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Surgical Technique

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1. cceee 25 Stability blocking Screw insertion eee eee 25 Final view Stability blocking SCTeWS eee e 26 Appendix B sss 27 TRIGEN STABLE LOK Nut and Washer 27 Nota Bene The technique description herein is made available to the healthcare professional to illustrate the authors suggested treatment for the uncomplicated procedure In the final analysis the preferred treatment is that which addresses the needs of the patient The following technique is for informational and educational purposes only It is not intended to serve as medical advice It is the responsibility of treating physicians to determine and utilize the appropriate products and techniques according to their own clinical judgment for each of their patients For more information on the TRIGEN META NAIL Retrograde Femoral Nail System including its indications for use contraindications and product safety information please refer to the product s label the Instructions for Use REF 81068703 packaged with the product and if using the TRIGEN SURESHOT Distal Targeting System the TRIGEN SURESHOT Distal Targeting System User Manual REF 7118 1540 The TRIGEN META NAIL Retrograde Femoral Nail is indicated for fractures of the femur including stable and unstable distal metaphyseal fractures diaphyseal fractures intraarticular fractures periprosthetic fractures nonunions malunions and for the prophylactic nailing of impending pathologica
2. Note The TRIGEN Nail Cap Set screw engages the most distal locking screw to create a fixed construct i ty Hun ER Figure 31 Note If cross threading occurs rotate the Nail Cap or Nail Cap Set Screw counter clockwise until its threads line up with those of the nail Proceed with Nail Cap insertion until it is tight Nail extraction optional Standard technique Use the Medium Hexdriver T handle assembly to remove the Nail Cap or Nail Cap Set Screw if implanted all of the proximal locking screws and all but one of the distal locking screws 2 Thread the Cannulated Impactor Medium 7167 5081 or Cannulated Impactor Long 7163 1185 into the back of the Disposable Nail Extractor 7163 1320 3 Thread the assembly into the end of the nail 4 Remove the remaining distal locking screw 5 Use the Slotted Hammer with a back slapping motion to extract the nail Figure 32 Percutaneous technique In the absence of a Nail Cap or Nail Cap Set Screw 1 Use the Medium Hexdriver T handle assembly to remove all proximal locking screws and all but one of the distal locking screws 2 Under fluoroscopy insert a 3 2mm Brad Point Guide Pin into the end of the nail either using power or by hand Figure 33 3 Make a incision large enough to accept the 12 5mm Entry Reamer at the pin skin site 4 Advance the 12 5mm Entry Reamer over the pin and into the end of the nail to remove any bony ingrowth Fi
3. 4 0mm Drill Sleeve into the desired cartridge hole and down to the bone Figure 4 Drill both cortices with the 4 0 mm Long Pilot Drill Note Use caution during drilling and insertion Figure 4 of blocking screws in the AP plane Do not drill past the posterior cortex or insert a screw that is too long Damage to the neurovascular structures located posterior and distal femur may result Read the exposed drill bit calibrations to determine the screw length or remove the 4 0mm Drill Sleeve and measure with the Screw Depth Gauge Use the Medium Hexdriver T handle assembly to insert the screw until the screw engages the Figure 5 far cortex Implant the distal blocking screw and reduce the fracture _ Pass the 11 0mm T handle Awl into the proximal fragment Figure 5 10 Reposition either the Blocking Screw Cartridge or the awl as necessary and repeat this blocking screw technique for additional nails e NAI L P ml 3 MCF N PNW AJ IRACA p AA ML blocking screw insertion O O To prevent anterior or posterior malalignment of Figure 6 the distal fragment blocking screws may also be placed in the ML mediolateral plane 1 Attach the Blocking Screw Device to the 11 0mm T handle Awl 2 Rotate the Blocking Screw Device into the desired position in the ML plane Figure 6 3 Tighten the device to the awl and insert the appropriate Blocking Screw Cartridge Figure 7 4 Adjust the Cartrid
4. to the femoral attachment of the posterior cruciate ligament Figure 1 Establish the entry portal Insert the 11 0mm T handle Awl 7165 4522 manually to a depth just distal to the fracture Figure 2 Note When creating the initial entry point pay close attention to the trajectory of the awl and the relationship to the anatomic axis of the femur Correct awl trajectory in the distal fragment must be established prior to alignment with the anatomic axis of the proximal fragment to ensure accurate fracture reduction when the nail is inserted AP blocking screw insertion In order to prevent varus or valgus malalignment of the distal fragment blocking screws can be placed in the AP plane Attach the Blocking Screw Device 7165 4515 to the 11 0mm T handle Awl and move it into the desired position in the AP plane Figure 3 Note The Blocking Screw Alignment Pins 7165 4523 can be screwed into the three threaded holes on the metal handle of the Blocking Screw Device to serve as external points of reference during fracture alignment Tighten the device to the awl and insert the appropriate Blocking Screw Cartridge 7165 4511 7165 4513 or 7165 4514 Figure 1 Figure 2 T handle Awl Metal handle Cartridge Figure 3 23 Adjust the cartridge proximally or distally within the Blocking Screw Device to determine blocking screw position Insert the gold 9 0mm Drill Sleeve and silver
5. Information 1 800 821 5700 Orders Inquiries 1 800 238 7538 2015 Smith amp Nephew Trademark of Smith amp Nephew Certain marks Reg US Pat amp TM Off 01362 V2 71181613 REVC 05 15
6. 0 1 5mm larger than the selected nail size Figure 19 3 Insert the Obturator 7167 4078 into the back of the reamer unit during retraction to ensure proper Guide Rod placement during reaming 4 Continue to confirm correct Guide Rod placement in the proximal femur Figure 19 throughout reaming Note Periodically move the reamer backward and forward in the canal to clear debris from the cutting flutes Nail assembly 1 Use the Guide Bolt 7165 4506 to attach the META NAIL Drill Guide 7165 4502 to the nail 2 Tighten with the Guide Bolt Wrench 7163 1140 and T handle The nail is correctly aligned when The vertical black line on the posterior side of the insertion barrel aligns with the line on the posterior side of the nail META NAIL 4 Drill Guide The A on the anterior side of the nail aligns with the A on the anterior side of the TRIGEN META NAIL insertion barrel Figure 20 l Figure 20 The apex of the nail s AP Bow faces posteriorly and the drill guide is oriented anteriorly Figure 21 Note The bevel on the front of the nail marks the connection to the drill guide and can be seen in the lateral view as a means to determine proximal insertion depth Note Do not use the META NAIL Extension Drill Guide as the insertion barrel of the META NAIL Extension Drill Guide is too short to adequately countersink the nail 3 Attach the Anterior Drop 7165 4501 to th
7. 28 The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with the 4 0mm AO Long Drill 7163 1121 14 Proximal locking Proximal locking is performed in the AP plane using a free hand technique _ Confirm fracture reduction and align the C Arm over the desired locking hole NO Obtain a perfect circle image of the locking hole Note If using the SURESHOT Distal Targeting System refer to the TRIGEN SURESHOT Distal Targeting System s User Manual REF 7118 1540 Use a blunt object to dimple the skin at the Figure 29 approximate location of the locking hole ic Make a small stab incision at the site of screw entry Insert the 4 0mm Long Pilot Drill and drill both cortices gt Ln O Measure for screw length using the Screw Depth Gauge or Leave the drill in place insert the Long Screw Length Sleeve down to bone and read the exposed calibrations from the drill Figure 29 7 Use the Medium Hexdriver T handle assembly to insert the appropriate length screw The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with the 4 0mm AO Long Drill 7163 1121 TRIGEN Nail Cap and Nail Cap Set screw insertion optional 1 Remove the drill guide Anterior Drop assembly b 2 Attach the selected Nail Cap Figure 30 or Figure 30 Nail Cap Set Screw to the Medium Hexdriver T handle assembly 3 Insert the Nail Cap into the end of the nail until it is tight
8. O Mini Connector Optional Trinkle to Mini Connector Optional Qty d d d d O l d d d d 19 TRIGEN META NAIL Instrument Set Set No 7165 4002 Cat Item 7165 4501 7165 4502 7165 4503 7165 4505 7165 4506 7165 4520 7165 4554 7163 1025 Description META NAIL Anterior Drop META NAIL Drill Guide META NAIL Extension Drill Guide Extension Guide Bolt 23mm Guide Bolt Long 51mm Long Screw Length Sleeve Cannulated Impactor Short Large Nail Extractor META NAIL Disposables Set No 7165 4003 Cat Item 7163 1110 7163 1117 7163 1626 7167 4130 or 7163 1436 7165 4528 7163 1320 Description 4 0mm Long Pilot Drill 4 0mm Short Drill 3 0mm x 1000mm Ball Tip Guide Rod 3 2mm Brad Point Guide Pin Universal Compression Driver Disposable Nail Extractor Qty Blocking Screw Instrument Set Optional Set No 7165 4001 Cat Item 7165 4515 7165 4509 7165 4522 7165 4511 7165 4513 7165 4514 7165 4523 7163 4508 Description Blocking Screw Device Tibial Blocking Screw Attachment 11 0mm T handle Awl 8 5mm 10mm Blocking Screw Cartridge 11 5mm 13mm Blocking Screw Cartridge Offset Blocking Screw Cartridge Blocking Screw Alignment Pin Retrograde Femoral Blocking Screw Attachment The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with 4 0mm AO Long Drill 7163 1121 The 4 0mm Short Drill 7163 1117 is interchangeable with 4 0mm AO Short Drill 7163 1123
9. TRIGEN META NAIL Retrograde Femoral Nail System NATO CIC TIO ID osesecesececasecececececececececececacecacecccasecacasacocavesacasaaccssasasasacze 2 TRIGEN META NAIL Retrograde Femoral Nail Specifications 3 SU IC Ke ae U 4 Establish the incision and entry DOnt 5 Entry portal acquisition co cc cxdecisnveacecoateenta ieusorseeriesoretsnesbel cosas dteesiestenes 6 EMU VON ellen date esata EE 7 Alternative technique Entry portal 7 Reduce the rache 8 Determine the implant length eee ee 9 Reamed Iechniadue 10 Nail assembly 11 Nail AS SY UO Was sacsaciteasteesse erextratisintuncatnavisndounpiaewass a umeheamedd ea eunmaeks 12 cne Glas Bre aT 12 Lock the SCre W inact ancisssrassigyansrertuiniviedamsvenmedetiedwonnyiea hictbhveee strata 13 STAN NO CIN x apeciecey acco te E A E eet getoeecet 14 POON VOCS aeaea E E eames 15 TRIGEN Nail Cap and Nail Cap Set screw insertion optional 16 Nail extraction Opional cc ceccesecesecesecesessseesseesseeneeenees 17 An alternative method for extraction 00 cc cccc cc ceccceecesceneeeseeeees 18 Catalog information sss sese eee sees e seene 19 Appendix A H 23 Blocking screw technique ee ee eee 23 Establish the entry Goral ccc cc cccccecesecesecesecsseesseeseeseenes 23 AP blocking Screw insertion eee eee 23 ML blocking screw insertion eee ee eee 24 Blocking screw insertion with a reducer sse eee 25 Final view AP and ML blocking screw insertion
10. The Disposable Nail Extractor 7163 1320 is interchangeable with the Large Nail Extractor 7163 1278 located in the original TRIGEN Instrument Set 7163 1326 and the HFN Instrument Set 7170 0001 20 Qty 5 0mm Internal Captured Screws Gold TRIGEN META NAIL 10mm Retrograde Femoral Set No 7165 1000 Cat Item Length 7164 5020 5 0mm x 20mm 5 Omm Cat Item Length 7164 5022 5 0mm x 22 5mm 7165 3018 18cm 7164 5025 5 0mm x 25mm 7165 3020 20cm 7164 5027 5 0mm x 27 5mm 7165 3022 22cm 7164 5030 5 0mm x 30mm 7165 3024 24cm 7164 5032 5 0mm x 32 5mm 7165 3026 26cm 7164 5035 5 0mm x 35mm 7165 3028 28cm 7164 5037 5 0mm x 37 5mm 7165 3030 30cm 7164 5040 5 0mm x 40mm 7165 3032 39cm 7164 5042 5 0mm x 42 5mm 7165 3034 34cm 7164 5045 5 0mm x 45mm 7164 5047 5 0mm x 47 5mm 7164 5050 5 0mm x 50mm Cat Item Length 7164 5052 5 0mm x 52 5mm 7165 3036 36cm 7164 5055 5 0mm x 55mm 7165 3038 38cm 7164 5057 5 0mm x 57 5mm 7165 3040 40cm 7164 5060 5 0mm x 60mm 7165 3042 42cm 7164 5062 5 0mm x 62 5mm 7165 3044 wee 7164 5065 5 0mm x 65mm 7165 3046 ae 7164 5067 5 0mm x 67 5mm 7164 5070 5 0mm x 70mm T 7164 5072 5 0mm x 72 5mm se eae cL 7164 5075 5 0mm x 75mm 7164 5077 5 0mm x 77 5mm 7164 5080 5 0mm x 80mm 7164 5085 5 0mm x 85mm 7164 5090 5 0mm x 90mm 7164 5095 5 0mm x 95mm 7164 5100 5 0mm x 100mm 7164 5105 5 0mm x 105mm 7164 5110 5 0mm x 110mm Contained in the standard implant set 21 TRIGEN META NAIL 11 5mm Retrograde F
11. d Awl Figure 9 Note Introduce the 3 2mm T handle Trocar 7167 4074 Figure 10 into the back of the assembly prior to insertion in order to prevent awl slippage and the accumulation of cortical bone within the cannulation Insert the awl into the distal femur to a depth of 6 8cm Figure 9 Figure 10 Figure 11 Reduce the fracture Open the Gripper 7167 4080 Se Insert the smooth end of the 3 0mm Ball Tip Guide Rod 7163 1626 into the front of the Gripper Figure 12 and gently close the trigger grip Connect the 8 5mm Reducer and the Reducer Connector 7167 4077 so that the words Slot Figure 12 Orientation on the connector are in line with the opening at the Reducer s tip Figure 13 Trigger grip gt Connect the Reducer and connector to Reducer the T handle 7167 4076 or 7167 4576 to complete the assembly l l Reducer Connector Note If blocking screws are desired at this point in the procedure refer to Appendix A the Blocking Screw Technique at the back of this document Figure 13 Advance the Reducer through the Entry Tube into the intramedullary canal Figure 14 Use the curved tip of the Reducer to direct the 3 0mm Ball Tip Guide Rod past the fracture into the region of the distal epiphyseal scar Note The guide rod should be center center in the AP and lateral views Figure 15 Once the guide rod is at the desired depth Figure 14
12. detach the Gripper and prepare to remove the Reducer from the femoral canal Remove the Reducer from the femoral canal Note During extraction slide the Obturator 7167 4078 into the T handle in order to maintain guide rod position within the canal Figure 16 Figure 15 Figure 16 Determine the implant length 1 Confirm that the Ruler 7167 4079 opens easily If it does not adjust the thumb wheel connection at the end to ensure free movement 2 After the Reducer has been removed reconfirm the guide rod placement within the proximal femur Figure 17 3 Slide the Ruler over the guide rod until its metal tip contacts the distal femur Figure 17 4 Confirm guide rod position in the window at the opposite end of the Ruler in order to ensure accurate implant measurement Figure 18 Window a 5 Push down on the top of Ruler until it contacts the 3 0mm Ball Tip Guide Rod 6 Read the implant length from the exposed calibrations at the end of the Ruler 7 Confirm fracture reduction to ensure that the implant length is not underestimated Note When selecting the implant length consider that the nail must be countersunk below the articular surface of the distal femur Thumb wheel Figure 18 Reamed technique 1 Use the 9 0mm End Cutting Reamer Head 7111 8231 and Flexible Reamer Shaft 7111 8200 to ream the intramedullary canal sequentially in half millimeter increments to a size 1
13. e Drill Guide Figure 22 4 To verify the accuracy insert a gold 9 0mm Drill Sleeve 7163 1152 and silver 4 0mm Drill Sleeve 7167 4083 into the Drop Figure 22 5 Pass a 4 0mm Long Pilot Drill 7163 1110 through the drill sleeves Figure 21 META NAIL 4 Anterior Drop Note An incorrectly attached nail will 9 0 Drill Sleeve not target Figure 22 The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with the 4 0mm AO Long Drill 7163 1121 11 Ka ic Ln O NO RE O Detach and remove the Anterior Drop Attach the Cannulated Impactor Medium Orient the drill guide assembly in the AP Use light blows on the Slotted Hammer Check the final nail position in both the AP and Remove the guide rod once the nail has been Attach the Anterior Drop Following nail insertion confirm that the nail Nail insertion 7167 5081 to the drill guide Figure 23 anteroposterior position 7167 4082 to tap and advance the nail over the guide rod to the desired depth Note If excessive force is required to insert the nail additional reaming of the intramedullary canal may be required Figure 23 Verify fracture reduction as the nail crosses the fracture site Pay close attention to rotation length alignment distraction and or shortening lateral views for correct alignment Check nail depth Distal In the AP and lateral views confirm nail posit
14. emoral Set No 7165 1001 Cat Item Length Cat Item Length 7165 3218 18cm 7165 3236 36cm 7165 3220 20cm 7165 3238 38cm 7165 3222 22cm 7165 3240 40cm 7165 3224 24cm 7165 3242 42cm 7165 3226 26cm 7165 3244 44cm 7165 3228 28cm 7165 3246 46cm 7165 3230 30cm 7165 3248 48cm 7165 3232 32cm 7165 3250 50cm 7165 3234 34cm TRIGEN META NAIL 13mm Retrograde Femoral Set No 7165 1002 Cat Item Length Cat Item Length 7165 3418 18cm 7165 3436 36cm 7165 3420 20cm 7165 3438 38cm 7165 3422 22cm 7165 3440 40cm 7165 3424 24cm 7165 3442 42cm 7165 3426 26cm 7165 3444 44cm 7165 3428 28cm 7165 3446 46cm 7165 3430 30cm 7165 3448 48cm 7165 3432 32cm 7165 3450 50cm ma 7165 3434 34cm Nail Cap Set Screw Cat No 7165 6000 hee TRIGEN Nail Caps Cat Item Length 7163 4000 Omm 7163 4005 pmm 1 7163 4010 10mm ut 7163 4015 15mm 7163 4020 20mm STABLE LOK Nut Used with 5 0mm internal captured screws Rr Cat No 7163 2001 Aia CAUTION U S Federal law restricts these devices to sale by or on the order of a physician Contained in the standard implant set 22 NO _ NO Appendix A Blocking screw technique Incision and entry point Make a 3 4cm midline incision followed by a medial parapatellar capsular incision to expose the intercondylar notch Gently retract the patellar tendon laterally Note Locate the entry point within the intercondylar notch just anterior and lateral
15. ge proximally or distally within the Blocking Screw Device to determine the blocking screw position 5 Insert the blocking screw as previously described Figure 7 The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with the 4 0mm AO Long Drill 7163 1121 24 Blocking screw insertion with a reducer Blocking screws can also be inserted by attaching the Blocking Screw Device to the Reducer instead of the 11 0mm T handle Awl Figure 8 Follow the previously described blocking screw insertion technique Final view AP and ML blocking screw insertion Once blocking screw insertion is complete remove the Blocking Screw Device from the 11 0mm T handle Awl or Reducer Figure 8 NO Obtain both AP and lateral radiographic images to confirm accurate placement Note The Awl or Reducer provides a reliable indication of the nail s insertion trajectory based upon the location of the blocking screws ic Confirm proper screw placement Figure 9 Proceed with nail insertion gt Figure 9 Stability blocking screw insertion Following nail insertion and confirmation of fracture reduction blocking screws may be placed on either side of the nail in the metaphyseal region for additional stability Screws may be inserted in both the AP and ML planes _ With the nail inserted attach the Retrograde Femoral Blocking Screw Attachment 7165 4508 Figure 10 to the Anterior Dro
16. gure 34 Note It is the flared portion of the Entry Reamer that enters the top of the nail 5 Thread the Cannulated Impactor Medium or Cannulated Impactor Long 7163 1185 into the back of the Disposable Nail Extractor 7163 1320 6 Thread the assembly into the end of the nail 7 Remove the remaining distal locking screw 8 Extract the nail with a back slapping motion The Cannulated Impactor Long is located in the original TRIGEN Instrument Set 7163 1326 The Disposable Nail Extractor 7163 1320 is interchangeable with the Large Nail Extractor located in the original TRIGEN Instrument Set 7163 1326 and the HFN Instrument Set 7170 0001 Figure 32 Figure 33 Figure 34 Guide rod jamming technique 1 Advance the end of a 3 0mm Ball Tip Guide Rod through the end of the nail 2 Insert the smooth end of a 2 0mm ball tip guide rod 7175 1146 in the same manner 3 With both guide rods in place attach the Gripper to the end of the 3 0mm Ball Tip Guide Rod 4 Pull the Gripper back so that it wedges the ball tip against the 2 0mm Guide Rod 5 Backslap against the Gripper with the Slotted Hammer to extract the nail Available sterile packed For nail removal only do not use for nail insertion 18 Guide rods Cat No Description 7175 1146 2 0mm x 600mm Ball Tip Guide Rod 7163 1626 3 0mm x 1000mm Ball Tip Additional removal items Cat No Description 115074 Large Extractor H
17. ion within the distal femur The notch at the nail drill guide junction will be visible in the lateral view Each circular groove on the drill guide s Figure 24 insertion barrel represents a 10mm depth interval Figure 24 Proximal _In the AP view confirm that the nail has been inserted to the desired depth Figure 25 Note Femoral fractures should be treated with the longest nail possible in order to reduce the likelihood of stress risers fully seated and drill guide are securely connected as hammering can loosen the Guide Bolt Note If using the SURESHOT Distal Targeting System refer to the TRIGEN SURESHOT Distal Targeting System s User Manual REF 7118 1540 for the field accuracy check instructions Figure 25 12 Lock the screw Locking screw options Distal locking options include three statically locked threaded holes that are targeted through the orange and green color coded holes on the Anterior Drop Figure 26 Proximal locking options include two statically locked non threaded AP holes Figure 27 Gold 5 0mm locking screws are compatible with 10 11 5 and 13mm diameter nails Note For information regarding Drill Depth Measurement Software DDM using the TRIGEN SURESHOT Targeting System refer to the TRIGEN SURESHOT Targeting System User Manual 7118 1540 The DDM software can be used for distal locking only Note The 4 0mm Short Step Drill 7164 1123 may be used t
18. l penetration of the opposite cortex and soft tissue is complete Make a small incision over the drill bit and down to the cortex to allow a path for the STABLE LOK Nut Note Ensure sufficient soft tissue release to properly seat the nut Remove the retaining rod from the Multipurpose Driver 7163 1161 Assemble the STABLE LOK Nut Figure 2 onto the driver guide it over the Long Pilot Drill and thread the nut securely into the bone Remove the drill Insert the TRIGEN Screw Depth Gauge 7163 1189 into the 4 0mm hole and hook it onto the far side of the nut Note The length of the Internal Hex Head Screw should correspond exactly with the reading on the Screw Depth Gauge Note If a lag technique will be used consider the appropriate amount of compression when choosing the correct screw length Figure 1 Figure 2 STABLE LOK Nut 2 8 Attach the Multipurpose Driver Part 7163 1161 to a second T handle or Straight Ratcheting Driver 7175 1141 9 Insert the Multipurpose Driver through the STABLE LOK incision portal to hold the nut in place while inserting the screw 10 Place the Washer on the Internal Hex Head Screw and advance the screw through the pre drilled hole until it engages the STABLE LOK Nut on the far cortex Figure 3 Figure 3 28 Notes Smith amp Nephew Inc www smith nephew com 1450 Brooks Road Memphis TN 38116 USA Telephone 1 901 396 2121
19. l fractures The META NAIL System can be used with or without the SURESHOT Distal Targeting System If using the SURESHOT Distal Targeting System be sure to read and understand the TRIGEN SURESHOT Distal Targeting System User Manual REF 7118 1540 Only trained operators are allowed to use the TRIGEN SURESHOT Distal Targeting System Top view of nail Driving end of nail ML view Note These views are not to scale and should be used as a pictorial representation only Non driving end of nail Specifications TRIGEN META NAIL Retrograde Femoral Material Diameter Lengths Nail color Cross section Distal diameter driving end Proximal diameter non driving end Smallest through diameter Wall thickness Guide bolt thread Screw diameter Screw color Major diameter Minor diameter core Screw lengths Hex size Alternative hexdrivers Alternative modes Distal Locking driving end Static lock locations orientations Static locking hole dimensions Proximal Locking non driving end Static lock locations orientations Static locking hole dimensions Proximal screw hole diameter AP bow radius AP bow location TI6AI4V 10 11 5 and 13mm 18 50cm Gold Round 12mm 10 11 5 diameter 13mm 13 diameter 10 11 5 and 13mm 5 0mm 2 3mm 10 diameter 3 0mm 11 5 diameter 2 3mm 13 diameter 5 16 24 UNF 5 0mm Gold 5 0mm 4 3mm 25 110
20. mm 4 7mm RT Femoral and Recon 7 0mm Cannulated Screw PERI LOC 4 7mm Hexdriver PROFIX 4 7mm Hexdriver No 15mm ML Threaded can be locked with META NAIL cap set screw 30mm 25 Threaded w bushing 40mm 25 Threaded w bushing Threaded 4 5mm minor diameter Threaded 5 3mm major diameter 15mm AP 35mm AP 5 3mm 5 3mm 2m Starts 100mm from driving end Set does not include all sizes Additional sizes may be special order only NO oo gt Position the patient supine on a radiolucent Rotate the C Arm to ensure optimal AP Use a bolster or radiolucent triangle to Surgical technique Patient positioning table Flex the affected limb approximately 45 over a posterior support to assist with fracture reduction Figure 1 Check for length and rotation by comparison to the unaffected limb anteroposterior and lateral visualization of the entire femur The C Arm should be able to freely access the femur up to and including the intertrochanteric area A distraction device may also be applied to obtain and or maintain traction Figure 1 Address intra articular fracture components with interfragmentary screw fixation prior to nail insertion Be sure to place the screws in the anterior and posterior aspect of the distal femur and safely out of the nais intended path Note Cannulated screw Guide Pins allow confirmation of definitive screw placement prior to fracture fixatio
21. n and nail insertion maintain limb position Rotate the C Arm to ensure optimal AP and lateral visualization of the entire femur A distraction device may also be applied to obtain and or maintain traction Figure 2 Caution If using the TRIGEN SURESHOT Distal Targeting System verify that there are no metal objects in the immediate targeting area Metal interference will cause the SURESHOT System to be inaccurate Figure 2 Establish the incision and entry portal 1 Inspect the Entry Portal Tube 7167 4060 to ensure that it is not damaged bent or Entry Portal Tube chipped Any flaws in the tube can lead to damage of the surrounding tendons and tissues 2 Assemble the Honeycomb 7167 4075 Entry Portal Handle 7167 4092 and Entry Tube Figure 3 by pulling back the black trigger of Entry Portal Handle the Entry Portal Handle and inserting the Entry Figure 3 Tube into the handle ring m Honeycomb Turn the tube until it clicks into the locked position Optional Suction can be applied to the Entry Portal Handle 3 Make a 3 4cm midline skin incision followed by a medial parapatellar capsular incision to expose the intercondylar notch Figure 4 Gently retract the patellar tendon laterally Figure 4 amp o Entry portal acquisition Locate the entry point within the intercondylar notch just anterior and lateral to the femoral attachment of the posterior cruciate ligame
22. nt Figure 5 _ Attach a 3 2mm Brad Point Guide Pin 7167 4130 or 7163 1436 to the drill via the Mini Connector 7163 1186 Insert the Guide Pin into the distal femoral metaphysis to a depth of 6 8cm Figure 6 Note The entry portal instrumentation serves as a soft tissue protector The Guide Pin should be in line with the femoral axis in the AP view and anterior to Blumensaat s Line in the lateral view Figure 7 Note If suboptimal Guide Pin insertion occurs rotate the Honeycomb within the Entry Portal Tube to the desired location and insert another 3 2mm Brad Point Guide Pin Figure 8 Note Do not over insert the Guide Pin as this can establish a false trajectory and cause fracture malalignment Figure 5 Figure 6 Blumensaat s Line Figure 7 Figure 8 _ NO ic 2 Entry portal After Guide Pin placement remove the Honeycomb 7167 4075 from the Entry Tube along with any additionally inserted Guide Pins Attach the 12 5mm Entry Reamer 7163 1116 to a power drill Advance the reamer over the Guide Pin and through the Entry Tube to a depth of 6 8cm Figure 8 _Check the position of the Entry Reamer via radiographic imaging and then remove the Entry Reamer and Guide Pin Alternative technique Entry portal With the Entry Tube and Entry Portal Handle still in the joint space attach the T handle 7167 4076 or 7167 4576 to the Cannulate
23. o drill a gold 5 0mm locking screw in the instance of hard cortical bone The 4 0mm Short Step Drill diameter transitions from 4 7mm to 4 0mm to facilitate screw insertion without compromising purchase Figure 26 Figure 27 The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with the 4 0mm AO Long Drill 7163 1121 13 Distal locking 1 Make a small incision at the site of screw entry 2 Insert the gold 9 0mm Drill Sleeve 7163 1152 4 0mm Drill Sleeve 7167 4083 and Screw Depth Gauge 7163 1189 through the desired slot on the Anterior Drop Figure 28 down to the bone 3 Drill both cortices with the 4 0mm Long Pilot Drill 4 Measure for screw length using either the calibrations on the 4 0mm Long Pilot Drill or by removing the 4 0mm Drill Sleeve and using the Screw Depth Gauge 5 Attach the appropriate length screw to the end of the Medium Hexdriver 7163 1066 6 Use power to insert the screw through the gold 9 0mm Drill Sleeve until the laser etched ring on the Hexdriver reaches the back of the Drill Sleeve 7 Attach the T handle to the Hexdriver 8 Manually tighten the screw If additional fixation is required the TRIGEN STABLE LOK Nut and Washer Part 7163 2001 offers increased purchase in low density or osteoporotic bone For information about how to use the STABLE LOK Nut and Washer refer to Appendix B TRIGEN STABLE LOK Nut and Washer at the back of this document Figure
24. ook 115073 Small Extractor Hook Catalog intormation TRIGEN Base Instrument Set Set No 7167 4012 Cat Item 7112 9401 7112 9402 7167 4021 7163 1066 7163 1068 7163 1116 7163 1140 7163 1152 7163 1161 7163 1186 7163 1189 7167 4000 7167 4060 7167 4074 7167 4075 7167 4076 or 7175 4576 7167 4077 7167 4077 Description Small Outer Case Lid for Outer Case TRIGEN Base Tray _ Medium Hexdriver Short Hexdriver 12 5mm Entry Reamer Guide Bolt Wrench 9 0mm Drill Sleeve Multipurpose Driver Mini Connector Screw Depth Gauge Cannulated Awl Entry Portal Tube 3 2mm T handle Trocar Honeycomb T handle Reducer Reducer Connector i o E mec ee ff j i Qty d n n a d a NN lal d d Aa d Cat Item 7167 4078 7167 4079 7167 4080 7167 4081 7167 4082 7167 4083 7167 4084 7167 4085 7167 4092 7167 1212 7111 8200 7163 1130 7164 1123 7163 1121 7167 1123 7167 4130 7163 1070 7175 1153 7163 1187 Description Obturator Ruler Gripper Impactor Slotted Hammer 4 0mm Drill Sleeve Screwdriver Release Handle Screw Length Sleeve Entry Portal Handle TRIGEN Reamer Set Optional SCULPTOR Flexible Reamer Optional Flexible Reamer Extender Optional TRIGEN 4 0 Diaphyseal Drill 4 0mm Long AO Pilot Drill 333mm Disposable 4 0mm Short AO Pilot Drill 161mm Disposable 3 2mm x 343mm Brad Point Tip Guide Pin Disposable Long Hexdriver Optional A
25. p triangle to triangle for AP screws and square to square for ML screws Figure 10 2 Follow the previously described techniques for cartridge positioning and blocking screw insertion Figure 11 Note The AP blocking screws targeted through the two holes built into the Anterior Drop cannot be used if the most superior oblique distal locking screw has been inserted Figure 11 25 Final view Stability blocking screws 1 Once stability blocking screw insertion is complete remove the Blocking Screw Attachment and Anterior Drop from the drill guide 2 Obtain both AP and lateral radiographic images to confirm accurate placement Figures 12 and 13 26 Figure 13 NO oo Ln NO The TRIGEN STABLE LOK Nut and Washer 7163 2001 offers increased purchase in low density or osteoporotic bone Used with a corresponding 5 0mm TRIGEN Internal Hex Head Screw Figure 1 the STABLE LOK Nut and Washer resists screw back out while improving fixation To implant the cortical screw use the TRIGEN 4 0mm Long Pilot Drill 7163 1121 the TRIGEN Screw Depth Gauge 7163 1189 and a second TRIGEN T Handle 7167 4076 or 7167 4576 Alternatively use the optional Straight Ratcheting Driver 7175 1141 attached to a short or medium TRIGEN Hexdriver 7163 1068 7163 1066 Use powered instrumentation to advance the TRIGEN 4 0mm Long Pilot Drill into the bone Continue to advance the drill until ful

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