy Synthes Expert ALFN Surgical Technique

7 Indications The Expert Adolescent Lateral Femoral Nail is indicated for use in adolescent and small-stature adult patients to stabilize: Fractures of the femoral shaft Subtrochanteric fractures Ipsilateral neck/shaft fractures Impending pathologic fractures Nonunions and malunions Note: ASLS, the Angular Stable Locking System, is indicated in cases where increased stability is needed in fractures closer to the metaphyseal area or in poor quality bone. For more details regarding the intramedullary fixator principle, please consult the ASLS technique guide ( ) and concept flyer ( ). Expert ALFN Surgical Technique DePuy Synthes 5

8 Clinical Cases Case 1 standard transverse locking 16-year-old female, 45 kg Isolated transverse femoral shaft fracture Preoperative Case 2 antegrade locking 15-year-old male, 55 kg Oblique midshaft femoral shaft fracture Preoperative 6 DePuy Synthes Expert ALFN Surgical Technique

9 Intraoperative Follow-up (6 weeks after surgery) Postoperative Follow-up (4 months after surgery) Expert ALFN Surgical Technique DePuy Synthes 7

10 Clinical Cases Case 3 recon locking 12-year-old male, 43 kg Pathologic proximal femoral shaft fracture Preoperative Case 4 distal locking 12-year-old male, 30 kg Oblique distal third femoral shaft fracture Preoperative 8 DePuy Synthes Expert ALFN Surgical Technique

11 Postoperative Follow-up (3 weeks after surgery) Postoperative Follow-up (1 month after surgery) Expert ALFN Surgical Technique DePuy Synthes 9

12 Preoperative Planning Use the AO preoperative planner templates for the Expert Adolescent Lateral Femoral Nail ( /605) to estimate nail length and medullary canal diameter. To estimate medullary canal diameter, place the template on the AP or lateral x-ray of the femur and measure the dia meter of the medullary canal at the narrowest part that will contain the nail. To estimate nail length, place the template on the AP x-ray of the uninjured femur and select the appropriate nail length based on patient anatomy. When selecting nail size, consider canal diameter, fracture pattern, patient anatomy and postoperative protocol. Expert Adolescent Lateral Entry Femoral Nail for Right Femur 8.2 mm, 9 mm and 10 mm diameter 240 mm to 400 mm lengths A-P View 15 mm 10 mm 5 mm 0 mm 15 mm 10 mm End Caps 5 mm 0 mm 8.2 mm 9 mm 10 mm 240 mm Lateral View Locking Screw Stardrive 4.0 mm, TAN [ ] Hip Screw Stardrive 5.0 mm, TAN [ ] 1.0 Magnification mm Synthes GmbH Eimattstrasse 3 For use only with the Original AO System of CH-4436 Oberdorf Instruments and Implants mm 9 mm 10 mm 240 mm 260 mm 260 mm 280 mm 280 mm 300 mm 300 mm 320 mm 320 mm 340 mm 340 mm 360 mm 360 mm 380 mm 380 mm Expert Adolescent Lateral Entry Femoral Nail 400 mm for Right Femur 400 mm Ö _AAjä AA /2009 Synthes, Inc. or its affiliates All rights reserved Synthes and Expert are trademarks of Synthes, Inc. or its affiliates Note: Templates are available in two sizes: actual size and 115s% magnification in which the image is enlarged 15% to correspond to typical radiographic magnification; however, variations in magnification levels are common. 1 Position patient Position the patient in the lateral decubitus or supine position on a fracture table or radiolucent operating table. Position the C-arm to allow visualization of the proximal femur in both the AP and lateral planes. To facilitate access to the medullary canal, abduct the upper part of the body approximately to the contralateral side and adduct the affected limb by Affected leg 10º 15º adduction 11 DePuy Synthes Expert ALFN Surgical Technique

13 2 Reduce fracture Perform closed reduction manually by axial traction under image intensifier control. The use of the large distractor may be appropriate in certain circumstances (refer to the technique guide ). 3 Confirm nail length Instrument Radiographic Ruler for Expert Femoral Nails The required nail length must be determined after reduction of the femoral fracture. Position the C-arm for an AP view of the proximal femur. With long forceps, hold the ruler alongside the lateral thigh, parallel to and at the same level as the femur. Adjust the ruler until the proximal end is at the desired nail insertion. Expert ALFN Surgical Technique DePuy Synthes 11

14 Preoperative Planning Move the C-arm to the distal femur. Verify fracture reduction. Align the proximal end of the radiographic ruler to the skin mark, and take an AP image of the distal femur. Read nail length directly from the ruler image, selecting the measurement proximal to the epiphysis, or at the chosen insertion depth. Note: It is recommended to treat the fracture with the longest nail possible without crossing the physis, taking into account patient anatomy or a previous implant. The distal end of the nail should be 15 mm from the physis. Back-hammering or dynamization to close a fracture gap must be taken into account when determining the nail length. A shorter nail should be chosen when back-hammering or dynamization is planned. The dynamic slot allows 7 mm of movement. 4 Confirm canal diameter Instrument Radiographic Ruler for Nail Diameters for Expert Femoral Nails The required nail length must be determined after reduction of the femoral fracture. Position the C-arm for an AP or lateral view of the femur at the level of the isthmus. Hold the radiographic canal width estimator over the femur with the diameter gauge centered over the narrowest part of the medullary canal. Read the estimated diameter measurement on the circular indicator that fills the canal. Note: If the reamed technique is used, the diameter of the largest medullary reamer must be at least 1.0 mm greater than the nail diameter. 11 DePuy Synthes Expert ALFN Surgical Technique

15 Opening the Femur 1 Approach Palpate the posterior edge of the greater trochanter. Make a 3 cm incision in line with the central axis of the intramedullary canal in the lateral view, and depending on the anatomy of the patient, 2 5 cm proximal to the tip of the greater trochanter. 2 Determine entry point 12 The insertion point is 12 lateral to the greater trochanter, as measured from a point 20 mm distal to the lesser trochanter. The entry point can also be described as lateral to the greater trochanter at the same level as the superior aspect of the base of the femoral neck (just above the piriformis fossa). This point can be found by extending a line horizontally from the base of the femoral neck to the lateral side of the femur. 20 mm Expert ALFN Surgical Technique DePuy Synthes 11

16 Opening the Femur 3 Insert guide wire Instruments Handle, with Quick Coupling and Protection Sleeve 13.0 for Expert Adolescent Lateral Femoral Nail, with Quick Coupling and Multihole Drill Guide for Protection Sleeve 13.0 or Drill Sleeve 13.0/3.2, for antegrade approach and Protection Sleeve 15.5 mm/13.7 mm, length mm and Trocar B 3.2 mm, L 172 mm Guide Wire B 3.2 mm, length 400 mm Insert the protection sleeve, wire guide and trocar assembly into the incision site and to the bone. Remove the trocar. Insert the guide wire through the wire guide. The guide wire must be inserted laterally at an angle of 12 to the center of the medullary canal. The tip of the guide wire should be centered in the medullary canal 20 mm distal to the lesser trochanter. Verify that the guide wire position allows adequate clearance on the lateral side of the femur for the opening drill bit. The guide wire is inserted with it centered in the lateral view. 11 DePuy Synthes Expert ALFN Surgical Technique

17 4 Open proximal femur to medullary canal Required set SynReam Intramedullary Reaming System in Vario Case Instruments Protection Sleeve 15.5 mm/13.7 mm, length mm or Multihole Drill Guide for Protection Sleeve 13.0 and Handle, with Quick Coupling Drill Bit B 13.0 mm Guide Wire B 3.2 mm, length 400 mm Drill to open cortex Drill through the protection sleeve. Drill the cortex until the drill bit stops in the sleeve. Remove the guide wire, drill bit and protection sleeve. Precaution: Dispose of the guide wire. Do not reuse. If reaming the medullary canal, proceed to page 17. Ream to open proximal femur Insert the 2.5 mm reaming rod. Using the flexible reamers, open the proximal femur to a depth of approximately 75 mm, starting with an 8.5 mm reamer and ending with a 13.0 mm reamer. 75 mm Expert ALFN Surgical Technique DePuy Synthes 11

18 Opening the Femur Alternative technique (with awl) Alternative instruments Awl B 14.0/3.2 mm, cannulated Guide Wire B 3.2 mm, length 400 mm Place the cannulated awl over the guide wire and open the medullary canal. Use a twisting motion to advance the awl to a depth of approximately 75 mm. Remove the guide wire and awl. Precaution: After opening the proximal femur, dispose of the guide wire. Do not reuse. 11 DePuy Synthes Expert ALFN Surgical Technique

19 5 Ream medullary canal (optional) Instruments / SynReam Intramedullary Reaming System Alternative: Rod Pusher for Reaming Rod with Hexagonal Screwdriver B 8.0 mm Note: For the detailed reaming procedure, please consult SynReam Surgical Technique If necessary, enlarge the femoral canal with the medullary reamer to the desired diameter. Check fracture reduction under image intensifier. Insert reaming rod Insert the SynReam reaming rod into the medullary canal until the desired insertion depth. The tip must be correctly positioned in the medullary canal since it determines the final distal position of the Expert ALFN. The use of the Reduction Instrument for Medullary Nails may be helpful in certain circumstances. Reaming Starting with the 8.5 mm diameter reaming head, ream to a diameter of 0.5 to 1.5 mm greater than the nail dia meter. Ream in 0.5 mm increments and advance the reamer with steady, moderate pressure. Do not force the reamer. Partially retract the reamer repeatedly to clear debris from the medullary canal. Use the holding forceps to retain the reaming rod while reaming and to prevent it from rotating. Expert ALFN Surgical Technique DePuy Synthes 11

20 Inserting the Nail 1 Assemble insertion instruments Instruments Connecting Screw, cannulated, with Internal M6x1 Thread and Insertion Handle, radiolucent, length 100 mm, for Expert ALFN or Connecting Screw, cannulated, for Expert Tibial and Femoral Nails, for No and Insertion Handle for Expert Adolescent Lateral Femoral Nail Rod Pusher for Reaming Rod with Hexagonal Screwdriver B 8.0 mm Screwdriver, hexagonal with spherical head B 8.0 mm or Screwdriver, hexagonal B 8.0 mm, with T-Handle, with spherical head, length 322 mm Match the tangs on the handle to the notches in the Expert Adolescent Lateral Femoral Nail. Place the connecting screw into the insertion handle and thread it into the proximal nail end, using the 8 mm hexa gonal screwdriver with spherical head. The Expert Adolescent Lateral Femoral Nails are labeled left or right on the proximal nail end. 11 DePuy Synthes Expert ALFN Surgical Technique

21 Slide the connecting screw onto the reaming rod push rod. Slide the assembly through the insertion handle and match the tangs on the handle to the nail. Tighten using the hex on the reaming rod push rod. Secure the assembly using the 8 mm hexagonal screwdriver with spherical head. Expert ALFN Surgical Technique DePuy Synthes 11

22 Inserting the Nail 2 Insert nail Instruments Driving Cap with thread, for Insertion Handle and Combined Hammer, 500 g and Hammer Guide or Connector, for Insertion Handle and Combined Hammer 700 g, can be mounted, for No and Hammer Guide, for No Screwdriver, hexagonal with spherical head B 8.0 mm or Screwdriver, hexagonal B 8.0 mm, with T-Handle, with spherical head, length 322 mm Pin Wrench B 4.5 mm, length 120 mm Combination Wrench B 11.0 mm Shaft, hexagonal, B 8.0 mm, cannulated, short, length 125 mm Slide the connector into the groove on the insertion handle and secure it using the 11 mm ratchet wrench. If patient anatomy allows, attach the driving cap in the medial position. Orient the insertion handle in an anterior position. Use the C-arm to verify fracture reduction. Insert the nail as far as possible. The nail rotates approximately 90 during insertion. The insertion handle rotates from an anterior to a lateral position during insertion of the last one-third of the nail length. If the nail does not rotate to the lateral position, remove the nail and reinsert it with the handle slightly lateral to the sagittal plane. Monitor nail passage across the fracture, and control in two planes to avoid malalignment. 22 DePuy Synthes Expert ALFN Surgical Technique

23 If desired, insert the nail using light hammer blows. Lock the head of the hammer in place by tightening the nut onto the threads located below the hammer head. Use the pin wrench if necessary. Strike the driving cap directly. Optionally, the hammer guide can be threaded onto the driving cap and the hammer can be used as a slide hammer. Loosen the nut from the threads located below the hammer head and secure the nut onto the threads located above the handle. Precaution: Do not mount the aiming arm until the nail has been completely inserted. Expert ALFN Surgical Technique DePuy Synthes 22

24 Inserting the Nail 3 Check proximal nail position Insert the nail until it is at or below the femoral opening. Check final nail position under image intensification in AP and lateral views. If primary compression or secondary dynamization is planned, it is recommended to overinsert the nail by more than 7 mm, which corresponds to the maximum distance between the positions in static and dynamic modes. Note: The distance between the markings on the insertion handle is 5 mm and corresponds to the extensions of the end caps. This feature can be used for overinsertion of the nail. 4 Check distal nail location Use image intensification to ensure the nail is centered in both AP and lateral views. Verify fracture alignment. Remove the reaming rod. 22 DePuy Synthes Expert ALFN Surgical Technique

25 Locking Options 130 CCD 120 Proximal locking with recon locking Proximal locking with 120 locking screw Expert ALFN Surgical Technique DePuy Synthes 22

26 Locking Options Proximal locking with dynamization Proximal locking with static transverse locking screw 22 DePuy Synthes Expert ALFN Surgical Technique

27 Proximal Locking Standard 1 Choose locking option For standard locking, three targeted proximal locking options are possible: antegrade locking 2 Dynamic locking (LM) 3 Static locking (LM) For immediate dynamization, insert one proximal locking screw through the dynamic slot. If dynamization may be required in the future, use the dynamic locking option with the 120 antegrade locking hole. 2 Mount aiming arm Instruments Screwdriver, hexagonal with spherical head B 8.0 mm or Screwdriver, hexagonal B 8.0 mm, with T-Handle, with spherical head, length 322 mm Aiming Arm for Expert Adolescent Lateral Femoral Nail or Aiming Arm, radiolucent, for Expert Adolescent Lateral Femoral Nail Confirm that the nail is securely connected to the insertion handle using the 8 mm ball hex screwdriver. Mount the aiming arm to the insertion handle. Expert ALFN Surgical Technique DePuy Synthes 22

28 Proximal Locking Standard 3 Insert trocar assembly Instruments Protection Sleeve 12.0/8.0, length 188 mm Drill Sleeve 8.0/3.2, for No Trocar B 3.2 mm, for No Insert the three-part trocar assembly (protection sleeve, drill sleeve and trocar) through the desired hole in the aiming arm, make a stab incision and insert the trocar to the bone. Remove the trocar. If using the 120 antegrade locking option, insert the trocar assembly through the hole labeled 120 on the insertion handle. Precaution: Do not exert forces on the aiming arm, protection sleeve, drill sleeves or drill bits. Such force may prevent accurate targeting through the proximal locking holes and damage the drill bits. 22 DePuy Synthes Expert ALFN Surgical Technique

29 4 Drill and determine locking screw length Instrument Drill Bit B 3.2 mm, calibrated, length 340 mm, 3-flute, for Quick Coupling Ensure that the drill sleeve is pressed firmly to the lateral cortex. Drill through both cortices until the tip of the drill bit just penetrates the far cortex. Confirm drill bit position. Ensure that the drill sleeve is pressed firmly to the lateral cortex and read the measurement from the calibrated drill bit at the back of the drill sleeve. This measurement corresponds to the appropriate length locking screw. Remove the drill bit and drill sleeve. Alternative instrument Depth Gauge for Locking Screws, measuring range up to 110 mm or Depth Gauge for Locking Screws, measuring range to 110 mm After drilling both cortices, remove the drill bit and drill sleeve. Disassemble the depth gauge into two parts: the outer sleeve and the measuring device with hook. Insert the measuring device into the protection sleeve. Make sure that the hook grasps the far cortex. Ensure that the protection sleeve is firmly pressed against the lateral cortex. Read the measurement from the back of the protection sleeve, which indicates the appropriate length locking screw. Expert ALFN Surgical Technique DePuy Synthes 22

30 Proximal Locking Standard Option: Locking with ASLS ASLS, the Angular Stable Locking System, can be used as an alternative to standard locking screws in any round hole of a Synthes cannulated titanium nail. For more details regarding the intramedullary fixator principle please consult the ASLS surgical technique ( ) and concept flyer ( ). Please note that for the use of ASLS special instruments are required. 3 Insert locking screw Instrument Screwdriver Stardrive, T25, length 330 mm or Screwdriver Stardrive, T25, self-holding, length 319 mm Insert the appropriate length locking screw through the protection sleeve using the Stardrive screwdriver. Verify locking screw length under image intensification. The tip of the locking screw should not project more than 2 mm to 4 mm beyond the far cortex. Note: A groove on the screwdriver provides a rough indication that the locking screw is fully inserted through the sleeve. Repeat for a second proximal locking screw if desired. 22 DePuy Synthes Expert ALFN Surgical Technique

31 Proximal Locking Recon (Optional) 1 Confirm nail position In the AP view, adjust the nail insertion depth to ensure that the two hip screws can be placed into the femoral head. Adjust nail position for correct anteversion through the lateral view. Precaution: Adjusting for the correct anteversion before making a skin incision is crucial to allow uncomplicated guide wire and screw insertion. 2 Mount aiming arm Instruments Screwdriver, hexagonal with spherical head B 8.0 mm or Screwdriver, hexagonal B 8.0 mm, with T-Handle, with spherical head, length 322 mm Aiming Arm for Expert Adolescent Lateral Femoral Nail or Aiming Arm, radiolucent, for Expert Adolescent Lateral Femoral Nail Confirm that the nail is securely connected to the insertion handle using the screwdriver, hexagonal with spherical head B 8.0 mm. Mount the aiming arm to the insertion handle. Expert ALFN Surgical Technique DePuy Synthes 22

32 Proximal Locking Recon (Optional) 3 Insert guide wires for hip screws Instruments Protection Sleeve 11.5/ Drill Sleeve 8.5/3.2, for No Trocar B 3.2 mm, for No Guide Wire B 3.2 mm, length 400 mm Insert both three-part trocar combinations (protection sleeve, drill sleeve, and trocar) through the aiming arm. Make a stab incision and insert the trocars to the bone. Following the arrows on the aiming arm, rotate the cams so that the protection sleeves are locked in the aiming arm. This will ensure proper measurement for the hip screws. Remove the inferior trocar. 33 DePuy Synthes Expert ALFN Surgical Technique

33 In case of an arrested or closed physis, insert a guide wire into the femoral head, stopping approximately 5 mm from the subchondral bone. If the physis in the femoral head is not fully arrested, stop the wire short of the physis. Check the guide wire placement radiographically in both planes. Remove the superior trocar and repeat steps for second guide wire. Precaution: Do not exert force on the aiming arm, protection sleeves, or drill sleeves. Such force may prevent accurate targeting through the locking holes. Expert ALFN Surgical Technique DePuy Synthes 33

34 Proximal Locking Recon (Optional) 4 Determine length and drill for inferior hip screw Instruments Direct Measuring Device for Guide Wires B 3.2 mm, length 400 mm or Direct Measuring Device for Guide Wires B 3.2 mm, length 400 mm Drill Bit B 3.2 mm, calibrated, length 474 mm, 3-flute, for Mini Quick Coupling, for Hip Screw Stardrive B 5.0 mm Fixation Sleeve Measure for the inferior screw. Ensure the protection sleeve is pressed firmly to the lateral cortex. Remove the wire guide and insert the specialty measuring device over the guide wire, into the protection sleeve, and to the bone. Read the length of the required hip screw directly on the measuring device. Remove the measuring device and the inferior guide wire. Attach the fixation sleeve to the stepped drill bit for the appropriate length screw. Guide the stepped drill bit through the protection sleeve to the bone. Drill to the stop. 33 DePuy Synthes Expert ALFN Surgical Technique

35 5 Insert inferior hip screw Instrument Screwdriver Stardrive, T25, length 380 mm or Screwdriver Stardrive, T25, self-holding, length 440 mm Insert the appropriate hip screw through the protection sleeve into the femoral neck using the long T25 Stardrive screwdriver. Verify the position of the locking screw under image intensification in both planes. A groove on the screwdriver indicates when the locking screw is fully inserted. 6 Insert superior hip screw Repeat steps 3 through 5 for the superior hip screw. Expert ALFN Surgical Technique DePuy Synthes 33

36 Distal Locking 1 Distal locking There are two transverse distal locking holes. 2 Align image Check the reduction and correct alignment of the fragments and leg length before locking the nail. Align the C-arm with the hole in the nail closest to the fracture until a perfect circle is visible in the center of the screen. 3 Determine incision point Place a Kirschner wire on the skin over the center of the hole to mark the incision point and make a stab incision. 33 DePuy Synthes Expert ALFN Surgical Technique

37 4 Drill Standard locking with locking screws Instrument Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, for Quick Coupling If using the standard freehand technique, insert the tip of the drill bit through the incision and down to the bone. Incline the drive so that the tip of the drill bit is centered over the locking hole. Hold the drill bit in this position and drill through both cortices. Technique tip: For greater drill bit control, discontinue drill power after perforating the near cortex. Manually guide the drill bit through the nail before resuming power to drill the far cortex. Expert ALFN Surgical Technique DePuy Synthes 33

38 Distal Locking Alternative instrument Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, with Coupling for RDL Using the radiolucent drive under image intensification, insert the tip of the drill bit through the incision and down to the bone. Incline the drive so that the tip of the drill bit is centered over the locking hole. The drill bit should almost completely fill the circle of the locking hole. Hold the drill bit in this position and drill through both cortices. Option: Locking with ASLS ASLS, the Angular Stable Locking System, can be used as an alternative to standard locking screws in any round hole of a Synthes cannulated titanium nail. For more details regarding the intramedullary fixator prin ciple please consult the ASLS surgical technique ( ) and concept flyer ( ). Please note that for the use of ASLS special instruments are required. 33 DePuy Synthes Expert ALFN Surgical Technique

39 5 Determine locking screw length Instruments Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, with Coupling for RDL or Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, for Quick Coupling Depth Gauge for Locking Screws, measuring range to 110 mm or Depth Gauge for Locking Screws, measuring range up to 110 mm Stop drilling immediately after penetrating the far cortex. Disassemble the power drive or radiolucent drive from the drill bit. Ensure the correct position of the drill bit in regard to the far cortex of the femur. Place the direct measuring device onto the drill bit. Read the graduation on the measuring device at the end of the drill bit. This corresponds to the appropriate locking screw length. Precaution: Drill bit location with respect to the far cortex is critical for measuring the appropriate locking screw length. Alternative instrument Direct Measuring Device for Drill Bits, length 145 mm or Direct Measuring Device for Drill Bits of length 145 mm, for Nos to Measure the locking screw length using the depth gauge for locking screws. Ensure the outer sleeve is in contact with the bone and the hook grasps the far cortex. Expert ALFN Surgical Technique DePuy Synthes 33

40 Distal Locking 6 Insert locking screw Instruments Screwdriver Stardrive, T25, self-holding, length 319 mm or Screwdriver Stardrive, T25, length 330 mm Holding Sleeve, with Locking Device or Inter-Lock Screwdriver, combined, Stardrive, T25/hexagonal B 3.5, length 330 mm Figure 1 Figure 2 Insert the locking screw using the screwdriver, and the holding sleeve with locking device, if desired. Verify locking screw length under image intensification. The screw tip should be about 2 mm beyond the far cortex. If needed, a second locking screw may be inserted using the same technique. Figure 3 Use the holding sleeve as described below: Insert the holding sleeve onto the shaft of the screwdriver and place the tip of the screwdriver in the recess of the locking screw (Figure 1). Push the holding sleeve in the direction of the locking screw. The sleeve now holds the locking screw. Lock the holding sleeve by tightening it counterclockwise (Figure 2). After insertion of the locking screw, release the holding sleeve by loosening it clockwise and pulling it back (Figure 3). Read the locking screw length directly from the depth gauge at the back of the outer sleeve. 33 DePuy Synthes Expert ALFN Surgical Technique

41 End Cap Insertion 1 Insert end cap Instruments Screwdriver Stardrive, T40, with spherical head, cannulated, length 277 mm or Screwdriver Stardrive, T40, cannulated, length 300 mm Guide Wire B 3.2 mm, length 400 mm Choose an end cap with the appropriate extension; 0 mm if the nail is not overinserted, 5 mm, 10 mm or 15 mm if the nail is overinserted. The end caps are cannulated for use over a guide wire, if necessary. Remove the nail insertion instruments. Optionally, for insertion of the 0 mm end cap, remove the connecting screw only. The insertion handle can r emain to help align the end cap to the top of the nail. The 0 mm end cap fits through the barrel of the insertion handle. Insert the guide wire into the proximal end of the nail. Engage the end cap with the cannulated screwdriver by exerting axial pressure. To prevent cross-threading, align the end cap with the nail axis and turn the end cap counterclockwise, until the thread of the end cap aligns with that of the nail. Turn the end cap clockwise to thread the end cap into the nail. Remove the guide wire and screwdriver. Expert ALFN Surgical Technique DePuy Synthes 33

42 End Cap Insertion Alternative instruments Screwdriver Stardrive, T40, cannulated, length 190 mm, with Lever Arm Combination Wrench B 11.0 mm The cannulated Stardrive, screwdriver, T40, with lever handle, may be used with the 11 mm combination wrench to insert the end cap. 44 DePuy Synthes Expert ALFN Surgical Technique

43 Implant Removal 1 Remove end cap and locking screws Instruments Screwdriver Stardrive, T25,self-holding, length 319 mm or Screwdriver Stardrive, T25, length 330 mm Screwdriver Stardrive, T40, with spherical head, cannulated, length 277 mm or Screwdriver Stardrive, T40, cannulated, length 300 mm Guide Wire B 3.2 mm, length 400 mm Optional instrument Inter-Lock Screwdriver, combined, Stardrive, T25/hexagonal B 3.5, length 330 mm or Holding Sleeve, with Locking Device Expert ALFN Surgical Technique DePuy Synthes 44

44 Implant Removal 2 Attach extraction screw and hammer guide Instruments Screwdriver Stardrive, T25, length 330 mm or Screwdriver Stardrive, T25,self-holding, length 319 mm Extraction Screw Hammer Guide, for No or Hammer Guide Before removing the final locking screw, screw the extraction screw into the nail and tighten it. The locking screw will prevent nail rotation as the extraction screw is tightened. Attach the hammer guide to the extraction screw. Remove the remaining locking screw with the screwdriver. Implant removal is an optional procedure. 3 Remove nail Instrument Combined Hammer 700 g, can be mounted, for No or Combined Hammer, 500 g Extract the nail by applying gentle blows with the hammer. Note: The nail will rotate about 90, similar to the movement during the insertion. 44 DePuy Synthes Expert ALFN Surgical Technique

45 Alternative Technique Extraction Hook For removal of broken nail Instruments * Extraction Hook B 3.7 mm, for Cannulated Nails Universal Chuck with T-Handle or Universal Chuck, small, with T-Handle Begin with Steps 1 and 2 of Implant Removal, then remove the extraction screw from the nail. * Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. Expert ALFN Surgical Technique DePuy Synthes 43

46 Implant Removal Option 1 1 Assemble extraction hook and universal chuck Insert the extraction hook into the universal chuck with T-handle. The hook should be parallel with the T-handle. This facilitates visualization of the hook position in the bone. 2 Insert extraction hook through nail Pass the extraction hook through the cannula of the nail, including the distant fragment. Precaution: Under image intensification, verify that the hook has passed through and engaged the distant end of the nail. 3 Extract nail Extract both nail fragments. Technique Tip: Keep the patient s limb restrained to increase the efficiency of the extraction force. 44 DePuy Synthes Expert ALFN Surgical Technique

47 Option 2 1 Remove near nail fragment Attach the appropriate extraction bolt or extraction screw to the nail. Remove the near nail fragment using the extraction bolt or extraction screw. Technique Tip: The extraction hook can be used as an alternative to extraction instrumentation. 2 Ream canal Ream the medullary canal 1 mm larger than the nail diameter to clear a path for the distant nail fragment. 3 Align extraction hook Insert the extraction hook and explanted near nail fragment into the medullary canal. The near nail fragment aligns the extraction hook with the cannulation of the distant nail fragment. Expert ALFN Surgical Technique DePuy Synthes 44

48 Implant Removal 4 Engage distant fragment Pass the extraction hook through the cannula of the distant nail fragment. Precaution: Under image intensification, verify that the hook has passed through and engaged the distant end of the nail. 5 Extract nail Extract both nail fragments. Technique Tip: Keep the patient s limb restrained to increase the efficiency of the extraction force. 46 DePuy Synthes Expert ALFN Surgical Technique

49 Implants Expert Adolescent Lateral Femoral Nail Available for left or right femur Anatomic nail design based on a femoral canal tracing study* 120 antegrade Recon locking 20.6 mm 12.5 mm mm 50 mm Material Titanium-6% aluminum 7% niobium alloy Diameters 8.2 mm, cannulated 9.0 mm, cannulated 10.0 mm, cannulated Lengths 240 mm through 400 mm in 20 mm increments Dynamic transverse Static transverse 7 mm Cross Section Helical fluted Proximal locking Dynamization slot (LM) Static transverse locking hole (LM) 120 antegrade locking Two recon locking holes Distal locking Two transverse locking holes (LM) LM * L. Ehmke, et al. LM 12 mm 42 mm Expert ALFN Surgical Technique DePuy Synthes 44

50 Implants Expert Adolescent Lateral Femoral Nail, sterile Length (mm) B mm Right Left S S S S S S S S S S S S S S S S S S Length (mm) B mm Right Left S S S S S S S S S S S S S S S S S S Length (mm) B mm Right Left S S S S S S S S S S S S S S S S S S 44 DePuy Synthes Expert ALFN Surgical Technique

51 Expert End Cap for Adolescent Lateral Femoral Nail B 8.2 mm, Titanium Alloy (TAN), (dark purple)* Titanium alloy** Protect nail threads from tissue ingrowth Cannulated to allow insertion over a guide wire T40 Stardrive recess 0 mm: Sits flush with end of nail 5 mm, 10 mm and 15 mm extensions: Extend nail height if nail is overinserted Article No. Extension (mm) Hip Screw Stardrive B 5.0 mm, self-tapping, Titanium Alloy (TAN), (dark purple)* Titanium alloy** Lengths: 50 mm 125 mm (5 mm increments) 3.2 mm core diameter Partially threaded Self-tapping, blunt tip T25 Stardrive recess for improved torque transmission and self-retention on screwdriver Article No. Length (mm) Article No. Length (mm) * Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. ** Titanium 6% Aluminum 7% Niobium alloy Expert ALFN Surgical Technique DePuy Synthes 44

52 Implants Locking Screw Stardrive B 4.0 mm, for Medullary Nails, Titanium Alloy (TAN), (dark blue)* Titanium alloy** Lengths: 18 mm 80 mm (2 mm increments) 3.3 mm core diameter Fully threaded Self-tapping, blunt tip T25 Stardrive recess for improved torque transmission and self-retention on screwdriver Article No. Length (mm) Article No. Length (mm) * Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. ** Titanium 6% Aluminum 7% Niobium alloy 55 DePuy Synthes Expert ALFN Surgical Technique

53 Instruments Standard instrumentation Combination Wrench B 11.0 mm Pin Wrench B 4.5 mm, length 120 mm Drill Bit B 13.0 mm, cannulated, length 290 mm, 3-flute Shaft, hexagonal, B 8.0 mm, cannulated, short, length 125 mm Guide Wire B 3.2 mm, length 400 mm Universal Chuck with T-Handle Expert ALFN Surgical Technique DePuy Synthes 55

54 Instruments Extraction Screw Radiographic Ruler for Expert Femoral Nails, length 475 mm Radiographic Ruler for Nail Diameters for Expert Femoral Nails, length 365 mm * Drill Bit B 3.2 mm, calibrated, length 340 mm, 3-flute, for Quick Coupling, for No Protection Sleeve 12.0/8.0, length 188 mm Drill Sleeve 8.0/3.2, for No Trocar B 3.2 mm, for No * Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. 55 DePuy Synthes Expert ALFN Surgical Technique

55 Connecting Screw, cannulated, with Internal M6x1 Thread Hammer Guide Depth Gauge for Locking Screws, measuring range up to 110 mm Aiming Arm, radiolucent, for Expert Adolescent Lateral Femoral Nail Insertion Handle, radiolucent, length 100 mm, for Expert Adolescent Lateral Femoral Nail Cam-Lock Lever for Aiming Arm Handle, with Quick Coupling for Protection Sleeves Expert ALFN Surgical Technique DePuy Synthes 53

56 Instruments Protection Sleeve 13.0 for Expert Adolescent Lateral Femoral Nail, with Quick Coupling Multihole Drill Guide for Protection Sleeve 13.0, for Expert Adolescent Lateral Femoral Nail Screwdriver, hexagonal B 8.0 mm, with T-Handle, with spherical head, length 322 mm Screwdriver Stardrive, T25, self-holding, length 319 mm Screwdriver Stardrive, T40, with spherical head, cannulated, length 277 mm Combined Hammer, 500 g Driving Cap with thread, for Insertion Handle 54 DePuy Synthes Expert ALFN Surgical Technique

57 Optional instruments Tissue Protector Extraction Hook B 3.7 mm, for Cannulated Nails Distal Depth Gauge for Locking screw, short Awl B 14.0/3.2 mm, cannulated Protection Sleeve 11.5/ Drill Sleeve 8.5/3.2, for No Trocar B 3.2 mm, for No Expert ALFN Surgical Technique DePuy Synthes 55

58 Instruments Fixation Sleeve Rod Pusher for Reaming Rod with Hexagonal Screwdriver B 8.0 mm Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, with Coupling for RDL * Drill Bit B 3.2 mm, calibrated, length 145 mm, 3-flute, for Quick Coupling Screwdriver Stardrive, T40, cannulated, length 190 mm, with Lever Arm Drill Bit B 3.2 mm, calibrated, length 474 mm, 3-flute, for Mini Quick Coupling, for Hip Screw Stardrive B 5.0 mm * Available nonsterile or sterile-packed. Add S to catalog number to order sterile product. 55 DePuy Synthes Expert ALFN Surgical Technique

59 Direct Measuring Device for Drill Bits, length 145 mm Inter-Lock Screwdriver, combined, Stardrive, T25/hexagonal B 3.5, length 330 mm Inter-Lock Screwdriver, combined, Stardrive, T25/hexagonal B 3.5, length 224 mm Handle for Scalpel, long Direct Measuring Device for Guide Wires B 3.2 mm, length 400 mm Expert ALFN Surgical Technique DePuy Synthes 57

60 Instruments Intramedullary Reduction Tool, curved, with Quick Coupling, Hex 12 mm T-Handle, cannulated, with Quick Coupling, Hex 12 mm Screwdriver Stardrive, T25, self-holding, length 250 mm Inter-Lock Screwdriver Stardrive, T40, length 377 mm Screwdriver Stardrive, T25, self-holding, length 440 mm 58 DePuy Synthes Expert ALFN Surgical Technique

61 Alternative instruments Universal Chuck, small, with T-Handle Extraction Screw Hammer Guide, for No Trocar B 3.2 mm, length 172 mm Drill Sleeve 13.0/3.2 for antegrade approach Connecting Screw, cannulated, for Expert Tibial and Femoral Nails, for No Connector, for Insertion Handle Combined Hammer 700 g, can be mounted, for No Expert ALFN Surgical Technique DePuy Synthes 55

62 Instruments Depth Gauge for Locking Screws, measuring range up to 110 mm Direct Measuring Device for Guide Wires B 3.2 mm, length 400 mm Screwdriver, hexagonal with spherical head B 8.0 mm Direct Measuring Device for Drill Bits of length 145 mm, for Nos to Screwdriver Stardrive, T25, length 330 mm Screwdriver Stardrive, T25, length 380 mm, long Screwdriver Stardrive, T40, cannulated, length 300 mm 66 DePuy Synthes Expert ALFN Surgical Technique

63 Holding Sleeve, with Locking Device Insertion Handle for Expert Adolescent Lateral Femoral Nail Aiming Arm for Expert Adolescent Lateral Femoral Nail Protection Sleeve 15.5 mm/13.7 mm, length mm Expert ALFN Surgical Technique DePuy Synthes 66

64 Instruments Comparison Table Standard Article Alternative Article Standard Article Alternative Article Standard Article Alternative Article DePuy Synthes Expert ALFN Surgical Technique

65 Standard Article Alternative Article Standard Article Alternative Article Standard Article Alternative Article Expert ALFN Surgical Technique DePuy Synthes 63

66 Instruments Handling Information Insertion Handle ( ) Radiolucent Attachment for driving cap with threaded end ( ) Aiming Arm ( ) Easy snap-on and snap-off mechanism Friction and True locking Backward compatible with existing devices Radiolucent More soft tissue clearance Easy disassembly for cleaning 1. Some force is required to push the cam lock mechanism over the wings. 2. To fix the cam lock mechanism at the corresponding pins, the cam lock must be pushed back in open position. Inter-Lock Screwdriver Compatible with all Synthes T25 or 3.5 mm hexagonal recess. For further information, please refer to brochure Tear drop shape Silicon handle Precaution: When removing implants after long-term implantation, especially in the presence of large amounts of bony ingrowth, first use a solid screwdriver to loosen the screw. The inter-lock screwdriver can then be used to remove the screw from the surgical site. If using the inter-lock screwdriver with locking screws, use a solid screwdriver for final tightening. Scalpel Handle ( ) For channel cutting to minimize muscle force on the protection sleeves Yellow Silicon handle indicates sharpness of instrument 1. Attach a blade to the scalpel holding the end of the handle. 2. Pass the scalpel handle through the aiming arm holes and perform a minimally invasive and accurate incision. 3. Remove the scalpel from the aiming arm. 64 DePuy Synthes Expert ALFN Surgical Technique

67 IMN Reduction Tool and T-Handle with Quick Coupling ( and ) Fracture Reduction Tool Flat curved tip to aid fragment alignment Supplied separately due to length T-Handle Can be added to the auxiliary bin in the Modular Femur Set 12 mm Hexagonal Quick Coupling with marking for orientation Multihole Drill Guide for Protection Sleeve ( ) Center hole and offset holes (4 mm and/or 6 mm) Color coded 1 2 If the initial Kirschner wire (1) is placed slightly offset, a second Kirschner wire (2) can be inserted to correct the placement. Expert ALFN Surgical Technique DePuy Synthes 65

68 Set List Modular Cases The modularity of the system enables sets to be confi gured according to the hospital s clinical needs. Each set confi guration consists of basic instruments, dedicated system instruments and optional instruments (if required). For femoral nails (LFN, ALFN, R/AFN) the femur set must be added to the set configuration. New modular trays also contain the ASLS instruments. For further information about ASLS refer to pages 77 and 78. ETN R/AFN LFN ALFN Instruments for ETN Instruments for R/AFN Instruments for LFN Instruments for ALFN The instrument modules listed on the right side are available. ETN Aiming Arm (separate) Instruments for Expert Femoral Nail Basic Instruments for Expert Nail Additional Instruments for Expert Nail (Optional) For ease of use within the operating theatre, all modular trays have an additional marking: Mandatory modular trays have a solid white marking Optional trays have a hatched black marking Each system has a control picture for reference 66 DePuy Synthes Expert ALFN Surgical Technique

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