Snmek 1

1
(No Transcript)
2
Dictionary of medical expressions adduction -
motion with direction to the axis of body or
limb cranial direction to the upper part of
body diaphysis middle part of bone distal
long-distance, placed on oposite side than the
beginning intertrochanteric - fracture between
trochanters lateral side, external, except of
center pertrochanteric fracture throught the
trochanter proximal closer to the beginning,
opposite of distal reduction fracture
correction, giving back in orginal position
subtrochanteric - fracture below trochanter
valgosity joint valgus (knees and hips)
ventral frontal, anterior
3
SHORT RECONSTRUCTION NAIL - Instructions
Indication
synthesis of fragmantation pertrochanteric,
intertrochanteric, upper subtrochanteric
fractures and its combination with neck fracture
4
SHORT RECONSTRUCTION NAIL - Instructions
System
Consists some type or size of nail, one or
two screws, that are inserted into a neck plate
that is possible to be inserted under screw heads
plug that is used for nail closing locking
screws that are used for distal locking
adjusting screws that are used for locking of
proximal or distal screws
5
SHORT RECONSTRUCTION NAIL - Instructions
Short reconstruction nail
It is an implant of a circular section. The
diameter of proximal part - 80 mm (regardless of
nail size) is strengthened to 15 mm. Proximal
part of the length 90 mm is bent at the angle
630.This flexion enables nail introducing from
the top of large trochanter. The nail is
universal, it means that the same one is used for
operation of both limbs, right and left one. It
is hollow which enables its introduction with
using of a guiding wire. Versions full or
cannulated
6
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
Patient position
Patient position is as same as the position at
synthesis with using of common medullary femoral
nails. The position on an extention table has to
enable (except of imaging of fracture site and
site of distal locking) neck and head imaging in
the full range in two basic projections.
1.Fracture reposition
Make a reduction with using of X-ray on a
traction table in a zero rotation
and, eventually, adduction. Torso deflection to
the healthy side at obese patients. Unsatisfied
reduction is possible to finish after nail
introduction into the diaphysis by lifting an
aiming device up against ventral dislocated neck
or by a pressure with using of Hohmann retractor,
raspatorium, Steinmann or reposition forceps from
an incision for compression screws. This
position is possible to ensure with using of
K-wires that are placed outside of intended
implant, but usually it is not essential.
7
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
2.Incision
Make incision of length cca. 5 mm, cranially
from large trochanter. Introduce a perforator
into the trochanter or into the fragmantation
area at an angle 6 to the diaphysis. Double
projection control with using of X-ray is
essential. With using of one perforator an
opening with maximal diameter 14,1 mm is made.
For creation of opening in cancellous part of
femur is suitable to use manual awl with
dimension of 5 mm, afterwards an introducer is
inserted. Pre-drilling is performed to approriate
diameter of the intended diameter of nail.
8
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
3. Pre-drilling
It is essential to pre-drill the opening in the
proximal part in the length 80 mm and opening
diameter has to be for 0,5 or 1,0 mm larger, it
means medullary cutters with diameter 15,5 or
16,0 mm. Futher part of femur cavity is drilled
by cutter in that way the opening diameter is 1,0
mm larger than the diameter of nail.
4. Guiding wire changing
Replace the guiding wire for pre-drilling by
guiding wire for nail introduction. Standard
inclination of a screw in a nail is 130. In
the case of larger slip or neck valgosity
planning use the nails with screw inclination
135. At the neck varosity or at patients where
the larger slide is not required, is possible to
use a nail with inclination 125.
9
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
5. Nail and aiming device assembling
After irrigation selected nail is assembled with
one of aiming devices. The aiming device
125/135 is used for introduction of nail with
neck angle 125 or 135. The aiming device
130/45is used for introduction of nail with
neck angle 130. Assembling is performed with
using of AD screw. Approriate sleeves are set in
the aiming device and the control of all opening
is performed, if aiming device and selected nail
correspond. It is suitable to use eg. trocar for
control. An introducing bar of mallet is set the
aiming device to, according to way of nail
introduction. It is recommended to set an
impactor up, because the nail should be inserted
by hand only, eventually by very fine strokes
(for short reconstruction nail).
10
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
5. Nail and aiming device assembling
Aiming device enables to introduce 2 screws into
the neck and 2 screws at the distal locking (for
short reconstruction nail). All screws can be
pre-drilled and inserted through the sleeve of
aiming device. Prior to pre-drilling it is
essential to remove introducer. Aiming devices
130/40 125/135 are supplied as a complete
that contains three main parts (2 exchangeable
arms and fixing part of nail. Its mutual
interchangeability with the futher same products
is not possible. Please, any dibutations or
unclearnesses discuss with our sales
representative.
11
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
6. Opening control
Check if the openings of nail are oriented to
the neck and head.
7. Aiming device
Inclination of the aiming device is according to
neck anteversion, it is performed by dorsal
rotation (or by table inclination to the healthy
side).
8. Incision
Make the incision in the length of cca 4 cm
on the lateral side in subrotrochanteric area for
introduction of two screws . Nail fixation is
performed with using of double projection
imaging. Afterwards sleeve, sleeve 1 and guiding
wire are inserted into the opening of aiming
device that is oriented into the neck.
12
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
8. Incision
Prior to pre-drilling with using of guiding wire
it is suitable to make input depression into the
corticalis with using of trocar. Guiding wire can
be tended to trend of cheating by proximal
sidestepping. First it is recommended to aim
distal proximal opening accurately. Guiding wire
goes through cca 10 mm above the Adams arch in
the anteroposterioric projection, through the
middle of neck and head in the lateral
projection. Guiding wire is inserted into the
approriate distance 3 5 mm. Recommended
introduction s. picture 1. It is essential to
introduce the second guiding wire that prohibits
the rotation during the pre-drilling and
consequential milling of openings for screw
introduction.
13
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
9. Screw Introduction
Futher step is introduction of distal screw. The
length of protruding end of guiding wire is
subducted with the help of measuring instrument.
This subducted dimension is used for stop setting
of drill tip and screw length. Afterwards
extraction of guiding wire replace the sleeve 1
by sleeve 2. At pre-drilling of opening into the
neck use the drill tip with stopper, for drilling
away of corticalis.
14
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
9. Screw Introduction
Afterwards set the stop of drill tip and finish
the drilling. Prior to finishing the drilling out
it is essential to perform X-ray control ,
s.picture 2.
15
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
10. Screw and Plate
Selected screw is fixed in the T-wrench and is
introduced through the sleeve into the neck,
s.picture 3. Screws are self-taping, therefore it
is not essential to cut the thread in. Caution
screw distance from the end of hip head is
mentioned as a theoretical value in the
picture. This value will be smaller owing to
approximation and compression of neck fragments.
It is not possible to set it in advance, operator
has to count with this eventuality. Values are
set in the case that a plate is used under the
screw head (s. article 11). Without usage of this
plate the dislocation of screw can happen for
cca 2 mm to the head end of hip joint.
16
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
10. Screw
The method of proximal screw introduction is as
same as introduction of distal screw.
17
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
11. Plate
When it is your purpose to make the compression
of neck directly on the operating table, it is
possible to insert the plate under the head of
screw. Otherwise the head edge of screw can be
pressed into the bone and be damaged.
Recommended method is as follows - introduce
distal screw into the neck in that way to reach
the second bone fragment (head), but the
screw is not tightened. - first insert the plate
among the aiming device and patient on the distal
screw, afterwards perform the introduction
of proximal screw to the neck proximal screw
is put through the plate hole. - tightening of
screws is performed with appropriate compression
18
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
12. Distal locking
Distal locking of short reconstruction nail is
very easy matter. The sleeve 2 is inserted in the
appropriate holes of aiming device and afterwards
the futher sleeves according to the type of used
locking screw Locking screw (partial thread)
the sleeve 4 is inserted into the sleeve 2 and
the opening is pre-drilled through the both
corticalis with the help of drill of
diameter 3,5 mm. The sleeve 4 is replaced by the
sleeve 3 and the closer corticalis is drilled
away with the drill of diameter 5 mm. Locking
screw (full thread) the sleeve 4 is inserted
into the sleeve 2 and the opening is
pre-drilled through the both corticalis with the
drill of diameter 3,5 mm. Locking screw 5 mm
the sleeve 3 is inserted into the sleeve 2 and
the opening is pre-drilled through the both
corticalis with the drill of diameter 5 mm.
19
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
12. Distal locking
Prior to drilling it is suitable to make the
depression with using of trocar 1 that is
introduced through the sleeve 2. The depth gauge
is inserted through the sleeve 2 and the length
of locking screw is found out. The selected
locking screw is inserted through this sleeve
with using of T-screwdriver. Distal opening is
possible to use for dynamic compression (roughly
5 mm).
20
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
13. Locking
If it is essential to lock the neck fracture in
reduced position, it is possible to lock screws
in the neck with the help of adjusting screws.
Afterwards use the one of two adjusting screws
for locking the proximal or distal screw in the
neck.
14. Closing of nail
The nail is closed with the help of plug that is
possible to be introduced in such a way that the
AD screw is removed from the aiming device, it is
kept on the nail and the plug is inserted through
the hub of aiming device. The plug is not used in
the case of adjusting screw introduction.
21
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
Finishing of operation

• After irrigation injuries are sutured. The
  suction drain is put in the area where the nail
  was inserted into the femur. Injury is covered by
  soft bandage and X-ray documentation is
  performed.
• Remarks
• Prior to nail introduction and after nail and
  aiming device assembling, it is
• essential to check if all openings, that will
  be used for screw insertion,
• correspond to openings of aiming device.
• During nail introduction the mallet should be
  used in the case of necessity
• only. The nail should be introduced in the
  common case by hand. This rule is
• not valid at the introduction of long
  reconstruction nail.
• Usage of plate under the screw head depends on
  operators decision only.
• Implant is designed so that the operation
  method is not influenced by its
• usage or non-usage. However the plate should be
  used in those cases
• the compression of neck fracture is required
  directly on the operation table or
• corticalis do not offer any possibility of
  support of screw head.
• Implants can be supplied in two versions,
  stainless or titanium alloys.
• However these two versions can not be combined
  at one patient.

22
SHORT RECONSTRUCTION NAIL - Instructions
Operation method
Remarks
Patient must be warned that implant is not
designed to bear whole weight of patient.
Subsidiary aids must be used during the whole
process of healing. Recommended method of
implant extraction If the distal screws have not
been removed during the healing process of
fracture, they are removed now, together with the
proximal screws that are placed in the neck. The
plug is removed out of the nail. An extrac- tion
bar of mallet is screwed on the inner cavity of
proximal end of nail, the weight is set to and
the handle is mounted on. The nail is ex- tracted
by the strokes that are made against the handle.
23
SHORT RECONSTRUCTION NAIL - Instructions

• Guiding wire diameter 2,5 mm
• Sleeve diameter 10,0 mm
• Sleeve 1 diameter 2,55 mm
• Sleeve 2 diameter 8,0 mm
• Sleeve 3 diameter 5,0 mm
• Sleeve 4 diameter 3,5 mm
• Drill tip
• T-Wrench
• Mallet
• Extraction bar
• Impactor
• Wrench, 10/12
• T-Screwdriver 175 mm
• Trocar
• Trocar 1
• Depth gauge
• Aiming device 135/125 130/45
• Diameter Measuring Instrument
• Bolt Screw

Instrument Set
24
Thanks a lot for your attention!