Technique Guide. 3.5 mm LCP Clavicle Hook Plates. Part of the Synthes locking compression plate (LCP) system.

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1 Technique Guide 3.5 mm LCP Clavicle Hook Plates. Part of the Synthes locking compression plate (LCP) system.

2 Table of Contents Introduction 3.5 mm LCP Clavicle Hook Plates 2 AO Principles 4 Indications 5 Surgical Technique Lateral Clavicle Fractures 6 Dislocation of the Acromioclavicular Joint 13 Implant Removal 20 Product Information Implants 21 Set List 22 Image intensifier control Synthes

3 3.5 mm LCP Clavicle Hook Plates The 3.5 mm LCP Clavicle Hook Plate provides fixation for lateral clavicle fractures and for acromioclavicular joint injuries. Lateral clavicle fracture Acromioclavicular joint dislocation Anatomically precontoured The plate facilitates optimal implant placement and surgery to provide an improved outcome. Rounded shaft profile minimizes the risk of soft tissue irritation between the plate and surrounding soft tissue, the acromioclavicular joint and the rotator cuff Undercuts in shaft reduce impairment of blood supply 12º bend in shaft eases implant placement 2 Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

4 Intraoperative choice of hook size 6 sizing templates help in selection of the proper hook size Optimized implant selection Left and right plates 4, 5, 6 and 7 hole plates 3 hook depths: 12 mm, 15 mm and 18 mm Stainless steel and titanium Locking compression plate (LCP) Locking screws provide ability to create a fixed-angle construct while utilizing familiar AO plating techniques Reduced impairment of periosteal blood supply due to the limited plate contact Fixed-angle construct provides advantages in osteopenic bone or multifragmentary fractures where traditional screw purchase is compromised Smooth hook design and posterior hook offset 3 different hook depths 12 mm, 15 mm and 18 mm Combi hole Intraoperative choice between compression and angular stable locking With standard screws: interfragment or dynamic-axial compression With locking screws: stable plate-screw connection without loss of reduction, regardless of plate modeling Synthes 3

5 AO Principles In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation. 1 These principles, as applied to the 3.5 mm LCP clavicle hook plate, are: Anatomic reduction Fixation of lateral clavicle fractures and dislocations with the anatomically precontoured 3.5 mm LCP clavicle hook plate allows anatomic reduction. Stable fixation The 3.5 mm LCP clavicle hook plate is available in four lengths and three hook sizes for optimal sizing and screw positioning for each patient. The 12 bend in the shaft eases implant placement. Preservation of blood supply The LCP concept and the limited-contact undercuts on the shaft of the 3.5 mm LCP clavicle hook plate allow preservation of the blood supply through minimal bone-to-plate contact. The rounded shaft profile, smooth hook design and posterior hook offset minimize the risk of impingement between the plate and surrounding soft tissue, the acromioclavicular joint, and the rotator cuff. Early, active mobilization The 3.5 mm LCP clavicle hook plate, combined with AO technique, provides stable fracture fixation with minimal trauma to vascular supplies. This helps create an improved environment for bone healing, accelerating the patient s return to previous mobility and function. 1. M.E. Müller, M. Allgöwer, R. Schneider, and H. Willenegger. Manual of Internal Fixation, 3rd Edition. Berlin: Springer-Verlag, Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

6 Indications Fixation of lateral clavicle fractures and dislocations of the acromioclavicular joint. Synthes 5

7 Lateral Clavicle Fractures 1 Position the patient Required set Small Fragment LCP Instrument and Implant or Set, with self-tapping screws Small Fragment LCP Instrument and Titanium Implant Set, with self-tapping screws Place the patient in the beach-chair position and tilt the head away from the affected side. Use a sandbag under the thoracic spine to allow the scapula to fall backward. This aids in realignment and reduction of the fracture and assists regaining length. Excessive extension of the neck should be avoided. Note: For information on fixation principles using conventional and locked plating techniques, please refer to the Small Fragment Locking Compression Plate (LCP) Technique Guide. 6 Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

8 2 Approach If image intensification is to be used, determine that access for the C-arm is sufficient for the anteroposterior and cephalic tilt views. Through either a superior or transacromial incision, expose the deltotrapezial fascia. Take care to avoid injury to the lateral supraclavicular nerves. 3 Reduce the fracture and provide temporary fixation Perform temporary fixation of the fracture with Kirschner wires or pointed reduction forceps. Identify the posterior aspect of the acromioclavicular joint capsule. Perform a 5 mm detachment of the extracapsular fibers of the trapezius from the medial border of the acromion, to allow passage of the hook of the plate under the acromion. Synthes 7

9 Lateral Clavicle Fractures continued 4 Determine hook size and plate length Instruments Sizing Template for LCP Clavicle Hook Plate, 12 mm hook depth, left Sizing Template for LCP Clavicle Hook Plate, 12 mm hook depth, right Sizing Template for LCP Clavicle Hook Plate, 15 mm hook depth, left Sizing Template for LCP Clavicle Hook Plate, 15 mm hook depth, right Sizing Template for LCP Clavicle Hook Plate, 18 mm hook depth, left Sizing Template for LCP Clavicle Hook Plate, 18 mm hook depth, right Sizing templates aid in determining the appropriate hook size. To determine hook size, start by passing the 12 mm hook sizing template under the acromion. Place the shaft of the sizing template onto the superior aspect of the clavicle. If it is difficult to lower the shaft onto the reduced clavicle, try the 15 mm hook template or the 18 mm hook template. After determining the correct size, choose the appropriate implant. Once the plate shaft is placed on the clavicle, the end of the hook should be in contact with the underside of the acromion. Confirm that the correct anatomic alignment of the clavicle and acromion has been restored without impinging on the rotator cuff. Use the C-arm to verify that full shoulder motion, particularly in abduction and external rotation, can be achieved without the hook impinging on the humeral head. The plate length must be appropriate for fixation on the medial side of the fracture. Check plate positioning with AP and axial C-arm views. Note: Do not bend or implant the sizing templates. 8 Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

10 5 Adapt plate to the patient s anatomy (optional) Optional instruments Bending Iron, for 2.7 mm and 3.5 mm plates and Bending Pliers, for 2.7 mm and 3.5 mm plates Important: Since the plate shaft is anatomically precontoured (12 ), bending or twisting of the plate is not generally necessary, but may be needed in some cases. Contour the plate using the appropriate bending instruments. The Combi holes should not be deformed excessively during bending, as this may interfere with the insertion of locking screws. If possible, bend the plate between the Combi holes. Notes: Do not bend or twist the shaft between the holes more than 20. Do not bend the hook more than 10. Do not bend the plate and hook back and forth. Take care to avoid scratching the plate surface. Synthes 9

11 Lateral Clavicle Fractures continued 6 Fix the plate temporarily Instruments mm Kirschner Wire with Thread mm Drill Sleeve mm Wire Sleeve Position the implant and confirm the correct plate position under the image intensifier, using a K-wire for temporary fixation. Drill the K-wire through the drill sleeve in the distal hole to fix the distal part of the plate. By aligning the medial and lateral fracture fragments with the plate using reduction forceps, indirect reduction and definitive fixation can be performed. 10 Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

12 7 Screw insertion Instruments mm Drill Bit, quick coupling, gold, 110 mm mm Drill Bit, quick coupling, 110 mm Handle, with quick coupling, small Small Hexagonal Screwdriver with Holding Sleeve or Small Hexagonal Screwdriver Shaft Depth Gauge, for 2.7 mm and smaller screws mm Universal Drill Guide Determine whether cortex screws, locking screws, or a combination of both will be used. Note: When treating lateral clavicle fractures, it is recommended to begin fixation in the most lateral hole with a 3.5 mm locking screw or 3.5 mm cortex screw. Fixation with 3.5 mm cortex screws Use the 2.5 mm drill bit through the 3.5 mm drill guide to drill for the threaded hole and the 3.5 mm drill bit to drill for the gliding hole. Determine the required length of the cortex screw with the depth gauge. Insert the self-tapping 3.5 mm cortex screw using the small hexagonal screwdriver shaft connected to a power tool, or use the small hexagonal screwdriver with holding sleeve. Synthes 11

13 Lateral Clavicle Fractures continued 7 Screw insertion continued Instruments mm Drill Bit, quick coupling, 165 mm Handle, with quick coupling, small mm Threaded Drill Guide StarDrive Screwdriver Shaft, quick coupling, T Depth Gauge, for 2.7 mm and small screws Torque Limiting Attachment, 1.5 Nm Fixation with 3.5 mm locking screws Carefully screw the 2.8 mm threaded drill guide into a threaded hole of the plate. Use a 2.8 mm drill bit to predrill the screw hole through both cortices. Use the depth gauge to check the length of screw. Insert the locking screw using the StarDrive screwdriver shaft manually, or under power with the torque limiting attachment (TLA). When using power, reduce speed when tightening the head of the screw into the plate, and insert until a click is heard. Repeat the procedure until all predetermined holes are used. Perform a final check to confirm all screws are locked. It is recommended that final tightening is done manually. Notes: Always use a TLA when using power to fully insert screws. Do not mix titanium and stainless steel implants. To ensure a stable fixation of the implant, use at least two screws in the medial part of the plate. One or two screws can be used to fix the lateral fragments. 12 Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

14 Dislocation of the Acromioclavicular Joint Required set Small Fragment LCP Instrument and Implant Set, with self-tapping screws or Small Fragment LCP Instrument and Titanium Implant Set, with self-tapping screws 1 Position the patient Place the patient in the beach-chair position and tilt the head away from the affected side. Use a sandbag under the thoracic spine to allow the scapula to fall backward. This aids in realignment and reduction of the fracture and assists regaining length. Excessive extension of the neck should be avoided. Note: For information on fixation principles using conventional and locked plating techniques, please refer to the Small Fragment Locking Compression Plate (LCP) Technique Guide. Synthes 13

15 Dislocation of the Acromioclavicular Joint continued 2 Approach If image intensification is to be used, determine that access for the C-arm is sufficient for the anteroposterior and cephalic tilt views. Through either a superior or transacromial incision, expose the deltotrapezial fascia. Take care to avoid injury to the lateral supraclavicular nerves. 3 Reduce the dislocation and provide temporary fixation Elevate the arm and scapula toward the clavicle. Reduce the acromion to the clavicle in the horizontal and vertical planes. Temporary fixation may be achieved by a transacromial K-wire passed into the distal clavicle. Identify the posterior aspect of the acromioclavicular joint capsule. Perform a 5 mm detachment of the extracapsular fibers of the trapezius from the medial border of the acromion, to allow passage of the hook of the plate under the acromion. 14 Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

16 4 Determine hook size and plate length Instruments Sizing Template for LCP Clavicle Hook Plate, 12 mm hook depth, left Sizing Template for LCP Clavicle Hook Plate, 12 mm hook depth, right Sizing Template for LCP Clavicle Hook Plate, 15 mm hook depth, left Sizing Template for LCP Clavicle Hook Plate, 15 mm hook depth, right Sizing Template for LCP Clavicle Hook Plate, 18 mm hook depth, left Sizing Template for LCP Clavicle Hook Plate, 18 mm hook depth, right Sizing templates aid in determining the appropriate hook size. To determine hook size, start by passing the 12 mm hook sizing template under the acromion. Place the shaft of the sizing template onto the superior aspect of the clavicle. If it is difficult to lower the shaft onto the reduced clavicle, try the 15 mm hook template or the 18 mm hook template. After determining the correct size, choose the appropriate implant. Once the plate shaft is placed on the clavicle, the end of the hook should be in contact with the underside of the acromion. Confirm that the correct anatomic alignment of the clavicle and acromion has been restored without impinging on the rotator cuff. Use the C-arm to verify that full shoulder motion, particularly in abduction and external rotation, can be achieved without the hook impinging on the humeral head. The plate length must be appropriate for fixation on the medial side of the fracture. Check plate positioning with AP and axial C-arm views. Note: Do not bend or implant the sizing templates. Synthes 15

17 Dislocation of the Acromioclavicular Joint continued 5 Adapt plate to the patient s anatomy (optional) Optional instruments Bending Iron, for 2.7 mm and 3.5 mm plates and Bending Pliers, for 2.7 mm and 3.5 mm plates Important: Since the plate shaft is anatomically precontoured (12 ), bending or twisting of the plate is not generally necessary, but may be needed in some cases. Contour the plate using the appropriate bending instruments. The Combi holes should not be deformed excessively during bending, as this may interfere with the insertion of locking screws. If possible, bend the plate between the Combi holes. Notes: Do not bend or twist the shaft between the holes more than 20. Do not bend the hook more than 10. Do not bend the plate and hook back and forth. Take care to avoid scratching the plate surface. 16 Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

18 6 Fix the plate temporarily Instruments mm Kirschner Wire with Thread mm Drill Sleeve mm Wire Sleeve Position the implant and confirm the correct plate position under the image intensifier, using a K-wire for temporary fixation. Drill the K-wire through the wire sleeve in the distal hole to fix the distal part of the plate. Synthes 17

19 Dislocation of the Acromioclavicular Joint continued 7 Screw insertion Instruments mm Drill Bit, quick coupling, gold, 110 mm mm Drill Bit, quick coupling, 110 mm Handle, with quick coupling, small Small Hexagonal Screwdriver with Holding Sleeve or Small Hexagonal Screwdriver Shaft Depth Gauge, for 2.7 mm and smaller screws mm Universal Drill Guide Determine whether cortex screws, locking screws, or a combination of both will be used. Fixation with 3.5 mm cortex screws Use the 2.5 mm drill bit through the 3.5 mm drill guide to drill for the threaded hole and the 3.5 mm drill bit to drill for the gliding hole. Determine the required length of the cortex screw with the depth gauge. Insert the self-tapping 3.5 mm cortex screw using the small hexagonal screwdriver shaft connected to a power tool, or use the small hexagonal screwdriver with holding sleeve. 18 Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

20 Instruments mm Drill Bit, quick coupling, 165 mm Handle, with quick coupling, small mm Threaded Drill Guide StarDrive Screwdriver Shaft, quick coupling, T Depth Gauge, for 2.7 mm and small screws Torque Limiting Attachment, 1.5 Nm Fixation with 3.5 mm locking screws Carefully screw the 2.8 mm threaded drill guide into a threaded hole of the plate. Use a 2.8 mm drill bit to predrill the screw hole through both cortices. Use the depth gauge to check the length of screw. Insert the locking screw using the StarDrive screwdriver shaft manually, or under power with the torque limiting attachment (TLA). When using power, reduce speed when tightening the head of the screw into the plate, and insert until a click is heard. Repeat the procedure until all predetermined shaft holes are used. Perform a final check to confirm all screws are locked. It is recommended that final tightening is done manually. Notes: Always use a TLA when using power to fully insert screws. Do not mix titanium and stainless steel implants. To ensure a stable fixation of the implant, use at least two screws in the medial part of the plate. One or two screws can be used to fix the lateral fragments. Synthes 19

21 Implant Removal Required instruments Handle, with quick coupling, small Small Hexagonal Screwdriver Shaft StarDrive Screwdriver Shaft, T15, quick coupling Caution: It is recommended that the 3.5 mm LCP clavicle hook plate is removed after healing to prevent potential irritation of the acromion or impinging on the rotator cuff. Implant removal is usually done three months after implantation. To remove the implants, unlock all locking screws before removing them completely. The plate may otherwise rotate while the last screw is being removed, causing soft tissue damage. 20 Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

22 Implants 3.5 mm LCP Clavicle Hook Plates Available in: 4 lengths 3 hook sizes Left and right versions Stainless steel and titanium Sterile packed Stainless Length* Hook depth Steel Titanium (mm) (mm) S S 4 holes, right S S 4 holes, left S S 4 holes, right S S 4 holes, left S S 4 holes, right S S 4 holes, left S S 5 holes, right S S 5 holes, left S S 5 holes, right S S 5 holes, left S S 5 holes, right S S 5 holes, left S S 6 holes, right S S 6 holes, left S S 6 holes, right S S 6 holes, left S S 7 holes, right S S 7 holes, left S S 7 holes, right S S 7 holes, left mm Locking Screws, self tapping, with StarDrive recess mm 60 mm mm Cortex Screws, self-tapping mm 50 mm *Hook length of 26 mm is included in full length measurement Note: 3.5 mm locking screws are available in 316L stainless steel and titanium alloy (Ti-6Al-7Nb) Synthes 21

23 3.5 mm LCP Clavicle Hook Templates and Graphic Case Set ( ) Graphic Case mm LCP Clavicle Hook Plate Graphic Case Instruments Sizing Templates for LCP Clavicle Hook Plate mm, left mm, right mm, left mm, right mm, left mm, right Required Set Small Fragment LCP Instrument and Implant Set, with self-tapping screws or Small Fragment LCP Instrument and Titanium Implant Set, with self-tapping screws Note: For additional information, please refer to package insert. 22 Synthes 3.5 mm LCP Clavicle Hook Plates Technique Guide

24 Synthes (USA) 1302 Wrights Lane East West Chester, PA Telephone: (610) To order: (800) Fax: (610) Synthes (Canada) Ltd Meadowpine Boulevard Mississauga, Ontario L5N 6P9 Telephone: (905) To order: (800) Fax: (905) Synthes, Inc. or its affiliates. All rights reserved. Combi, LCP and Synthes are trademarks of Synthes, Inc. or its affiliates. Printed in U.S.A. 4/09 J7244-C

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