Stryker T2 Operative Technique
Operative Technique
KnifeLight
Carpal Tunnel Ligament Release
T2
Recon Nailing System R2.0
Operative Techn ique
Hip & Femur Fractures
Hip
Femur
T2 Recon Nailing System
We greatly acknowledge and
appreciate the contributions to this
operative technique made by:
Kevin W. Luke, M.D.
Parkview Orthopaedic Group
Assistant Clinical Professor
Department of Orthopaedic Surgery
University of Illinois
Illinois, Chicago
USA
Anthony T. Sorkin, M.D.
Rockford Orthopaedic Associates, LLP
Clinical Instructor
Dep. of Surgery University of Illinois
College of Medicine
Director Orthopaedic Traumatology
Rockford Memorial Hospital
Rockford, Illinois
USA
Ariaan D.P. van Walsum, MD
Trauma surgeon
Medical Spectrum Twente
Enschede
Netherlands
Don Weber, MD, FRCSC
Associate Clinical Professor of
Orthopaedics
Chief of Orthopaedics
University of Alberta Hospital
Edmonton, Alberta
Canada
Contributing Surgeons
2
This publication sets forth detailed
recommended procedures for using
Stryker Osteosynthesis devices and
instruments.
It offers guidance that you should
heed, but, as with any such technical
guide, each surgeon must consider
the particular needs of each patient
and make appropriate adjustments
when and as required.
A workshop training is required prior
to first surgery.
All non-sterile devices must be
cleaned and sterilized before use.
Follow the instructions provided in
our reprocessing guide (L24002000).
Multi-component instruments must
be disassembled for cleaning. Please
refer to the corresponding assembly/
disassembly instructions.
See package insert (L22000007) for
a complete list of potential adverse
effects, contraindications, warnings
and precautions. The surgeon must
discuss all relevant risks, including
the finite lifetime of the device, with
the patient, when necessary.
Warn ing :
Fixation Screws:
Stryker Osteosynthesis bone
screws are not approved or
intended for screw attachment
or fixation to the posterior elements (pedicles) of the cervical,
thoracic or lumbar spine.
3
Contents
Page
1. Introduction & Features 5
Implant Features 5
Technical Specifications 6
Instrument Features 7
2. Indications, Precautions & Contraindications 8
3. Pre-operative Planning 9
4. Locking Options 10
5. Operative Technique 11
Patient Positioning and Fracture Reduction 11
Incision 11
Entry Point 12
Re a ming 14
Nail Selection 16
Assembly of the Targeting Device and the Nail 17
Nail Insertion 18
Final Seating with Impactor 18
Guided Locking for the Recon Mode 19
Guided Locking for Antegrade Femoral Mode 29
Freehand Distal Locking 32
Set Screw or End Cap Insertion 34
Nail Removal 34
Ordering Information – Implants 35
Ordering Information – Instruments 37
4
Introduction
Over the past decades antegrade
and retrograde femoral nailing have
become widely accepted choices for
the treatment of femoral fractures.
The T2 Recon nail is one of the first
femoral nailing systems to offer a
greater trochanter entry point with
both recon and antegrade locking
options.
Through the development of a
common, streamlined instrument
system and intuitive surgical approach,
both in principle and in detail, the T2
Recon Nail offers the potential for
more efficient treatment of fractures
as well as simplifying the training
requirements for all person nel
involved.
Furthermore, the T2 Recon Nail offers
the following competitive advantages:
• Versatility-offerstheabilityto
switch from antegrade to a recon
option without changing either
the nail or targeting arm.
• ReconSetScrew-thisoptional
screw sets the most proximal
Lag Screw thus minimizing
the potential for screw sliding
(Z-effect).
• LockingOptions-distaloptions
include dynamic as well as static.
• DistalTargeting-eliminatesthe
need for freehand locking of either
the static or dynamic modes.
RequiresoptionalGamma3/T2
ReconDTSR2.0
The T2 Recon Nail is the realization
of excellent biomechanical intramedullary stabilization for internal
femoral fixation with several locking
options to address fracture variability.
As with all other T2 Nails, the T2
Recon Nail is made of Type II
anodized Titanium Alloy (Ti6Al4V)
for enhanced biomechanical and
biomedical performance*.
The T2 Recon Nail features a 125°
CCDanglewitha10°anteversion
angle. The 2 proximal holes, each
utilize 6.5mm cannulated Lag
Screws. This CCDangle allows easy
insertion of the 2 lag screws into the
femoral head.
Alternatively a proximal 70° Oblique
hole with 7° retroversion provides
a 5mm Fully Threaded Screw for
targeting the lesser trochanter in the
Femoral Antegrade mode.
The 6.5 mm Cannulated Lag Screws
have a unique thread design that
provide an excellent grip. Improved
front cutting flutes allow for lesser
insertion torque and thinner flanks for
less bone removal.
Secure placement of the Lag Screws
within small neck diameters can be
achieved due to 10mm separating the
two 6.5mm lag screws or 17mm outer
distance between the 6.5mm Lag screws.
Two Set Screws are available:
- Recon Set Screw: Tightens the
6.5mm proximal Lag Screw (Recon
Mode) and
- Antegrade Set Screw: Tightens the
oblique 5mm Fully Threaded Screw
(Femoral Antegrade Mode).
Available as left and right versions,
the T2 Recon Nail incorporates an
antecurvature radius of 2.0M, as
well as a 4° medial lateral bend for
trochanteric insertion.
The distal locking configuration
features a round and an oblong hole to
allow for staticand/ordynamic
distal locking.
Low profile 5mm cortical screws,
common to the T2 Nailing System,
are designed to simplif y the surgical
procedure and promote a minimally
invasive approach.
5mm Fully Threaded Locking Screws
are available for distal locking (Recon
or Femoral Antegrade Mode) and
for the proximal locking in Femoral
Antegrade Mode.
End Caps are available in various
lengths to provide a better fit.
See the detailed chart on the next page
for the design specifications and size
offerings.
Implant FeaturesIntroduction
* Axel Bauman n, Nils Zander, Ti6Al4V with
Anodization Type II: Biological Behaviour and
Biomecha nical Effects, White Paper, March 2005.
5
Introduction
NailDiameter 9, 11, 13 and 15mm
(Left and Right)
Sizes 280−480mm,
in 20mm increments
Note:
• Proximal diameter is 13mm for
the 9 and 11mm Nails and 15mm
for the 13 and 15mm Nails.
• Check with your local
representative regarding
availability of nail sizes.
5.0mm Fully Threaded
Locking Screws
L = 25–120mm
6.5mm Cannulated
Lag Screws
L = 65–130mm
Antegrade Set Screw
End Caps
Stand ard +5mm +10mm +15mm
0mm
Antecurvature
radius 2.0M
40mm
20mm
15mm
0mm
4° Medial Lateral bend
44mm
70°
125°Nail angle
0mm
26mm
10.5 mm
Technical Specifi cations
Recon Set Screw
17.0 mm
Note:
Screw length is measured
from top of head to tip.
6
Introduction
Instrument Features
A major advantage of the T2
instrument platform is the integration
of core instruments that can be
used not only for the complete T2
Nailing System, but for future Stryker
Osteosynthesis nailing systems,
thereby, reducing complexity and
inventory.
The T2 instrument platform offers
precision and usability, as well as
ergonomically styled targeting devices.
Except for the addition of a small
number of dedicated instruments, the
T2 Femur instrument platform is used
for the T2 Recon Nail.
The T2 Recon targeting device is
designed to provide two proximal locking
options: Recon or Antegrade Femoral
Modes.
Reconmode: Provides two (2)
proximal holes targeting the femoral
neck and head:
• B Targets the Proximal Recon
6.5 mm Lag Screw
• A Targets the Distal Recon
6.5 mm Lag Screw
Antegrade Femoral Mode : Provides a
single 5mm Oblique Screw targeting
the lesser trochanter. LEFT is used for
a left nail and RIGHT for a right nail.
With the exception of the carbon
fi ber targeting device, dedicated
instruments for the recon mode are
color coded with “bronze”.
This makes it easy to differentiate
them from the core T2 instrument
platform.
Drills
Drillsfeaturecolorcodedrings:
4.2mm = Green
(Consistent with the Gamma3 and
T2 Instrument Plat form, this drill
features a green color ring.)
The 4.2mm drills are used for 5.0mm
Fully Threaded Locking Screws (either
for distal locking or for proximal
oblique locking).
6.5mm
The Solid Stepdrill for the Lag Screw
is color coded with “bronze”.
Targeting holes
for Recon Mode
B
A
Targeting holes
for Antegrade
Femoral Mode
Left
Right
7
Indications, Precautions & Contraindications
Indications
The T2 Recon Nail is indicated for:
• Subtrochanteric fractures
• Intertrochanteric fractures
• Ipsilateral neck/shaft fractures
• Comminuted proximal femoral
shaft fractures
• Femoral fi xation required as a
result of pathological disease
• Temporary stabilization of
fractures of the femoral shaft ranging from the femoral neck to
the supracondylar regions of the
femur.
Precautions
Contraindications
The physician’s education, training
and professional judgement must
be relied upon to choose the most
appropriate device and treatment.
Conditions presenting an increased
risk of failure include:
• Any active or suspected latent
infection or marked local
infl ammation in or about the
affected area.
• Compromised vascularity that
would inhibit adequate blood
supply to the fracture or the
operative site.
• Bone stock compromised by
disease, infection or prior
implantation that can not provide
adequate support and/or fi xation
of the devices.
• Material sensitivity, documented
or suspected.
• Obesity. An overweight or obese
patient can produce loads on the
implant that can lead to failure
of the fi xation of the device or to
failure of the device itself.
Stryker Osteosynthesis systems have
not been evaluated for safety and use
in MR environment and have not been
tested for heating or migration in the
MR environment, unless specified
otherwise in the product labeling or
respective operative technique.
Antegrade Mode
Recon Mode
• Patients having inadequate tissue
coverage over the operative site.
• Implant utilization that would
interfere with anatomical
structures or physiological
performance.
• Any mental or neuromuscular
disorder which would create an
unacceptable risk of fi xation
failure or complications in
postoperative care.
• Other medical or surgical
conditions which would preclude
the potential benefi t of surgery.
8
An X-Ray Recon Template (1806-3080)
is available for pre-operative planning.
Thorough evaluation of pre-operative
radiographs of the affected extremity
is critical. Careful radiographic
examination of the trochanteric
region and neck regions can reduce
the potential of intra-operative
complications.
Note:
TheX-RayReconTemplate
features a scale of 1.15:1 which
is adapted to conventional
analoguousX-Rays.Fordigital
X-Rays,attentionhastobe
paid that the magnification is
corresponding with the template.
According to the fracture type either
Recon or Antegrade Femoral Mode
can be chosen.
Evaluation of the femoral neck
angle on the pre-operative X-Rays is
mandatory as the T2 Recon Nail has a
fixed 125° neck angle for the two Lag
Screws. Proper placement of both Lag
Screws in the femoral head is essential.
If possible, X-Rays of the contralateral
side should be used to determine the
normal neck angle and length of the
femur.
The proper nail length should extend
from the tip of the greater trochanter
to the epiphyseal scar.
Note:
Check with your local
representative regarding
availability of nail sizes.
Pre-Operative Planning
9
Locking Options
The T2 Recon Nail can be locked
proximally with two 6.5mm Lag
Screws (Recon Mode, Fig. 1) or with
one 5mm Fully Threaded Screw
(Antegrade Femoral Mode, Fig. 2).
For both Recon and Antegrade
Femoral applications, depending
on fracture pattern, either static or
dynamic distal locking can be used.
Fig. 1
Fig. 2
Recon Mode
Antegrade Femoral Mode
10
Operative Technique
Fig. 3
Fig. 5
Fig. 4
Patient positioning for T2 Recon
Nail insertion is surgeon dependent.
However, it is recommended that
patients are positioned in either the
supine or lateral position on a fracture
table to allow closed reduction of the
frac ture (Fig. 3).
Manipulate and reduce the fracture
in the usual fashion, according to the
fracture type. Reduction should be
achieved as anatomically as possible.
If this is not possible, reduction in
one plane should be complete, leaving
reduction in the other plane to be
achieved prior to reaming and nail
insertion.
The unaffected leg is abducted as far
as possible to ease image intensifi er
positioning. This will also allow easier
access to entry point.
Patient Positioning and Fracture Reduction
Incision
The design of the T2 Recon Nail, with
a 4° medial lateral bend, will only
allow for insertion through the tip of
the greater trochanter.
With experience, the tip of the greater
trochanter can be identifi ed by
palpation (Fig. 4).
A longitudinal skin incision of
approximately 3−5cm is made starting
just above the greater trochanter to the
iliac crest (Fig. 5). The incision is then
deepened to expose the tip of greater
trochanter.
Smaller or larger incisions may be
used based on individual patients
anatomy and at the surgeon’s
discretion.
Note:
The targeting instruments of the
T2ReconNailhavebeendesigned
to allow for a more percutaneous
approach.
11
The entry point is located at the
junction of the anterior third and
posterior two-thirds of the greater
trochanter on the medial edge of the tip
itself (Fig. 6).
Note:
Before opening the tip of greater
trochanter, image intensifi er
views(A/PandM/L)should
be used to confi rm correct
identifi cation of the entry point.
The medullary canal can be opened
with the
• CurvedAwl/CurvedAwl,90°
Handle or
• OneStepConicalReamer.
Note:
Densecorticalbonemayblock
the tip of the Awl during opening
of the entry portal. Inserting
fi rst the optional Awl Plug into
the Awl will avoid penetration of
bone debris into the cannulated
Awl shaft. The Awl Plug is
thenremovedforGuideWire
insertion.
• Entry point with Curved Awl
Once the tip of the greater trochanter
has been opened (Fig. 7a), the
Ø3 × 1000mm Ball Tip Guide Wire
may be advanced through the
cannulation of the Curved Awl with
the Guide Wire Handle and Chuck
(Fig. 7 b).
The proximal femur may then be
prepared with the One Step Conical
Reamer.
anterior posterior
1
/
3
2
/
3
Fig. 6
Fig. 7a
Fig. 7b
Operative Technique
Entry Point
• The Tip of the
Greater Trochanter
Fig. 7a
12
Fig. 9
Fig. 8
K-Wire
Fig. 8a
Operative Technique
• Entry point with
One Step Conical Reamer
Alternatively, the 13mm diameter
One Step Conical Reamer for the
9 and 11mm nails or the 15mm
diameter Reamer for the 13 and 15mm
nails may be used for opening the
medullary canal and reaming of the
trochanteric region.
Under image intensifi cation control,
the entry point is made with a
Ø3.2 × 400mm Recon K-Wire which
is attached to the Guide Wire Handle
and advanced into the medullary
canal. Confi rm its placement within
the center of the medullary canal
on A/P and lateral image intensifi er
views.
Note:
TheReconK-Wireusedforthe
entry point should not be used
again for the Lag Screw insertion.
It is recommended that a new
K-Wirebeutilized.
The Recon Protection Sleeve and
Multi-hole Trocar are positioned with
the central hole over the K-Wire.
Note:
The Multi-hole Trocar has a
special design for more precise
insertionoftheØ3.2mmRecon
K-Wire(Fig.8).Besidethecentral
hole, 4 other holes are located
eccentrically at different distances
from the center (Fig. 8a) to easily
revise insertion of the guiding
K-Wireintheproperposition
(entry point).
When correct placement of the guiding
Recon K-Wire is confi rmed on image
intensifi er views (A/P and lateral),
keep the Tissue Protection Sleeve
in place and remove the Multi-hole
Trocar.
The T-Handle is attached to the
One Step Conical Reamer and hand
reaming is performed over the Recon
K-Wire through the Tissue Protection
Sleeve (Fig. 9).
The Recon K-Wire is then removed
and replaced with the Ø3 × 1000mm
Ball Tip Guide Wire.
13
The Ø 3 × 1000mm Ball Tip Guide
Wire is inserted with the Guide
Wire Hand le throug h the frac tu re site
to the level of the epiphyseal scar.
The Ø 9mm Universal Rod with
Reduction Spoon may be used as a
fracture reduction tool to facilitate
Guide Wire insertion through the
fracture site (Fig. 10).
Note:
The Ball Tip at the end of the
GuideWirewillstoptheBixcut
reamer* head (Fig. 11).
Caution:
Prior to reaming, it is important
to check the centered
intramedullary position of the
GuideWirewiththeimagein-
ten sifi er. Lateral displacement
oftheGuideWirecouldleadto
resection of more bone on the
lateral side of the wire, which in
turn will lead to an offset position
of the nail and increase the risk of
a shaft fracture.
Note:
Make sure that the reduction
is maintained throughout the
reaming process.
Reaming is commenced in 0.5mm
in crements until cortical contact
occurs (Fig. 12).
For easier nail insertion, the
medullary canal should be reamed at
least 2mm more than the diameter of
selected nail (Fig. 13).
Fig. 10
Fig. 12
Fig. 13
Fig. 11
Operative Technique
Reaming
* see pages 36-37 for additiona l Bixcut Reamer
system details
+ 2mm more than the
selected nail diameter
14
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