Foot Surgery Innovation in Forefoot Reconstruction BAROUK SCREW FRS SCREW TWISTOFF SCREW MEMORY STAPLE VARISATION STAPLE

Transcription

1 Foot Surgery Innovation in Forefoot Reconstruction BAROUK SCREW FRS SCREW TWISTOFF SCREW MEMORY STAPLE VARISATION STAPLE 3

2 Contents BAROUK Screw 2 FRS Screw 3 TWISTOFF Screw 4 MEMORY 12 and 20 Staples 5 VARISATION Staple 6 BAROUK Screw Surgical Technique 7 FRS Screw Surgical Technique 12 TWISTOFF Screw Surgical Technique 17 MEMORY 12 and 20 Surgical Technique 19 VARISATION Surgical Technique 28 Ordering Information 29

3 Designed by surgeons for surgeons, the DePuy Forefoot range offers specialist solutions for arthrodesis and osteotomy of the forefoot. Indications include: Hallux Valgus Osteotomies Arthrodesis Osteosynthesis 1

4 BAROUK Screw Developed by Dr. L. S. Barouk over 15 years ago the BAROUK screw has a long history of use with over 59,000 cases per year. 1 This easy to use fixation device has been designed for use in Scarf osteotomy of the first metatarsal and can be used in both cortical and cancellous bone. The BAROUK screw has been described as relatively simple and free from complications. 3 Early functional recovery and reliable fixation has encouraged the use of the BAROUK screw in a variety of other indications. Indications: Fixation of fracture or osteotomies of the foot such as: - Scarf osteotomy of the first matatarsal - Hallux valgus correction - Osteosyntheses of small bones / fragments Threaded head can be countersunk, eliminating the need for later removal and reducing the risk of skin breakdown and subsequent infection 2 Self-tapping cannulated screw for easy insertion The longer pitch of the distal threads combined with shorter threads in the proximal section ensures optimal compression in both cortical and cancellous bone across the osteotomy site mm diameter K-wire facilitates easy and accurate insertion 2

5 FRS Screw The FRS screw is the result of a collaboration between Dr. L. S. Barouk and Dr. L. S. Weil. The FRS screw is the evolution of the BAROUK screw, designed specifically for the dedicated foot and ankle specialist, it builds on the features that have made the BAROUK screw the number one forefoot screw in the UK. Indications: Fixation of fracture or osteotomies of the foot such as: - Scarf osteotomy of the first matatarsal - Hallux valgus correction - Osteosyntheses of small bones / fragments Headless - Inserted below the bone surface to minimise soft tissue irritation Longer 4.5 mm head increases stability and fixation Titanium alloy - Increases implant strength and biocompatibility Self-tapping cannulated screw for easy insertion Screw designed specifically for digital shaft osteotomies Dual thread design - Cortical (proximal portion) and cancellous (distal portion) utilised to create compression across osteotomy site as the screw is inserted Cannulated - Allows for accurate screw length measurement and the ease of guided insertion 3

6 TWISTOFF Screw The TWISTOFF screw is designed for use in the Weil osteotomy of the lateral metatarsals. The TWISTOFF screw can address static problems encountered in the last four rays, while allowing retention of metatarsals heads. Indications: Osteotomies of the lesser metatarsal such as a Weil osteotomy Twist-off feature allows for a clean break between shank and screw, as screw head engages bone Titanium alloy construction for increased implant strength and biocompatibility Design enables tightening or removal with a dedicated screwdriver One-piece design that supports direct connection to a drill or large diameter pin driver Compression capabilities with a threadfree segment that achieves automatic compression at the osteotomy site Self-drilling and self-tapping with a tapered flat head to ensure cortical drilling Size configuration: 2 mm diameter, mm long 4

7 MEMORY 12 and 20 Staples The MEMORY staple is a compressive construct that provides initial stability to facilitate functional recovery. The staple has built-in elasticity which provides dynamic compression, even when secondary osteoporotic resorption occurs at fragment ends. Indications for the 12 mm Memory Staple: Osteotomies of the first phalanx of the foot Indications for the 20 mm Memory Staple: Arthrodesis of the first metatarsal phalangeal joint Permanent compression gives the construct immediate and lasting stability Construct that increases stability: both legs produce compression in the same plane Bicortical staple for even compression without deviation of the bone Cold staple for controlled compression Design and mechanical characteristics ensure continuous distribution of forces: reliable and controlled compression 12 mm or 20 mm interaxis distance to keep the legs at an optimum distance from the osteotomy line 5

8 VARISATION Staple Designed to provide fixation following extra-articular osteotomies of the forefoot including osteotomy of the first phalanx. Indications: Extra-articular osteotomies of the forefoot Sizes include 1 mm diameter and 8 and 10 mm wide Stainless steel construction Dedicated instrumentation designed to ease implant insertion Straight and oblique designs 6

9 BAROUK Screw Surgical Technique Scarf Osteotomy Lateral Release Using the intermetatarsal approach, sesamoid bones are dissected free by making a longitudinal incision between the lateral sesamoid and the retained lateral collateral ligament (Figure 1). This incision is extended anteriorly and the abductor hallucis is released from its phalangeal insertion. Thus, following Scarf osteotomy, the metatarsal head will position itself above sesamoid bones (Figure 2). Figure 1 Figure 2 Approach and Exostosectomy Proximal midplantar dissection provides exposure of the midplantar margin and the plantar surface, which are fundamental references for the longitudinal cut. Longitudinal resection is performed in the alignment of the medial aspect of the metatarsal shaft. Care should be taken to avoid damage to the medial plantar artery (Figure 3). Figure 3 Scarf cuts - Longitudinal cut On the medial aspect, it should parallel the proximal medial border, and therefore be oblique and directed anteriorly and dorsally. It reaches the head 3 mm under its superior margin. Then the oblique longitudinal cut parallels the plantar surface, runs laterally, and ends close to the inferior margin. This preserves the lateral aspect of the dorsal fragment which constitutes a sagittal beam, and allows major lateral displacements as well as metatarsal head lowering (Figure 4). Figure 4 7

10 BAROUK Screw Surgical Technique Scarf Osteotomy Scarf Cuts - Transversal cuts Transverse cuts are made at a 60 angle to the longitudinal cut, forming proximal and distal chevrons (Figure 5). This provides better fragment coaptation as well as a larger interfragmental surface area. Having a slight posterior obliquity, they are perpendicular to the second metatarsal (Figure 6). Figure 5 Figure 6 Displacements Among the five displacements allowed by Scarf osteotomy, three are extremely useful and easy to perform: Horizontal displacements, shortening and lowering. 1. Horizontal Displacements 2. Shortening 3. Rotation in the transverse plane 4. Lowering 5. Elevation 8

11 Oblique Insertion of the Screw A clamp has been specifically designed to hold fragments with a variable lateral displacement. Initial placement of two 1.0 mm K-wires ensures precise and atraumatic positioning of the screw (Figure 7). Figure 7 The Scarf drill is inserted over the K-wires (straight or tapered step). The drill features a countersink for the screw head (Figure 8). A screw length gauge is used to determine the appropriate length of the distal screw. This screw will have to be 6 mm less than the measured length to avoid cartilage penetration. The screw head must be completely countersunk. Figure 8 Oblique Insertion of the Screw Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 9

12 Bicortical Proximal Screwing Figure 9 The K-wire should enter the dorsal fragment at some distance from the lateral margin to avoid interference with the sagittal beam (lateral aspect of the dorsal fragment). Penetration of the plantar fragment occurs laterally, close to the inferior margin, where bone is the hardest (Figure 9). Oblique screwing does not adversely affect the holding capacity of the screw or the displacement of fragments. Anteromedial resection is possible because of the lateral position of the distal screw. Medial capsular tightening is performed. It is particularly useful in medium and major displacements. Medial Resection and Capsular Tightening Anteromedial resection is possible because of the lateral position of the distal screw. Medial capsular tightening is performed. It is particularly useful in medium and major displacements (Figure 10). Figure 10 10

13 BAROUK Screw Surgical Technique Other Applications Chevron Osteotomy with BAROUK Screw The BAROUK screw can be used when ever osteosynthesis of cancellous bone is required, particularly in the first metatarsal (distal or proximal end, chevron osteotomy) (Figure 11). Figure 11 Weil Osteotomy with BAROUK Screw The BAROUK screw is used in Weil osteotomy of the middle metatarsals, in cases where a TWISTOFF screw is not sufficient to ensure osteosynthesis, and is generally used in osteotomy of the fifth metatarsal. The BAROUK screw can be a very efficient and atraumatic osteosynthesis device (Figure 12). Figure 12 11

14 FRS Screw Surgical Technique Instruments Reverse Ruler -5 mm Pre-drilling Katsuja Drill Bits a. 1.8 mm diameter b. 2.0 mm diameter Head Relief Drills c. 2.5 mm diameter d. 3.0 mm diameter Depth Gauge Can be used as an alternative to determine the screw lengths. a. 1.8 mm b. 2.0 mm c. 2.5 mm d. 3.0 mm Osteomy Guide Certain surgical indications (chevron or scarf technique) require the use of an osteotomy guide. Place a 0.9 mm wire in position Pivot the guide on the wire Slide the saw blade into the guide to make the cut 12

15 Indications for the FRS Screw First Ray Lateral Ray 1. Scarf osteotomy 2. Distal chevron osteotomy 4. Fixation of basal osteotomy for raising of a middle metatarsal 5. Fixation of Weil osteotomy of the lateral rays to avoid pain associated with screw heads (particularly the fifth ray) 3. Basal osteotomy of metatarsals 13

16 Screw Placement in the Scarf Osteotomy Figure 1a Whether the screw is to be used in osteotomy of the first metatarsal or in basal raising of the lateral metatarsals, or any other indication, the placing technique is identical and based on simple, accurate and atraumatic placement. In the example below screw placement is demonstrated on a Scarf osteotomy. Distal Fixation Figure 1 With the osteotomy line completed, the displacement is fixed using the dedicated forceps and a 0.9 mm K-wire placed distally (Figures 1 and 1a). -5 mm The K-wire is progressively withdrawn until it is just level with the second cortical layer. The measurement is taken using the reverse ruler (Figure 2). Figure 2 Figure 3 The length of the screw must be 5 mm less than the measurement obtained. A drill bit matching the screw diameter selected is used with a K-wire to prepare the screw hole (Figure 3). For 3.0 mm screw placement use the 2.0 mm drill and the 3.0 mm head relief drill. For 2.5 mm screw placement use the 2.0 mm drill and the 2.5 mm head relief drill. For 2.5 mm screw placement on porotic bone only, use the 1.8 mm drill and the 2.5 mm head relief drill. 14

17 Screw Placement in the Scarf Osteotomy The screw is introduced on the K-wire until the head is buried (Figure 4). The K-wire can then be withdrawn. Figure 4 Proximal Screw Placement The proximal screw is introduced in the same way, taking care not to place it in the lateral part of the dorsal aspect of the metatarsal (Figure 5). Since the proximal screw is bicortical the size is determined by taking a direct reading from the rule. A B A B Figure 5 15

18 BRT Osteotomy - Barouk, Rippstein and Toullec 60 0 Basal reconstruction of the lateral metatarsals (BRT) Basal osteotomy (metatarsalgia with no shortening) must conserve plantar cortical bone and show 60 orientation to the perpendicular with respect to the diaphyseal axis. A single saw cut is sufficient to raise the metatarsal by 3 mm (Figure 6). Figure 6 Fixation is generally achieved by introducing a 0.9 mm diameter K-wire. Placing of a 2.5 mm diameter FRS screw is highly adventageous in these narrow diaphyses (Figure 7). Figure 7 Post operative Rehabilitation Protocol Post operative rehabilitation protocol This protocol is the same as that following solid screw fixation of an osteotomy or fracture site. The stable result obtained with the FRS screw is such that early weight bearing and rapid functional rehabilitation are possible. Walking is resumed on the day following surgery, using the post operative shoe to relieve the forefoot. Two weeks later use shoes allowing weight bearing of the whole foot. Foot and toe physiotherapy begins on the day after the operation. 16

19 TWISTOFF Screw Surgical Technique Weil Osteotomies Surgical Approach The procedure is performed using a dorsal approach. Incision is initiated within the intermetatarsal space and extends to the web space. Osteotomy Skin retraction provides exposure of both extensor muscles; an incision is made between these two muscles, extending distally as far as possible. The joint is dislocated by placing the toe in plantar flexion, thus exposing the metatarsal head. Placing one Hohman retractor on each side of the metatarsal will make this manoeuvre much easier. The use of a modified Hinge spreader ensures a safe osteotomy by providing adequate protection. The cut is made horizontal and parallel to the sole. It starts in the cartilage of the head, near the dorsal margin, and should be at least 2.5 cm long. CAUTION: The direction of the cut should be adjusted according to the condition of the forefoot. In case of pes cavus, the cut may be too short and the resection level should therefore be raised. In case of pes planus (or for the fourth and fifth metatarsals), the cut may be too long and the resection level should be lowered. 17

20 TWISTOFF Screw Surgical Technique Weil Osteotomies Displacement In general, displacement is obtained immediately after resection. However, it should be controlled. The appropriate metatarsal formula is: index plus minus (M1 = M2). Then, metatarsal lengths follow a geometrical progression (3 mm - 6 mm - 12 mm). The assistant holds the head against the metatarsal with the forefinger. The placement of a dorsal Banaleck Clamp allows accurate head positioning as desired. Fixation The TWISTOFF self-breaking screw is driven into the bone following an oblique upward direction. When its head abuts against the dorsal cortex, the support snaps off. However, in osteoporotic bone this will have to be done by moving the drill forward. Compression can then be optimised with the use of the dedicated screwdriver. Final step Resection of the peak is the final step of this procedure. Despite shortening, Z-shaped release of extensor muscles is often necessary. 18

21 MEMORY 12 Staple Surgical Technique Osteotomies of the first phalanx of the foot Step 1: Make osteotomy cuts Closing wedge osteotomy to correct Hallux Valgus Interphalangeus. A standard medial based closing wedge osteotomy is performed. The proximal cut is performed first, leaving the lateral cortex intact. When the distal cut is made, the osteotomy is closed with a greenstick manoeuver (Figure 1). Figure 1 For derotation of the proximal phalanx. The osteotomy is made completely through the shaft of the phalanx. This is done either in isolation if no valgus deformity is present or after a closing wedge osteotomy if no valgus correction is desired (Figure 2). Step 2: Place a temporary axial pin A temporary axial pin prevents displacement of the fragments when the staple is introduced. The axial wire should remain just under the dorsal cortex to allow the placement of a MEMORY staple (Figure 3). It is important to maintain dorsal and medial bone contact to allow the osteotomy to heal. Figure 2 Figure 3 19

22 MEMORY 12 Staple Surgical Technique Step 3: Position drill guide The osteotomy should be positioned between the two arms of the drill guide. The distal arm of the drill guide should rest on the medial side of the proximal phalanx. This stage is essential because it ensures the oval part of the staple is correctly applied to the diaphyseal region of the proximal phalanx (Figure 4). Figure 4 Step 4: Insert proximal guide wire With the drill guide in proper position, insert the proximal guide wire to penetrate both the medial and lateral cortices (Figure 5). Remove the drill guide. Figure 5 20

23 MEMORY 12 Staple Surgical Technique Step 5: Position the cannulated drill bit The cannulated drill bit is placed over the guide wire that is already inserted, making it possible to drill the two cortices and prepare for the insertion of the proximal leg of the staple. Leave the cannulated drill bit in position and remove the guide wire (Figure 6). Figure 6 Step 6: Position the drill guide and drill distally with a non-cannulated drill bit The drill guide is put back onto the cannulated drill bit, then the distal hole is drilled using the solid drill bit. Because of the contour of the proximal phalanx, it is advisable to insure that the solid drill bit is parallel to the cannulated drill bit (Figure 7). Figure 7 21

24 MEMORY 12 Staple Surgical Technique Step 7: Select the MEMORY staple size Using standard technique, the depth gauge allows the determination of the length of each arm of the staple. In order to ensure good bicortical purchase, the surgeon should select a staple arm length 1 mm longer than the reading (Figure 8). Figure 8 Step 8: Verify the hole orientation The staple trial is put into position in order to verify the proper orientation of the drill holes. The surgeon has the final opportunity to verify that the toe is in proper position (Figure 9). Figure 9 22

25 MEMORY 12 Staple Surgical Technique Step 9: Remove the MEMORY staple from sterile package Note: Implants must be kept for at least 2 hours before implantation at a maximum temerature of -18 C and made available at the last minute, just before implantation. The surgeon must take care to flatten the eye of the staple and to ensure that the legs are parallel (Figure 10). Figure 10 Step 10: Insert the staple The staple is placed in position and then impacted using the MEMORY arthrodesis impactor (Figure 11). Remove the temporary axial pin. Precautions: The legs of the staple should not be opened wider than 90 degrees because this modifies the mechanical and dynamic properties of the nickel-titanium alloy. Do not touch the staple if it has started to close. The warmth of one s body will cause the staple to close faster. If the staple closes prematurely, discard it. Do not refreeze the staple. Figure 11 Post operative protocol The surgeon should use his or her standard post operative protocol for this type of osteotomy. 23

26 MEMORY 20 Staple Surgical Technique Arthrodesis of the first metatarsal phalangeal joint Step 1: Prepare the metatarsophalangeal joint for fusion A direct approach to the metatarsophalangeal joint is made. Perform metatarsal head and base of proximal phalanx preparation in the usual fashion, ensuring cancellous bone is exposed on both surfaces (Figure 1). Figure 1 Step 2: Insert temporary pin fixation Put the toe in desired position for fusion. Insert temporary fixation. Perform a double pin fixation of the joint. These should be inserted from a dorsomedial position of the construct to avoid collision when the staple is inserted. One pin is inserted in a distal lateral direction from the metatarsal neck. The second pin is inserted in the base of the proximal phalanx in a proximal lateral direction. This stabilises the metatarsophalangeal joint while the staples are inserted (Figure 2). Figure 2 24

27 MEMORY 20 Staple Surgical Technique Step 3: Verify position of the toe The position of the toe is verified by placing a platform against the plantar surface of the foot to simulate the floor (Figure 3). In the sagittal plane, the pulp of the toe should be elevated no more than 4-5 mm from the supporting platform. When the interphalangeal joint is plantar flexed, the pulp should easily contact the supporting surface. The toe should be positioned in a neutral rotation (nail plate parallel to the floor) and parallel to the second toe. 4-5 mm Figure 3 Step 4: Positioning the drill guide The drill guide, used for insertion of the medial staple, is put into position ensuring that it is centered over the arthrodesis (Figure 4). Drill the proximal hole first, penetrating both cortices. The drill bit is left in place and the distal hole is drilled. Figure 4 25

28 MEMORY 20 Staple Surgical Technique Step 5: Select the MEMORY staple size Using standard technique, the depth gauge allows determination of the length of the staple to be used. In order to ensure good bicortical purchase, the surgeon should select a staple length 1 mm longer than the reading (Figure 5). Figure 5 Step 6: Verify the hole orientation The staple trial is put into position in order to verify the proper orientation of the drill holes. The surgeon has the final opportunity to verify that the toe is in proper position (Figure 6). Step 7: Remove the first temporary fixation pin Remove one pin to allow the staple to achieve compression when inserted. Figure 6 Step 8: Remove the staple Note: Implants must be kept for at least 2 hours before implantation at a maximum temerature of -18 C and made available at the last minute, just before implantation. The surgeon must take care to flatten the eye of the staple and to ensure that the legs are parallel (Figure 7). Figure 7 26

29 MEMORY 20 Staple Surgical Technique Step 9: Insert the staple The MEMORY staple is placed in position and then impacted using the impactor. Remove the second pin (Figure 8). Figure 8 Step 10: Position the second staple Using the same procedure, the second staple is put into position at the dorsal surface near the lateral margins of the first metatarsal and the first proximal phalanx. It is positioned slightly proximal to the medial staple (Figure 9). Precautions: Prior to insertion, the legs of the staple should not be opened wider than 90 degrees because this modifies the mechanical and dynamic properties of the nickel-titanium alloy. Do not touch the staple if it has started to close. The warmth of one s body will cause the staple to close faster. If the staple closes prematurely, discard it. Do not refreeze the staple. Figure 9 Post operative protocol The surgeon should use his or her standard post operative protocol for this type of arthrodesis. Figure 10 27

30 VARISATION Surgical Technique Varisation of the First Phalanx The first phalanx of the great toe is exposed through a medial approach. Two cuts are made close to each other using the oscillating saw, leaving the lateral cortex intact. After removal of the medial or medial plantar wedge (where derotation is required) the CAWO (closing abductory wedge osteotomy) is maintained by the assistant. The staple is applied to the bone surface. One single pilot hole is drilled into the distal fragment (1.0 mm K-wire). The use of the special staple holder (for oblique staples) facilitates insertion of the staple with its two legs parallel to the joint line, without any risk of violation of the joint. 28

31 Ordering Information BAROUK Instruments Order Code PF541 PF540 PA720 A4137 Description Banalec Forceps - Left Banalec Forceps - Right Scarf Reduction Clamp Backaus Clamp 2.5 mm BAROUK Screw Order Code A5228 A4504 Description Screwdriver Scarf Scarf Screw Measurer BAROUK Implants 2.5 mm BAROUK Screw Non-Sterile Sterile Description P mm, Length 11.0 mm P mm, Length 12.0 mm P mm, Length 13.0 mm P mm, Length 14.0 mm P mm, Length 16.0 mm P mm, Length 18.0 mm P mm, Length 20.0 mm P mm, Length 22.0 mm 3.0 mm BAROUK Screw 3.0 mm BAROUK Screw Order Code Description A5345 Screwdriver Scarf PA246 Scarf Screw Measurer Instrument Cases Order Code Description Sterile Instrument Case PA242 Non-Sterile 3.0 Instrument Case A4513 Non-Sterile 2.5 Instrument Case Disposables Non-Sterile Sterile Description P mm, Length 10.0 mm P mm, Length 12.0 mm P mm, Length 14.0 mm P mm, Length 16.0 mm P mm, Length 18.0 mm P mm, Length 20.0 mm P mm, Length 22.0 mm P mm, Length 24.0 mm P mm, Length 26.0 mm P mm, Length 28.0 mm P mm, Length 30.0 mm P mm, Length 32.0 mm P mm, Length 34.0 mm Order Code Description mm Cannulated One-step Drill mm Cannulated One-step Drill Oblique mm Short One-step Drill mm K-wire, 70 mm mm Katsuya Drill mm Short One-step Drill mm K-wire, 50 mm mm One-step Drill 29

32 Ordering Information FRS Instruments Order Code A5737 A5733 A5734 A6310 PA720 A4137 Description 1.8 mm Hexagonal Screwdriver Depth Gauge Cutting Guide Reverse Ruler Forceps Instrument Cases Order Code Backaus Forceps Description Sterile FRS Case Sterile Forefoot Case A6362 A6363 A6364 A6365 A6366 Disposables Order Code Non-Sterile Instrumentation Tray Box Non-Sterile Instrumentation Tray Insert Non-Sterile Instrumentation Tray Lid Non-Sterile 2.5 mm Screw Module Non-Sterile 3.0 mm Screw Module Description mm K-wire, 70 mm x 52 mm Katsuya Drill x 62 mm Katsuya Drill x 62 mm Head Relief Drill x 62 mm Head Relief Drill FRS Implants 2.5 mm FRS Screw Non-Sterile Sterile Description P mm, Length 10.0 mm P mm, Length 12.0 mm P mm, Length 14.0 mm P mm, Length 16.0 mm P mm, Length 18.0 mm P mm, Length 20.0 mm P mm, Length 22.0 mm P mm, Length 24.0 mm P mm, Length 26.0 mm 3.0 mm FRS Screw Non-Sterile Sterile Description P mm, Length 14.0 mm P mm, Length 16.0 mm P mm, Length 18.0 mm P mm, Length 20.0 mm P mm, Length 22.0 mm P mm, Length 24.0 mm P mm, Length 26.0 mm P mm, Length 28.0 mm P mm, Length 30.0 mm P mm, Length 32.0 mm P mm, Length 34.0 mm 30

33 Ordering Information MEMORY 12 and 20 Instruments MEMORY 12 mm & 20 mm Order Code A4578 PA377 Description Drill Guide Handle Depth Gauge Disposables Order Code Description mm K-wire, 70 mm mm K-wire, 100 mm mm Cannulated Drill mm Standard Locking Drill mm Non-Locking Drill MEMORY 12 mm Order Code Description PA370 Staple Holder PA371 Staple Impactor PA372 Drill Guide PA376 Drill Trial MEMORY 20 mm Order Code Description A4508 Staple Holder A4509 Staple Impactor A4511 Drill Guide A5312 Drill Trial Instrument Cases Order Code Description Sterile Memory Case PA373 Non-Sterile Memory 12 Case A4512 Non-Sterile Memory 20 Case MEMORY 12 and 20 Sterile Implants Order Code P361 P363 P365 P367 P369 P3613 P3614 P3615 P3616 P3617 P370 P372 P374 P376 P378 P380 P382 P3712 P3714 P3716 P3718 P3720 Description Memory 12, Length 13.0 mm Memory 12, Length 14.0 mm Memory 12, Length 15.0 mm Memory 12, Length 16.0 mm Memory 12, Length 17.0 mm Memory 12, Length 13.0 / 15.0 mm Memory 12, Length 14.0 / 16.0 mm Memory 12, Length 15.0 / 17.0 mm Memory 12, Length 16.0 / 18.0 mm Memory 12, Length 17.0 / 19.0 mm Memory 20, 13.0 mm Memory 20, 15.0 mm Memory 20, 17.0 mm Memory 20, 19.0 mm Memory 20, 21.0 mm Memory 20, 23.0 mm Memory 20, 25.0 mm Memory 20, 12.0 / 15.0 mm Memory 20, 14.0 / 17.0 mm Memory 20, 16.0 / 19.0 mm Memory 20, 18.0 / 21.0 mm Memory 20, 20.0 / 23.0 mm 31

34 Ordering Information VARISATION Instruments TWISTOFF Instruments Order Code Description Order Code Description PA102 Staple Holder 90 PA450 TWISTOFF Screwdriver PA103 Staple Holder 26 PA104 Staple Impactor 90 PA105 Staple Impactor 26 Instrument Cases Instrument Cases Order Code Description Sterile Varisation Case PA106 Non-Sterile Varisation Case Order Code Description Sterile Instrument Case PA2800 Non-Sterile Instrument Case Disposables Disposables Order Code Description K-wire, 70 mm Order Code Description mm K-wire, 70 mm Implants Implants Non-Sterile Sterile Description P , Width 10.0 mm P , Width 8.0 mm P , Width 10.0 mm P , Width 8.0 mm Non-Sterile Sterile Description P mm, Length 11.0 mm P mm, Length 12.0 mm P mm, Length 13.0 mm P mm, Length 14.0 mm P mm, Length 15.0 mm 32

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36 References 1. On file at DePuy. Units sold Jones S, Ali F, Genever A, Flowers MJ, Bostock SH. Distal interphalangeal joint arthrodesis of the lesser toes using the Barouk screw. The Foot. 2003;13: Smith AM, Alwan T, Davies MS. Perioperative complications of the Scarf osteotomy. Foot Ankle Int. 2003;Mar;24(3): This publication is not intended for distribution in the USA. DePuy Orthopaedics EMEA is a trading division of DePuy International Limited. Registered Office: St Anthony s Road, Leeds LS11 8DT, England Registered in England No DePuy Orthopaedics, Inc. 700 Orthopaedic Drive Warsaw, IN USA Tel: +1 (800) Fax: +1 (574) DePuy International, Ltd. St Anthony s Road Leeds LS11 8DT England Tel: +44 (0) Fax: +44 (0) DePuy France SAS 7 Allée Irène Joliot Curie Saint Priest Cedex France Tel: Fax: DePuy International Ltd. and DePuy Orthopaedics, Inc All rights reserved version 1 Revised: 08/11