Zimmer Zimmer Herbert. Surgical Technique

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1 1 Zimmer Zimmer Herbert Bone Herbert Screw and Zimmer Cannulated Herbert Mini Bone Bone Screw Screw Surgical Technique

2 2 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw Table of Contents Indications for Use... 3 Instrumentation... 4 Herbert Bone Screws Surgical Techniques: Huene Alignment Guide Technique...4 Calibration Check...4 Straight Blade Apply Huene Alignment Guide Check Alignment Drill the Pilot Hole Drill the Main Hole Tap Read Calibration Insert Screw...7 Open Procedure for Free-Hand Guide Apply Free-Hand Guide Temporary K-Wrie Fixation Drill the Pilot Hole Drill the Main Hole Tap Insert Screw...10 Herbert Mini Bone Screw Surgical Technique: Open Procedure with Free-Hand Guide Apply Free-Hand Guide Drill the Pilot Hole Drill the Main Hole Tap Select the Appropriate Screw Insert Screw...13 Technique Variations Cortical Bone Fixation Ordering Information... 15

3 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 3 Indications for Use The Herbert Mini Bone Screw (2.5mm diameter, non-cannulated) and the Herbert Bone Screw (3.0mm diameter, non-cannulated) are indicated for fixation of intra-articular and extra-articular fractures, avulsions, non-union, and osteotomies of small bones and small bone fragments; as well as arthrodeses of small joints.

4 4 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw Instrumentation Herbert Instruments Huene Alignment Guide For use with the Herbert Bone Screw (3.0mm) Whenever possible, the Herbert Bone Screw is inserted through the Huene Alignment Guide (Figure 1). When the Alignment Guide cannot be applied, refer to page 8 for the Free-Hand Technique. This Alignment Guide locks the two bone fragments together and ensures accurate positioning of the screw. The barrel of the Alignment Guide is designed to precisely guide the instrumentation and clamps onto the near fragment of the bone. The blade hooks around the far bone fragments and has a small point to lock it into place. Thumb pressure is then used to tighten the Alignment Guide and compress the two bone fragments together. Once it has been satisfactorily applied, the Alignment Guide aligns the instruments and ensures accurate placement of the Herbert Screw within the bone. Calibration Check The calibration of the Huene Alignment Guide should be checked periodically as it is possible for the blade to become distorted. (The Blade is extremely thin at its tip, and it should not be used as a lever.) Assemble the Alignment Guide and insert the long Drill into the barrel. Apply tension to the blade as shown. Check to be sure that the blade tip is centered on the tip of the Drill within a 1 mm diameter range (Figure 2). Set the barrel between 22-30mm and check the calibration with the scale on the case. Incorrect position indicates blade damaged by bending This dimension should not be larger than approximately 2mm clearance Figure 1: Huene Alignment Guide ( ) with curved blade has right & left orientation Straight Blade This may be used when it is possible to apply the Alignment Guide for fixation of bones. Examples of its use have included: Bennett s fracture dislocations of the base of the first metacarpal Radial head fractures Fractures of the trapezium Intercarpal fusions Lock the Blade in the single (upright) position, and carefully hook into the far fragment of the bone after it has been suitably exposed. Align the Alignment Guide and clamp it firmly onto the near fragment of the bone (Figure 3). Carefully check the line and length before drilling. The barrel is calibrated to indicate a screw of the correct length to be buried within the bone. Check that blade and drill tips are within 1-2mm Blade Figure 3: Use of the Alternate Blade ( ) and the Huene Alignment Guide to reduce Bennett s fracture Drill #2 Figure 2: Procedure for checking blade

5 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 5 Herbert Bone Screws Surgical Techniques: Huene Alignment Guide Application 1Apply Huene Alignment Guide Set the blade of the Alignment Guide and firmly tighten the locking screws. Place the hook and barrel of the Alignment Guide perpendicular to the fracture and push the guide onto the bone using firm thumb pressure. 2Check Alignment Visually check the alignment of the Alignment Guide to ensure that the screw will lie in the optimum position. Also, check the reduction of the fracture and make any necessary adjustments. This position of the Alignment Guide can be checked with the image intensifier. Alignment Check with Guide Wire (Optional) Place the Free-Hand Guide Insert Sleeve ( ) into the barrel of the Alignment Guide. Drive a Guide Wire through the Insert Sleeve (Figure 4), to center the guide wire within the Alignment Guide and verify the position by x-ray or image intensifier. Remove the Guide Wire and Insert Sleeve. Straight Free-Hand Guide Free-Hand Blade Guide Insert SLeeve Insert Sleeve Guide Wire Barrel Figure 4: Optional use of the Free-Hand Guide Insert Sleeve and a K-wire to verify correct alignment of the Guide Read Measurement directly from the Alignment Guide 3Drill the Pilot Hole Insert the 2.4mm Pilot Drill ( ) into the barrel of the Alignment Guide. Turn the handle and advance the Drill until it bottoms out (Figure 5). Continue to turn the Drill in a clockwise direction during removal as this will remove bone and facilitate further instrumentation. Pilot Drill Figure 5: Determine the screw length from the calibrations on the Alignment Guide, and drill the pilot hole for the trailing threads

6 6 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 4Drill the Main Hole Insert the 2.0mm Main Drill ( ) into the Alignment Guide. Turn the Drill in a clockwise direction to maximize efficiency in cutting and chip removal. Advance the Drill until it bottoms out (Figure 6). If the bone is hard, withdraw the Drill periodically in a clockwise direction to remove bone fragments. Main Drill 5Tap Figure 6: Drill the main hole for the leading threads, and the shaft of the bone screw Tap the leading screw threads, using Herbert Bone Screw Tap ( ) when performing bicortical fixation. Insert the Tap using a clockwise movement until it bottoms out (Figure 7). Remove the Tap by turning in a counter-clockwise direction. It is essential that the Tap be inserted to the full drill depth in order to achieve the full compressive action of the screw. 6Read Calibration The screw length can be read directly from the calibrations on the Alignment Guide (Figure 7 Inset). This reading is the longest possible screw that should be used. If a shorter screw can be chosen without having threads present across the fracture site, selection of the shorter screw will reduce the risk of penetration. This is the reason for the preoperative calibration check recommended and described on page 4. However, too short a screw selection will result in threads present across the fracture line especially if the fracture is a proximal one. Screw threads across the fracture line can distract the bone fragments and contribute to failure of the device. Tap Read Measurement directly from the Alignment Guide Figure 7: Tap the full depth of the main drill hole for the leading threads

7 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 7 7Insert Screw Select the appropriate length screw and lift it out of the sterilization rack with the Screwdriver (Figure 8). Check the length of the screw against the calibrated scale located in the screw rack. (Packaged bone screws are presterilized.) Insert the screw through the Alignment Guide and turn the Screwdriver ( ) clockwise (Figure 9). As the trailing thread enters the bone, increased resistance will be felt and further reduction at the fracture site will be visible. Remove the Alignment Guide and turn the screw an additional one or two turns. This will apply additional reduction and/or compression at the fracture site and completely bury the screw head. If the screw has been placed in an articular joint, put the joint through a full range of movements to confirm secure fixation and to ensure that the screw has not penetrated. A check with the image intensifier at this stage verifies the position of the screw on the radiograph at the termination of the operative procedure. Figure 8: Lift the Herbert Screw from rack, Screwdriver fully engaged in hexagonal socket Screwdriver Figure 9: Insert the Herbert Bone Screw into the bone through the Alignment Guide

8 8 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw Open Procedure with Free-Hand Guide The technique should be used whenever the Alignment Guide cannot be applied. When using this technique, a Guide Wire should be used to maintain reduction and x-ray may be used to confirm proper position. The Free-Hand Guide and Insert Sleeve may be used both to direct the Guide Wire and also the accessory fixation wires parallel to the intended screw axis. It is imperative that the two fragments are held firmly together during free-hand insertion of the screw. This can usually be achieved by applying manual pressure on the handle of the Guide, and/or using the bone holding forceps as the fracture reduction clamp. 1Apply Free-Hand Guide Following fracture reduction use the Free-Hand Guide ( ) to compress the bone fragments and align the instruments (Figure 10). The Insert Sleeve ( ) can be inserted into the Free-Hand Guide, a Guide Wire may then be passed through the Insert Sleeve to check the exact alignment. Remove the Insert Sleeve. The Free-Hand Depth Gauge is then used in conjunction with the Guide Wire to determine the proper screw length. Insert the Gauge over the primary Guide Wire and into the barrel of the Free-Hand Guide until the tip touches the surface of the bone (Figure 11). Then read the screw length directly from the calibrations on the gauge. This reading is the longest possible screw that should be used. If a shorter screw can be chosen without having threads present across the fracture site, selection of the shorter screw will reduce the risk of penetration. The Guide Wire is then removed. It is imperative that only the wires included with the set are used to perform this procedure. These wires are sized appropriately for the Depth Gauges and the Free-Hand Guide Insert Sleeve. Free-Hand Guide Figure 10: Apply manual pressure to firmly hold anatomic reduction of the fracture fragment Read Measurement Free-Hand Depth Gauge FIgure 11: Optional measurement of the penetration depth of the K-wire (less 2mm). This may be helpful when determining the drill depth or ultimate screw length

9 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 9 Temporary K-Wire Fixation 2Whenever possible, place a second (accessory) wire through one of the alignment holes located on either side of the Free-Hand Guide to further secure the bone fragments (Figure 12). This will prevent any displacement or fragment rotation during the procedure. Use of these guide holes will ensure that the K-wires are parallel. They can accept a stabilization K-wire up to 1.1mm in diameter. 3Drill the Pilot Hole Insert the 2.4mm Pilot Drill ( ) into the barrel of the Free-Hand Guide. Turn the handle and advance the Drill until it bottoms out (Figure 13). This will remove a small amount of bone from the cortical surface and facilitate further instrumentation. If drilling into very dense cortical bone, use the Herbert 3.2mm Power Drill. Accessory Wire Guide Wire Free-Hand Guide Insert Sleeve Figure 12: Optional use of accessory stabilization wires. The Free-Hand Insert Sleeve may be used to insert a central K-wire and verify correct alignment of the Guide with image intensification or x-ray evaluation Pilot Drill Figure 13: Drill the proximal cortex for the trailing threads with the Pilot Drill Drill the Main Hole 4Insert the 2.0mm Main Drill ( ) into the Guide and advance it into the appropriate depth. Withdraw the Drill in a clockwise direction to maximize efficiency in cutting and chip removal. If the bone is hard, withdraw the Drill periodically to remove bone fragments. If a Guide Wire has not been used, the length of screw can be determined by reading directly off the calibrated scale the depth to which the Drill has been inserted (Figure 14). Read Measurement Main Drill Figure 14: Drill the main hole for the core diameter of the leading threads and the shaft

10 10 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw Tap 5Tap the leading screw threads. Insert the Tap ( ) using a clockwise turning movement until the appropriate depth is read on the calibrated barrel (Figure 15). Remove the Tap by turning in a counter-clockwise direction. It is essential that the Tap be inserted to the full drill depth, otherwise the compressive action of the screw may be lost. Read Measurement Tap Insert Screw 6Select the appropriate length screw and lift it out of the sterilization rack with the Screwdriver ( ). Check the length of the screw against the calibrated scale adjacent to the screw rack. (Packaged bone screws are presterilized.) Insert the screw and Screwdriver through the Free-Hand Guide, turning the Screwdriver clockwise (Figure 16). As the trailing thread enters the bone, increased resistance will be felt and further reduction at the fracture site will be visible. Remove the Free-Hand Guide. To apply additional reduction and/or compression at the fracture site, or to completely bury the screw head, rotate the screw one or more revolutions with the Screwdriver. Figure 15: Tap the full depth of the main drill hole for the leading thread form Screwdriver Figure 16: Implant the Herbert Bone Screw into the distal radius through the Free-Hand Guide

11 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 11 Herbert Mini Bone Screw Surgical Technique: Open Procedure with Free-Hand Guide The free-hand technique must be used with the Herbert Mini Bone Screw. The Free-Hand Guide is used to direct the instruments and screw. It is imperative that the two fragments are pre-compressed firmly together during free-hand insertion of the screw. This can usually be achieved by applying manual pressure on the handle of the Guide only using the Bone-Holding Forceps as a fracture reduction clamp. Use temporary K-wires to maintain the reduction. 1Apply Free-Hand Guide Once the fracture is reduced, apply the Free-Hand Guide ( ) to the bone (Figure 17). Whenever possible, place one or two accessory wires through the alignment holes on the Free-Hand Guide to further secure the bone fragments. This will prevent any displacement or fragment rotation during the procedure. Use of these guide holes will ensure that the K-wires are parallel. They can accept a stabilization K-wire up to 1.1mm in diameter. Free-Hand Guide Accessory Wire 2Drill the Pilot Hole Insert the 2.3mm Pilot Drill ( ) into the barrel of the Free-Hand Guide. Turn the handle and advance the Drill until it bottoms out (Figure 18). Removing the Drill in a clockwise direction will remove bone fragments and facilitate further instrumentation. Figure 17: Apply manual pressure to firmly hold the anatomic reduction of the fracture fragment. Inset shows holes used to place parallel accessory fixation wires through the Guide Pilot Drill Figure 18: Drill the pilot hole through the proximal cortex

12 12 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 3Drill the Main Hole Read Measurement Insert the 1.5mm Main Drill ( ) into the Free-Hand Guide to the appropriate depth as read on the calibrated barrel (Figure 19). Turn the Drill in a clockwise direction to maximize efficiency in cutting and chip removal. If the bone is hard, withdraw the Drill periodically to remove bone fragments. Main Drill 4 Tap Tap the leading screw threads. Insert the Tap ( ) using a clockwise turning movement until the appropriate depth is read on the calibrated barrel (Figure 20). Remove the Tap by turning in a counter-clockwise direction. It is essential that the Tap be inserted to the full drill depth, otherwise the compressive action of the screw may be lost. Tap Figure 20: Tap the full depth of the Main Drill for the leading threads and the shaft Figure 19: Drill the main hole for the core diameter of the leading threads and the shaft

13 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 13 5Select the Appropriate Screw Select the appropriate length screw, lifting it out of the sterilization rack with the Screwdriver ( ). Note that the calibrated barrel is designed to countersink the screw end(s) 1mm to 2mm below the cortical surfaces. If maximum bicortical fixation is desired, select a bone screw 2mm longer than the calibration read when drilling. Check the length of the screw against the calibrated scale adjacent to the screw rack. (Packed bone screws are presterilized.) 6 Insert Screw Insert the screw and Screwdriver through the Free-Hand Guide (Figure 21), turning the Screwdriver clockwise. As the trailing thread enters the bone, increased resistance will be felt and further reduction at the fracture site will be visible. Remove the Free-Hand Guide. Screwdriver To apply additional reduction and/or compression at the fracture site or to completely bury the screw head, rotate the screw one or more revolutions with the Screwdriver. Figure 21: Implant the Herbert Mini Bone Screw through the Free-Hand Guide (Bennett s Fracture fixation)

14 14 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw Technique Variations Cortical Bone Fixation (For the Herbert and Herbert Mini Bone Screws) The Herbert Bone Screw System was designed specifically for fixation of cancellous bone fragments and its use in cortical bone is not normally recommended. However, on certain occasions it may be desirable to insert the screw through a hard cortical surface, e.g.: Interphalangeal fusion of digits Fixation of oblique metatarsal osteotomies Fixation of very small or delicate bones 1. In very small or delicate bones, cortical bone may provide better fixation than cancellous. The resistance to pull-out and the capability of applying and maintaining rigid fixation is greater. It is desirable to capture cortical bone at both ends of the bone screw to optimize the reductive capabilities of these Herbert Mini Bone Screws. The surgeon should drill and tap for the leading threads through the opposite cortex. This will prevent the bone screw from accidentally stripping the cancellous thread purchase within the inner cortical wall. (Stripping the threads with excessive torque could result in distraction of the fracture fragment which has been previously reduced.) However, it is sometimes more difficult to fully seat the self-reducing and self-compressing Herbert and Herbert Mini Bone Screws bicortically in this type of bone. When using the Herbert Mini Bone Screws, this difficulty occurs when the cortices on both sides are greater than 5mm in thickness. 2. For use of the Herbert Bone Screw in dense cortical bone, use the 3.2mm Drill ( ) with power drill in place of the 2.4mm Pilot Drill. This facilitates entry of the trailing thread and prevents it from splitting the cortex. For use of the Herbert Mini Screw in dense cortical bone, the 2mm Drill ( ) should be used in place of the 1.5mm Mini Main Drill. Drill completely through both cortices. Figure 22: Showing correct method of drilling through cortical bone (power may be preferred) with the Free-Hand Guide located in a hollow created in the cortex with a rongeur or large drill Note: These alternative Drills do not fit into the Mini System s Free-Hand Guide. 3. Tap completely through both cortices before inserting the screw. If the bone is too hard for the points of the drill guide to engage, gouge out a small hollow to assist in location of the guide (Figure 22). Then drill and tap the medulla in the normal fashion. Take care to ensure that the leading end of the screw does not abut the opposite cortex. CAUTION: If complete reduction is attained prior to insertion of the bone screw, it is possible to generate torques which will cause failure of the tip of the Screwdriver prior to fully seating the bone screw. To avoid instrument breakage, one of two steps must be taken: A. Accept that the trailing threads of the bone screw will not fully seat. Closely monitor the hex tip of the Screwdriver. Be sure to stop torqueing the handle when you feel the hex tip begin to slip or deform. B. Counterbore the proximal cortex with the Herbert 3.2mm diameter Power Pilot Drill for a depth of 2mm to 3mm. NOTE: When attempting to maximize cortical fixation on both ends of the bone screw, a screw 2mm longer than indicated by the guide calibration should then be used to ensure that the leading threads are purchased in the cortical bone.

15 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 15 Ordering Information Implants Herbert Bone Screw System Prod. No. Description Quantity Herbert Bone Screw, 3.0mm Dia X 12mm Herbert Bone Screw, 3.0mm Dia X 14mm Herbert Bone Screw, 3.0mm Dia X 16mm Herbert Bone Screw, 3.0mm Dia X 18mm Herbert Bone Screw, 3.0mm Dia X 20mm Herbert Bone Screw, 3.0mm Dia X 22mm Herbert Bone Screw, 3.0mm Dia X 24mm Herbert Bone Screw, 3.0mm Dia X 26mm Herbert Bone Screw, 3.0mm Dia X 28mm Herbert Bone Screw, 3.0mm Dia X 30mm 2 Herbert Mini Bone Screw System Prod. No. Description Herbert Mini Bone Screw 2.5mm Dia X 10mm Herbert Mini Bone Screw 2.5mm Dia X 12mm Herbert Mini Bone Screw 2.5mm Dia X 14mm Herbert Mini Bone Screw 2.5mm Dia X 16mm Herbert Mini Bone Screw 2.5mm Dia X 18mm Herbert Mini Bone Screw 2.5mm Dia X 20mm Herbert Mini Bone Screw 2.5mm Dia X 22mm Herbert Mini Bone Screw 2.5mm Dia X 24mm 2

16 16 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw Instruments Herbert Mini Bone Screw Instruments Prod. No. Description Quantity Herbert Mini Bone Screw Pilot Drill 2.3mm Diameter Herbert Mini Bone Screw Main Drill 1.5mm Diameter Herbert Mini Bone Screw Tap Herbert Mini Bone Screw Screwdriver Herbert Mini Bone Screw Trephine Herbert Mini Bone Screw Free-Hand Guide Herbert Mini Bone Screw Screw/Instrument Case Herbert Bone Screw System Drill 2.0 mm Dia. 1 Herbert Bone Screw Instruments Prod. No. Description Quantity Herbert/Whipple Bone Screw System Free-Hand Guide Insert Sleeve Herbert/Whipple Bone Screw System Free-Hand Depth Gauge Herbert Bone Screw Instrumentation Pilot Drill 2.4mm Gauge Herbert Bone Screw Instrumentation Main Drill 2.0mm Dia Herbert Bone Screw Instrumentation Tap Herbert Bone Screw Instrumentation Screwdriver Herbert Bone Screw Instrumentation Elevator Herbert Bone Screw Instrumentation Trephine Herbert Bone Screw Instrumentation Huene Alignment Guide* Herbert Bone Screw Instrumentation Straight Blade (For Huene Alignment Guide)* Replacement Barrel 80mm Length (Huene Alignment Guide) Herbert Bone Screw System Drill 3.2mm Dia. (Optional) Herbert/Whipple Bone Screw System Free-Hand Guide Base Herbert/Whipple Bone Screw System with Huene Alignment Guide Screw/Instrument Case Herbert Bone Screw System General Instrument Case 1 * The Huene Alignment Guide ( ) comes with the Scaphoid Left Right Blade ( ). This blade is used with the Herbert/Whipple Screws. The Straight Blade ( ) is to be used with Herbert Bone Screws.

17 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 17 Instruments General Herbert/Herbert Mini Bone Screw Instruments Prod. No. Description Quantity Flat Depth Gauge Guide Wire Diameter.038 in (.97mm) Length 5.9 in. (15cm) Co-Cr Alloy Herbert Bone Screw Instrumentation Dissector Herbert Bone Screw Instrumentation Double-Ended Retractor Herbert Bone Screw Hand Rasp Herbert/Whipple Bone Screw System, Small Retractor Quick-Connect Handle Sharp Hook Key Periosteal Elevator 1/4 in. (6.4mm) Blade Width Heiss Soft Tissue Retractor Hohmann Retractor Small 6mm Width Hohmann Retractor Small 8mm Width Reduction Forceps Reduction Forceps w/points, Rachet, 130mm Sharp Hook 1

18 18 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw

19 Zimmer Herbert Bone Screw and Zimmer Herbert Mini Bone Screw 19

20 DISCLAIMER: This documentation 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 advise in whole or in part. Please refer to the package inserts for important product information, including, but not limited to, indications, contraindications, warnings, precautions, and adverse effects. Contact your Zimmer representative or visit us at The CE mark is valid only if it is also printed on the product label Rev Zimmer, Inc.

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