Surgical Technique International Version · prophylactic nailing of impending pathologic fractures; reconstruction following tumor resection and grafting; bone lengthening and shortening;

$Page 1: Surgical Technique International Version · prophylactic nailing of impending pathologic fractures; reconstruction following tumor resection and grafting; bone lengthening and shortening;$
Surgical TechniqueInternational Version


Nota Bene

The technique description herein is made available to the healthcare professional to illustrate the author’ssuggested treatment for the uncomplicated procedure. In the final analysis, the preferred treatment is thatwhich addresses the needs of the specific patient.

Table of ContentsFeatures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4INTERTAN System Case Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Design Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Nail Specifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Entry Point . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Fracture Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Nail Length Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Preparation of the Medullary Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Target Device Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Nail Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Anteversion Alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21AP Alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Guide Pin Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Lag Screw Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Single Lag Screw Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Integrated Interlocking Lag Screw Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Distal Locking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34Nail Cap Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Nail Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Catalogue Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

TRIGEN™ INTERTAN™ Intertrochanteric Antegrade NailSurgical Technique

As described by:Professor Dr. med. J.M. RuegerThomas A. Russell, MDRoy W. Sanders, MDPaul Tornetta, MD

2

Introduction

INTERTAN™ Nails -Designed for StabilityThe TRIGEN™ INTERTAN nail was designed as a trochanteric portal intramedullary nail especially shaped for fractures of the proximal femur. The INTERTAN system offers anatomically shaped trapezoidal implants as opposed to conventional circular shaped intramedullary nails.

The INTERTAN system offers an integratedinterlocking screw option to increase stability andresistance to intra-operative and post-operativefemoral head rotation, thus eliminating excessivesliding and the possibility of Z-effect. The INTERTANscrew is a 4th generation intramedullary nailcombining the rotational stability of the originalRUSSELL-TAYLOR™ Reconstruction Nail with theenhanced sliding and compression of the IMHS™Intramedullary Hip Screw. The INTERTAN systemscrew utilizes the best of both concepts.

The option of a single lag screw device placed inthe femoral head is available for rotationally stable proximal femur fractures.

Devices in the proximal femur are at their greatest stress levels when the hip is placed through itsflexion extension arc (ex: chair rise and climbingstairs). During this event, the trapezoidal shapeof the INTERTAN system enhances stability of theimplant within the femur. In addition, the integratedinterlocking screw configuration imparts rotationalstability in the femoral head and neck segment, andoffers a greater resistance to cutout. With thesefeatures, the INTERTAN system provides aninnovativetreatment option for proximal femur fractures.

3

This next generation nail in the TRIGEN™ systemprovides these clear advantages:Implants

• Additional strength and stability with a unique integrated interlocking screw and trapezoidalnail shape

• Improved resistance to femoral head rotationand cutout

• Active compression achieved through a linearmotion without rotation

• Single subtrochanteric lag screw option forstable fractures below the lesser trochanter

• Preloaded cannulated set screw convertsthe construct to a fixed angle device

• The small proximal diameter of the nailpromotes preservation of the lateral wallof the greater trochanter and gluteusmedius tendon

• Clothespin tip for stress modulation in thefemoral shaft

• Potential for improved patient mobilityand recovery

Instrumentation

• Familiar, easy to use, minimally invasiveTRIGEN instrumentation

• Anti-rotation bar maintains stability duringdrilling and screw insertion

• Alignment guides for proper lag screwplacement in the femoral neck and head

4

INTERTAN™ System Case Examples

Preoperative AP Preoperative Lateral

Postoperative AP Postoperative Lateral

12 Month AP 12 Month Lateral

Case 1

With Thanks to Dr. med. Andreas Ruecker University Hospital Hamburg - Eppendorf

5

Preoperative AP

Postoperative AP Postoperative Lateral

Case 2

6

Two-screw integrated interlocking provides:

• Improved resistance to femoral head rotation and cutout

• Active compression achieved through a linear motion without rotation

Design Features

4° Lateral offset fortrochantericinsertion

Figure 8 cross-sectionto improve resistanceof cutout

Preloaded cannulated set screw convertsconstruct to a fixed angle device or allowsfor post operative sliding

Trapazoidal nail shape providesadditional strength and stability in theproximal femur during flexion extensionsimilar to hip stem prosthesis

Small proximal diameter of the nailpromotes preservation of the lateralwall of the greater trochanter andgluteus medius tendon

Distal slot forstatic or 5mm ofdynamization androtational stability

Clothespin tip forstress modulationin the femoral shaftwhich reducesstiffness that cancause thigh painand periprostheticfracture

Optional distaldiameters foroptimal fit infemoral canal

Implant Specifications

NOTE: These views are not to scale and should be used as a pictorial representation only.

28.3mm

18, 20cm

10, 11.5, 13mm

4°

5mm

40mm / 18cm60mm / 20cm

16.25mm

15.25mm

11mm

32mm

Minor diameter tapers from 11-5.6mm

7mm

15.25mm

Integrated interlocking screws (sold together) 70-125mm

7.8mm

7

8

NOTE: These views are not to scale and should be used as a pictorial representation only.

Implant Specifications continued

16.25mm

10, 11.5, 13mm

15.25mm

26-46cm

2m APBow

28.3mm

40mm

15mm

20mm

11mm

32mm

Minor diameter tapers from 11-5.6mm

Subtrochanteric lag screw70-125mm

9

Indications

INTERTAN™ nails are indicated for simple longbone fractures; severely comminuted, spiral, longoblique and segmental fractures; nonunions andmalunions; polytrauma and multiple fractures;prophylactic nailing of impending pathologicfractures; reconstruction following tumor resectionand grafting; bone lengthening and shortening;subtrochanteric fractures; ipsilateral femoralshaft/neck fractures; intertrochanteric fractures;and intracapsular fractures.

10

Templates

Use the Smith & Nephew Preoperative INTERTAN™nail templates to determine the appropriate neckangle, nail length, nail diameter and proper screwlength. All INTERTAN nail templates are availablewith 117% magnification to compensate forradiographic magnification. Please keep in mindthat variations in magnification do occur.

When selecting the appropriate nail size take allaspects of the fracture into consideration.

15

5

cm

0

10

*Special Request

*75mm

85mm

95mm

105mm

115mm

*125mm

Top of Nail

10mm

20mm

*120mm110m

m100mm90m

m80mm*70m

m

13.0mm*

11.5mm

10.0mm

20

Lag Screw Centerline

16.3mm

15.2mm

mm3035 2555 4565

5060

5.0mm Gold Screw

40

10 1401201104030 13070 150 mm50mm 0 90 100

117% Magnification

60 8020

A/P ViewLateral View

20cm*

18cm

Shaft Diameter

Template

130°

OrthopaedicsSmith & Nephew, Inc.1450 Brooks RoadMemphis, TN 38116USA

Telephone: 1-901-396-2121For information: 1-800-821-5700For orders and order inquiries: 1-800-238-7538www.smith-nephew.com

™Trademark of Smith & Nephew. Reg. US Pat. & TM Off.

02/06 7167-4098

RIGHTLEFT

TRIGEN™ INTERTAN Nail X-ray Template Set

Cat. No. 7167-4200

11

Patient Positioning

Place the patient in the supine position on a fractureor radiolucent table with the unaffected limbextended below the affected limb and trunk. Flexthe affected hip 15º-40º. Apply traction througha skeletal traction pin or with the fracture table footholder. Adjust the affected limb for length androtation by comparison with the unaffected limb.Check rotation by rotating the C-arm in line withthe femoral neck anteversion and then make theappropriate correction. This is best checked byvisualizing the femoral anteversion proximally andmatching it with the correct rotation of the knee.

The lateral decubitus position may be selected incertain fracture configurations at the surgeon’sdiscretion.

For short nails only (not recommended for long nailprocedures), flex the hip and knee of the unaffectedextremity and place it in a leg holder. Abduction andinternal rotation of the hip allows unimpededfluoroscopic imaging.

12

Incision

Palpate the trochanter. Make a 3cm incisionapproximately 2-3cm proximal to the greatertrochanter. Carry the incision through thefascia. Do not damage the gluteal musclesby excessive manipulation.

13

Entry Point

Assemble the entry portal tube to the entry portalhandle and insert the honeycomb. The tubeassembly is oriented so that the superior side ofthe bevel is medial or lateral as desired. Advancethe assembly until it rests against the lateral aspectof the greater trochanter.

TRIGEN™ Tip: Attaching suction to the entry portalhandle provides an unobstructed view of the entrysite, assists in blood evacuation, and minimizesaerosolization of blood to the operative team.

Attach the 3.2mm guide pin to the mini-connector.The entry point for the guide pin is in line with themedullary canal in the ML view and 4º from centrein the AP view. Insert the guide pin through thehoneycomb and advance 2-3cm into the cortexat the tip of the greater trochanter. Once properplacement of the guide pin is achieved, removethe honeycomb.

TRIGEN Tip: A two guide pin technique may beused. The first pin is inserted through one of theoff-centre holes in the honeycomb just lateral tothe tip of the greater trochanter. The honeycombis then rotated to access the definitive site ofprecise portal placement. The second guide pincan then be easily and accurately placed in thedefinitive site.

Entry Portal Tube

Cat. No. 7167-4060

Entry Portal Handle

Cat. No. 7167-4092

Honeycomb

Cat. No. 7167-4075

3.2mm Guide Pin

Cat. No. 7167-4029

Mini-Connector

Cat. No. 7163-1186

AO Mini-Connector

Cat. No. 7175-1153

14

Opening the Proximal Femur

Insert the 12.5mm entry reamer until it “clicks” into the 16mm channel reamer. Attach the channel reamer assembly to power for reaming of the proximal section of the femur. Introduce the assemblyover the 3.2mm guide pin through the entry portal tube and advance 1-2cm into bone. The reamer assembly is then manipulated under image until the shaft axis and intended path of the reamer form an angle of approximately 4° in the AP view and is in line with the centre of the femoral canal in the ML view. Caution should be taken not to over estimate the angle, as too much of a lateral insertion angle may make advancement of the nail more difficult. Once the correct orientation is obtained, the reamer assembly is advanced to full depth seated against the entry portal tube. Remove the 12.5mm entry reamer and guide pin, keeping the entry portal tube and channel reamer in place.

TRIGEN™ Tip: View the channel reamer as a three step process:

1. Capture the guide wire with 1st 10mm of channel reamer insertion.

2.The next 20mm of the channel reamer aligns for varus, valgus, flexion, and extension alignment.

3.Controls trajectory of reamer path from proximal metaphysis into the medullary canal.

Note: Use caution not to insert the guide pinin so deeply, that a false trajectory is made inthe proximal femur introducing a malalignmentat the fracture.

Note: If the entry portal tube is not used,ensure that the channel reamer has reachedthe level of the lesser trochanter.

12.5mm EntryReamer

Cat. No. 7163-1116

16mm ChannelReamer

Cat. No. 7167-4062

15

Fracture Reduction

Assemble the modular reducer and attach theT-handle. Introduce the assembly through thechannel reamer and entry portal tube. Use thereducer to manipulate the proximal fragmentand reduce the fracture. Insert the reducer to thelevel of the distal epiphyseal scar once the distalfragment has been captured.

TRIGEN™ Tip: If the fracture is severely displaced,use the curved tip of the reducer to direct the3.0mm x 1000mm ball tip guide rod into the distalfragment of the femur. Under fluoroscopy, stop thereducer as it approaches the fracture site. Passthe guide rod through the reducer until the tipof the guide rod can be visualized at the endof the curved reducer. Rotate the reducer anddirect the guide rod to capture the distal fragmentthen advance the reducer into the distal fragment.The gripper is useful in holding onto the guide rodduring insertion, proper placement, and removal.

Reducer

Cat. No. 7167-4077

T-handle

Cat. No. 7167-4076

Gripper

Cat. No. 7167-4080

3.0mm x 1000mmBall Tip Guide Rod

Cat. No. 7163-1626

16

Guide Rod Placement

Insert the 3.0mm ball-tipped guide rod throughthe reducer and into the distal femur. The guiderod should be placed centre-centre in the shaft ofthe femur in the AP and ML views stopping in theregion of the distal epiphyseal scar. This minimizesthe chance of eccentric anterior placement of thenail in osteopenic femurs.

Reducer

Cat. No. 7167-4077

3.0mm x 1000mmBall Tip Guide Rod

Cat. No. 7163-1626

17

Nail Length Measurement

If a long nail has been chosen, it will be necessaryto measure for nail length. Confirm the distal tip ofthe 3.0mm x 1000mm ball tip guide rod is locatedat the desired position in the distal femur. Slide theruler over the proximal end of the guide rod.Advance the open end of the ruler through thechannel reamer and entry portal tube. The tip of theruler should be at the level of the greater trochanter.Read the nail length from the calibrations exposedat the other end of the ruler.

3.0mm x 1000mm

Ball Tip Guide Rod

Cat. No. 7163-1626

Ruler

Cat. No. 7167-4079

18

Preparation of Medullary Canal

Canal preparation is dependent upon surgicalpreference. If diaphyseal reaming is planned, useprogressive reamers over the guide rod through thechannel reamer and entry portal tube. Sequentiallyream in 0.5mm increments to approximately 1mmlarger than the chosen nail diameter. The obturatormay be used to ensure the guide rod stays inposition during reaming. Periodically move thereamer back and forth in the femoral canal to cleardebris from the cutting flutes of the reamer.

TRIGEN™ Tip: The obturator is used during sequentialreaming to maintain the position of the guide rod inthe canal. The holes in the black obturator head canbe used to hold the exposed end of the guide rod asreamer removal begins. The obturator shaft can thenbe inserted into the cannulation of the reamer tocontinue holding the guide rod position.

Note: The channel reamer will not accommodatereamer heads larger than 12.5mm.

Obturator

Cat. No. 7167-4078

19

Target Device Assembly

Select the appropriate radiolucent drill guide dropbased upon the neck angle chosen and attachthe drop to the drill guide handle. Confirm thepre-loaded cannulated set screw does not obstructthe lag screw hole in the nail. Insert the 7/16 guidebolt into the drill guide handle and attach the nailusing the guide bolt wrench with T-handle. Ensurethat the guide bolt is properly seated and threadedinto the nail. Any nail incorrectly attached will notaccurately target. Verify targeting accuracy byinserting the lag screw drill sleeve into the drill guideand confirm the 11mm lag screw drill passes easilythrough the nail. Once the correct nail assembly hasbeen verified remove the drill sleeve and attach theImpactor onto the drill guide to insert the nail.

7/16 Guide Bolt

Cat. No. 7167-4071

Guide Bolt Wrench

Cat. No. 7163-1140

Impactor

Cat. No. 7167-4081

T-handle

Cat. No. 7167-4076

Drill Guide Drop

Cat. No. 7167-400x

20

Nail Insertion

Verify proper fracture reduction. Advance the nailover the guide rod with the drill guide in the lateralposition and carefully seat in the proximal femur.Final nail position is achieved with a gentleimpaction force applied by the hammerafter confirmation of proper anteversion andAP alignment.

Select the appropriate radiolucent drill guide dropbased upon the neck angle chosen and attachthe drop to the drill guide handle.

TRIGEN™ Tip: For long nails, orient the nail andguide 90º anteriorly. Advance the nail over theguide rod until the nail taper is reached and thenrotate the guide to the lateral position.

Drill Guide Handle

Cat. No. 7167-4001

21

Anteversion Alignment

Anteversion alignment is achieved using theradio-opaque embedded wire in the drill guidehandle. Position the C-Arm for an antevertedlateral image. Rotate the drill guide until both thenail and wire are centered within the femoral head.This may also require adjustment of the C-Arm.

Drill Guide Handle

Cat. No. 7167-4001

22

AP Alignment

Rotate the C-Arm to the AP position. Attach thealignment tower to the drill guide and insert thealignment arm. Verify the markings on the alignmentarm match the operative side. Use the C-Arm toposition the drill guide so the alignment arm andthe center of the lag screw hole in the nail are inline with the femoral head. The alignment armfacilitates visualization of the central axis of thelag screw. Centre-centre alignment applies to boththe single subtrochanteric lag screw and the 11.0mmlag screw of the integrated interlocking screws.

Alignment Arm

Cat. No. 7167-4066

Alignment Tower

Cat. No. 7167-4018

23

Final Seating of the Nail

Remove the guide rod prior to the last 2cm offinal seating. Confirm the nail is in the desiredposition and exert a gentle impaction force withthe hammer to fully seat the nail.

Note: The trapezoidal cross section of the nailhelps control rotation during insertion similar tothe press fit of uncemented hip stem techniques.

Note: If excessive impaction force was necessary,check to make sure the guide bolt is still tightand the set screw has not migrated into the lagscrew hole.

If the nail fails to advance sufficiently, use biplanarimaging of the nail tip and the fracture zone toidentify the source of impingement. Additionalreaming may be required, especially in theproximal metphyseal diaphyseal junction. In youngstrong bone, a narrow proximal metaphyseal todiaphyseal transition may require sequential flexiblecanal reaming over the guide wire to facilitatenail insertion.

Note: Since the channel reamer must be removedfor reaming over 12.5mm, exercise caution not toream out the lateral cortex in the proximal femur.

24

Guide Pin Insertion

Insert the adjustable lag screw drill sleeve and the4.0mm drill sleeve trocar into the drill guide. Firmlypress the trocar tip into the skin. Use this mark tomake a small incision down to bone. Advance thedrill sleeve and drill sleeve trocar through theincision. Verify the lag screw sleeve locks into thedrill guide.

Note: Both sleeves should rest gently againstbone. If the drill sleeves are pushed aggressivelyin position the drill guide may deflect.

Note: The lag screw drill sleeve is adjustable.The “0” setting will accommodate most patients.

Confirm the desired anteversion with the C-Armin the lateral position.

Lag ScrewDrill Sleeve

Cat. No. 7167-4023

4.0mm SleeveTrocar

Cat. No. 7167-4072

25

Make sure that the trocar sleeve is gently restingagainst bone and insert the 4.0mm long AO pilotdrill. Open the lateral cortex under power. Removethe drill bit and replace the trocar sleeve withthe lag screw 3.2mm guide pin sleeve. Advancethe 3.2mm guide pin through the guide pin sleevewhile maintaining the correct anteversion. Finalpositioning of the guide pin should be done withthe C-Arm in the AP plane. Insert the guide pinuntil the tip reaches the optimal tip-to-apexdistance (TAD). Reconfirm the final placementof the pin in both planes.

TRIGEN™ Tip: Utilize the 4.0mm drill sleeve trocar tooptimize drill position in the lateral cortex and helpprevent cephalad malposition of the guide pin.

Note: Do not use the trocar sleeve to read guide pinmarkings. The 3.2mm guide pin sleeve must beseated within lag screw drill sleeve.

4.0mm Long AOPilot Drill

Cat. No. 7164-1121

3.2mm Guide Pin

Cat. No. 7167-4029

Lag Screw 3.2mmGuide Pin Sleeve

Cat. No. 7167-4032

26

Lag Screw Measurement

Read the calibrations off the guide pin for lag screwmeasurement. Alternatively, lag screw measurementmay be obtained by inserting the lag screw lengthgauge over the guide pin until it sits flush withthe end of the lag screw 3.2mm guide pin sleeve.Confirm the guide pin sleeve is seated flush withinthe lag screw drill sleeve for an accuratemeasurement. Lag screw measurement isdetermined by lining up the end of the guide pinwith the calibrations on the length gauge.

Note: The lag screw measurement is independentof the proximity of the drill sleeve to the lateralcortex of the femur.

At this point in the procedure it is necessary todetermine if a single lag screw or an integratedinterlocking lag screw will be chosen. Once youcommit to a single lag screw techniqueyou cannot use the integrated interlockingscrew technique.

The single lag screw steps are tabbed in Blue.

The integrated interlocking screw steps aretabbed in Green.

Lag ScrewLength Gauge

Cat. No. 7167-4058

27

Single Lag Screw Insertion

Single Lag Screw DrillingConfirm that the guide pin tip is 5mm fromsubcondular bone for adequate screw depth. Drillover the guide pin under image using the 11.0mmlag screw drill. Confirm the guide pin is not beingforced forward. Drill until the lag screw drill reachesthe measured guide pin depth. This will be indicatedby the markings on the shaft of the lag screw drill.Care should be taken to ensure that orientation ofthe drill guide handle is not altered. Markings on thelag screw drill reference the face of the drill sleeve.

TRIGEN™ Tip: Use the obturator to maintainthe position of the guide pin during lag screwdrill removal.

Lag Screw SelectionIf compression is not needed then select a lagscrew length equal to the measurement taken fromthe drilling depth. For example, if the drilling depthwas 100mm then select a 100mm lag screw.

If compression is needed then select a lag screwlength equal to the measurement taken from theguide pin minus the desired amount of compression.For example, if the drilling depth was 100mm and upto 5mm of compression is needed, then select a95mm lag screw. By selecting a 90mm lag screw amaximum of 10mm of compression can be achieved.

Note: It is not recommended to exceed 10mmof compression.

Sing

le L

ag S

crew

Inse

rtio

n

11mm Lag ScrewDrill

Cat. No. 7167-4008

Subtroch Lagscrewdriver

Cat. No. 7167-4068

T-handle

Cat. No. 7167-4076

28

Sing

le L

ag S

crew

Inse

rtio

n

Lag Screw InsertionWithout CompressionAttach the selected INTERTAN™ SubtrochantericLag Screw to the subtroch lag screwdriver.Thread the compressing dial onto the end ofthe driver until the “0” mark is visible. Attach theT-handle and insert the driver assembly into thelag screw drill sleeve. Advance the driver byrotating it clockwise until the dial is flush againstthe drill sleeve. At final seating, the T-handle mustbe positioned perpendicular or parallel to the drillguide to properly orient the lag screw.

INTERTAN Lag Screw InsertionWith CompressionAttach the selected subtrochanteric lag screw tothe subtroch lag screwdriver.

Option #1: 5mm of Compression

If the lag screw selected is 5mm less than whatwas drilled for, thread the compressing dial ontothe end of the driver until the “5” mark is visible.


If the lag screw selected is 10mm less than whatwas drilled for, thread the compressing dial ontothe end of the driver until the “10” mark is visible.

Attach the T-handle and insert the driver assemblyinto the lag screw drill sleeve. Advance the driverby rotating it clockwise until the compressing dialis flush against the drill sleeve. At final seating, theT-handle must be positioned perpendicular or parallelto the drill guide to properly orient the lag screw.

Single Lag Screw Insertion continued

Subtroch LagScrewdriver

Cat. No. 7167-4068

Compressing Dial

Cat. No. 7167-4069

T-handle

Cat. No. 7167-4076

29

Compression is achieved by rotating thecompressing dial clockwise until desiredcompression is achieved or the “0” mark onthe subtroch lag driver is visible.

Note: The red marking on the driver signifiesthat the compression limit has been reached.

Locking Set ScrewTo prevent sliding, tighten the set screw firmlyusing the set screwdriver and T-handle assembly.To permit sliding, reverse the set screw ¼ turncounterclockwise once the set screw is tightened.Screw design prevents medial screw migrationinto the femoral head.

Confirm the set screw is engaged in a migrationlimiting slot on the lag screw by gently turning theT-handle. If turning the T-handle is limited, then theset screw is properly engaged.

Sing

le L

ag S

crew

Inse

rtio

n

Subtroch LagScrewdriver

Cat. No. 7167-4068

Compressing Dial

Cat. No. 7167-4069

T-handle

Cat. No. 7167-4076

30

Inte

grat

ed I

nter

lock

ing

Lag

Scre

w In

sert

ion Integrated Interlocking Lag Screw Insertion

Compression Screw PreparationAttach the 7.0mm compression screw starter drillto power and perforate the lateral cortex beneaththe lag screw 3.2mm guide pin sleeve to preparethe bone for the head of the compression screw.Advance the drill until the built in positive stopabuts the guide pin sleeve. Remove the starter drill.

Note: It is imperative to abut the starter drill priorto drilling for the compression screw. The starterdrill prepares the lateral cortex for the compressionscrew head which is larger than its shaft. Failure tocomplete this step may cause inefficient compressionand/or cephalad malposition.

Attach the 7.0mm compression screw drill to power andinsert it into the same hole as the starter drill. Advancethe drill under fluoroscopy to a depth 5mm less than theguide pin depth. The markings on the compressionscrew are read from the face of the lag screw drill sleeve.

Remove the compression screw drill and replaceit with the anti-rotation bar. The anti-rotation barshould be introduced using hand force only. If thestarter drill has not been sufficiently used, thelateral cortex may deflect the anti-rotation bar. Ifdeflection occurs, reuse the starter drill to clearaway the bone at the nail interface to facilitateanti-rotation bar insertion.

Note: The anti-rotation bar provides stability of thehead and neck segment during lag screw drilling.

INTERTAN™ Lag Screw DrillingDrill over the guide pin using the 11.0mm lag screwdrill. Confirm under image the guide pin is not beingforced forward beyond the desired depth. Markings onthe lag screw drill reference the face of the drill sleeveand confirm guide pin depth. Care should be taken toensure orientation of the drill guide handle is not altered.

TRIGEN™ Tip: Use the obturator to maintain theposition of the guide pin during drilling.

7.0mm CompressionScrew Starter Drill

Cat. No. 7167-4070

7.0mm CompressionScrew Drill

Cat. No. 7167-4034

Anti-Rotation Bar

Cat. No. 7167-4073

31

INTERTAN™ Lag Screw SelectionIf compression is not needed then select the lagscrew length that is equal to the measurement takenfrom the drilling depth. For example, if the drillingdepth was 100mm, then select a 100mm Lag Screw.

If compression is needed then select the lag screwlength that is equal to the measurement taken fromthe drilling depth minus the desired amount ofcompression. For example, if the drilling depth was100mm and up to 5mm of compression is needed,then select a 95mm lag screw. By selecting a 90mmlag screw, a maximum of 10mm of compression canbe achieved. The INTERTAN lag screw will bepackaged with the 7.0mm compression screw. Thecompression screw is 5mm shorter than the lagscrew.

Note: It is not recommended to exceed 10mmof compression.

INTERTAN Lag Screw InsertionWithout CompressionAttach the selected INTERTAN lag screw to the lagscrewdriver. Insert the driver assembly into the lagscrew drill sleeve. Gently advance the driverthrough the drilled hole.

Rotate the driver, inserting the screw until the “0”mark on the driver is in line with the face of the lagscrew drill sleeve. At final seating, the T-handle of thelag screwdriver must be perpendicular to the drillguide to allow for the removal of the anti-rotation bar.

Remove the anti-rotation bar. Next attach thecompression screw to the compression screwhexdriver. Once the compression screw is properlysecured, attach the T-handle to the hexdriver. Advancethe compression screw by rotating the T-handleclockwise until the blue line on the driver shaft isaligned with the face of the lag screw drill sleeve.

Lag Screwdriver

Cat. No. 7167-4067

CompressionScrew Hexdriver

Cat. No. 7167-4035

T-handle

Cat. No. 7167-4076

Inte

grat

ed I

nter

lock

ing

Lag

Scre

w In

sert

ion

32

Integrated Interlocking Lag Screw Insertion continued

TRIGEN™ Tip: Even if no compression was planned2-3mm of compression can be achieved by rotatingthe compression screw T-handle until the red lineon the lag screwdriver becomes visible. Do notcompress past the red line.

TRIGEN Tip: If additional compression is neededthen remove the compression screw hexdriver andassemble the compressing dial onto the lagscrewdriver. Thread the compressing dial until isabuts the lag screw drill sleeve. Gently rotate thecompressing dial clockwise under image untildesired compression is achieved. A maximum of5mm of compression may be achieved.

INTERTAN™ Lag Screw InsertionWith CompressionAttach the selected INTERTAN lag screw to the lagscrewdriver. Insert the driver assembly into thelag screw drill sleeve. Gently advance the driverthrough the drilled hole.

Note: Release any traction on the fracture toallow compression.


Rotate the driver, inserting the screw until the “5”mark on the driver is in line with the face of thelag screw drill sleeve. At final seating, the T-handleof the lag screwdriver must be perpendicularto the drill guide to allow for the removal of theanti-rotation bar.


Rotate the driver, inserting the screw until the “10”mark on the driver is in line with the face of thelag screw drill sleeve. At final seating, the T-handleof the lag screwdriver must be perpendicularto the drill guide to allow for the removal of theanti-rotation bar.

Anti-Rotation Bar

Cat. No. 7167-4073

Lag Screwdriver

Cat. No. 7167-4067

Inte

grat

ed I

nter

lock

ing

Lag

Scre

w In

sert

ion

33

CompressionScrew Hexdriver

Cat. No. 7167-4035

Remove the anti-rotation bar. Next attach thecompression screw to the compression screwhexdriver. Once the compression screw is properlysecured, attach the T-handle to the hexdriver.Advance the compression screw by rotating theT-handle clockwise until the blue line on the drivershaft is aligned with the face of the lag screwdrill sleeve. At this point the compression screw isseated within the nail and compression can begin.

Continue to rotate the T-handle to linearly compressthe fracture. Rotating the T-handle will cause thegear mechanism of the integrated interlocking screwsto migrate the lag screwdriver back as compressionoccurs. When the blue line below the “0” mark on thelag screwdriver becomes visible, it is recommendedto stop compression.

TRIGEN™ Tip: An additional 2-3mm of compressioncan be achieved by rotating the compression screwT-handle until the red line on the lag screwdriverbecomes visible. Once the red line becomes visible,the compression limit has been reached.

Locking Set ScrewTo prevent sliding, tighten the preassembled setscrew firmly using the set screwdriver and T-handleassembly.

Note: The integrated interlocking lag screw isincapable of superior migration.

Note: The INTERTAN™ subtrochanteric lag screw isincapable of superior migration only if the set screwis engaged.

Inte

grat

ed I

nter

lock

ing

Lag

Scre

w In

sert

ion

Set Screwdriver

Cat. No. 7166-5014

34

Distal Locking Short Nails

Insert the 4.0mm drill sleeve into the 9.0mm drillsleeve and place this assembly through the drillguide. Make a stab incision and seat the drill sleeveassembly to bone. Drill through both cortices usingthe 4.0mm long AO pilot drill. The screw lengthcan be determined using the drill bit calibrationsmeasured against the 4.0mm drill sleeve or thescrew depth gauge. Attach the appropriate lengthinternal captured 5.0mm screw to the mediumhexdriver. Attach the T-handle to the hexdriver andinsert the screw. Targeted static (proximal) anddynamic (distal) locking options are available.

TRIGEN™ Tip: Use the screwdriver release handlethrough the T-handle to release the hexdriver fromthe screw.

9.0mm Drill Sleeve

Cat. No. 7163-1152

Screw Depth Gauge

Cat. No. 7163-1189

Medium Hexdriver

Cat. No. 7163-1066

4.0mm Long AOPilot Drill

Cat. No. 7164-1121

35

Distal Locking Long Nails

Distal locking in the long nail will require a free handtechnique. Use the screw length sleeve, 4.0mmshort AO pilot drill and the short hexdriver for thistechnique. Once “perfect circles” are established,make a stab incision. The short pilot drill is usedunder power to drill through the locking holes in thenail. The screw length can be determined using thedrill bit calibrations measured against the 4.0mmdrill sleeve or the screw depth gauge. Attach theappropriate length screw to the short hexdriver,connect the T-handle and insert the screw until itis fully seated.

Screw LengthSleeve

Cat. No. 7167-4085

4.0mm Short AOPilot Drill

Cat. No. 7164-1123

36

Nail Cap Insertion

It is recommended to use a nail cap to close theproximal end of the nail if osseous ingrowth isa concern. Attach the nail cap to the mediumhexdriver and then attach the T-handle. Insertthe assembly into the incision near the greatertrochanter and insert the end cap rotating theT-handle clockwise.

Note: The nail cap should be fully seated and flushwithin the nail at final seating.

Medium Hexdriver

Cat. No. 7163-1066

Nail Cap

Cat. No. 7167-5040

37

Nail Extraction Technique

Through a small incision, remove any distal lockingscrews using the short hex driver. Make an incisionover the proximal end of the nail. Under fluoroscopy,place a 3.2mm guide pin into the driving end of thenail. A mallet may be used to insert the guide pin,but usually power equipment is available and canbe used for percutaneous placement.

When the guide pin is in the nail, make a oneinch incision about the guide pin and advance the12.5mm entry reamer over the pin to remove theosseous ingrowth overlying the nail. Note thatthe tip of the reamer is straight for approximatelyone-half inch before flaring out. It is this portionof the reamer that enters the nail.

After reaming, remove the reamer and the guide pinand insert the 3.0mm ball tip guide rod. Attach theextractor to the impactor and tighten, then threadthe extractor into the nail (with the guide rod inplace). Place the guide bolt wrench shaft into theimpactor slot and turn clockwise until the impactor issecurely engaged into the nail.

After the impactor is securely engaged in the nail,remove the remaining lag screw.

Single Lag Screw RemovalMake a small incision at the lateral aspect ofthe INTERTAN™ subtrochanteric lag screw and removeany osseous ingrowth that may have formed intothe screw. Attach the lag screwdriver to the lagscrew. Confirm the lag screwdriver is fully seated andthe lag screw is captured. Remove the screw rotatingthe T-handle counterclockwise.

12.5mm EntryReamer

Cat. No. 7163-1116

3.2mm Guide Pin

Cat. No. 7167-4029

IMHS™ CP NailExtractor

Cat. No. 7168-7111

38

Nail Extraction Technique continued

Integrated InterlockingLag Screw RemovalMake a small incision at the lateral aspect of theintegrated interlocking lag screw and remove anyosseous ingrowth that may have formed into thescrews. Attach the long INTERTAN™ hexdriver to theinferior compression screw. Confirm the hexdriveris fully seated and remove the screw rotating theT-handle counterclockwise. Once the compressionscrew has been removed attach the lag screwdriverto the superior lag screw and remove the screwrotating the T-handle counterclockwise.

Confirm that all locking screws have been removedand remove the nail. Gently backslap the impactorwith the slotted hammer if needed.

Use extreme caution not to exert any side loads onthe impactor extractor assembly. Excessive pullingand pushing on the end of the impactor handlecould result in premature failure of the extractordevice. In the event of extractor, re-tighten thegripper adjacent to the impactor and proceed withthe extraction.

Recommended usage for the extractor: 7-10 timesthen replace.

39

An Alternative Method for Extraction

Jamming the Guide RodsUtilizing two guide rods, one 3.0mm ball tip andone 2.0mm smooth guide rod, advance the ball tipguide rod past the end of the nail then insert thesmooth guide rod in a similar manner, past the tipof the nail. Once both rods are in place, attach thegripper to the end of the ball tipped guide rod andpull back to wedge the ball tip with the smooth guiderod and the end of the nail. Backslap against thegripper to remove the nail.

Cat. No. Description

11-5120 2.0mm x 700mm smooth

7163-1626 3.0mm x 1000mm ball tip

7111-8280 2.0mm x 900mm smooth

7111-8202 3.0mm x 900mm ball tip

11-2069 3.0mm x 900mm ball tip

Note: Other items that may be helpful in removalare as follows:

Cat. No. Description

115074 Large Extractor Hook

115073 Small Extractor Hook

914659 Small Easy Out

914658 Large Easy Out

40

Cat. No. Description Qty.

7167-1210 TRIGEN™ 5.0mm Internal Captured 25mm-50mm Screw Set

7164-2225 Internal Hex Captured Screw 5.0mm x 25mm 1






7167-6032 INTERTAN™ Lag/Compression Screw Kit Set

7167-2030 INTERTAN Compression Screw 30mm 1

7167-7080 INTERTAN Lag/Comp Screw Kit 80mm x 75mm 1








7167-2000 INTERTAN Subtrochanteric Lag Screw Set

7167-8005 INTERTAN Subtrochanteric Lag Screw 105mm 1








Catalogue Information – Screws

41

Catalogue Information – Nails

ShortCat. No. Description Qty.

7167-1250 INTERTAN™ 125° 10mm & 11.5mm x 18cm Set

7167-5201 INTERTAN 10mm x 18cm 125° 1

7167-5202 INTERTAN 11.5mm x 18cm 125° 1

7167-1350 INTERTAN 130° 10mm & 11.5mm x 18cm Set

7167-5207 INTERTAN 10mm x 18cm 130° 1

7167-5208 INTERTAN 11.5mm x 18cm 130° 1

LongCat. No. Description Qty.

7167-1251 INTERTAN 125° 10mm x 34-40cm Set

7167-5221 INTERTAN 10mm x 34cm 125° Left Lime 1

7167-5222 INTERTAN 10mm x 34cm 125° Right Rose 1







7167-1351 INTERTAN 130° 10mm x 34-40cm Set









42


7167-1200 INTERTAN™ Disposable Set

7163-1121 4.0mm Long AO Pilot Drill (4.0mm x 333mm) 2

7163-1123 4.0mm Short AO Pilot Drill (4.0mm x 161mm) 2

7163-1626 3.0mm x 1000mm Ball Tip Guide Rod 2

7167-4029 3.2mm Guide Pin (3.2mm x 343mm) 3

Disposables

Long continuedCat. No. Description Qty.

7167-1252 INTERTAN™ 125° 11.5mm x 34-40cm Set

7167-5243 INTERTAN 11.5mm x 34cm 125° Left Lime 1

7167-5244 INTERTAN 11.5mm x 34cm 125° Right Rose 1







7167-1352 INTERTAN 130° 11.5mm x 34-40cm Set









43

Tray Outer Case (1)Cat. No. 652-4110

Lid for Tray (2)Cat. No. 652-4111

4.7mm Medium HexdriverCat. No. 7163-1066

Guide Bolt WrenchCat. No. 7163-1140

Screw Depth GaugeCat. No. 7163-1189

Set ScrewdriverCat. No. 7166-5014

12.5mm Entry ReamerCat. No. 7167-1116

Catalogue Information – InstrumentsINTERTAN™ System

130° Radiolucent Drill Guide DropCat. No. 7167-4003(135° Special Order)

Drill Guide HandleCat. No. 7167-4001

INTERTAN Instrument SetCat. No. 7167-5011

9mm Drill SleeveCat. No. 7163-1152

44

Low Profile Drill SleeveCat. No. 7167-4023

Lag screw guide pin sleevCat. No. 7167-4032

Compression Screw DriverCat. No. 7167-4035

Entry Portal TubeCat. No. 7167-4060

16mm Channel ReamerCat. No. 7167-4062

Alignment ArmCat. No. 7167-4066

Screw Length Gauge/Multi-TCat. No. 7167-4058

Comp Screw Starter DrillCat. No. 7167-4070

Lag Screw DriverCat. No. 7167-4067

11mm Lag Screw DrillCat. No. 7167-4008

Compression Screw DrillCat. No. 7167-4034

Alignment TowerCat. No. 7167-4018

45

Anti-Rotation BarCat. No. 7167-4073

HoneycombCat. No. 7167-4075

ReducerCat. No. 7167-4077

RulerCat. No. 7167-4079

Gripper Cat. No. 7167-4080

Impactor Cat. No. 7167-4081

ObturatorCat. No. 7167-4078

Entry Portal HandleCat. No. 7167-4092

AO Mini ConnectorCat. No. 7175-1153

Screwdriver Release HandleCat. No. 7167-4084

4.0mm Drill SleeveCat. No. 7167-4083

7/16 Guide BoltCat. No. 7167-4071

T-handleCat. No. 7167-4076

4.0mm Drill Sleeve TrocarCat. No. 7167-4072

46

125° Radiolucent Drill Guide DropCat. No. 7167-4002

Lag Screw TapCat. No. 7167-4009

Subtroch Lag ScrewdriverCat. No. 7167-4068

Multipurpose DriverCat. No. 7163-1161

Cannulated AwlCat. No. 7167-4000

Screw Length SleeveCat. No. 7167-4085

4.7mm Short HexdriverCat. No. 7163-1068

17mm Channel ReamerCat. No. 7167-4063

IMHS™ CP Nail ExtractorCat. No. 7168-7111

Slotted HammerCat. No. 7167-4082

T-handle TrocarCat. No. 7167-4074

INTERTAN Instrument SetCat. No. 7167-5012

Catalogue Information – Optional InstrumentsINTERTAN™ System

Compressing DialCat. No. 7167-4069

47


7167-1212 TRIGEN Reamer Set

7111-8200 Sculptor Flexible Reamer 1

7111-8232 9.0mm Reamer Head 1











7163-1130 Flexible Reamer Extender 1

TRIGEN™ Reamer Set (optional)

Catalogue Information – Replacement Parts


7167-4086 Subtroc Lag Screw Hexdriver Rod 1

7167-4087 Lag Wrench Retaining Rod Assembly 1

7167-4088 Compression Screw Hexdriver Shaft 1

7163-1169 Short Hexdriver Screw Retaining Shaft 1

7163-1167 Medium Hexdriver Screw Retaining Shaft 1

7163-1165 Long Hexdriver Screw Retaining Shaft 1

7163-1165 Multipurpose Driver Retaining Shaft 1

7167-4090 Tissue Protector Locking Collar 1

48

Notes


OrthopaedicsSmith & Nephew, Inc.1450 Brooks RoadMemphis, TN 38116USA

Telephone: 1-901-396-2121Information: 1-800-821-5700Orders/Inquiries: 1-800-238-7538

www.smith-nephew.com

™Trademark of Smith & Nephew. Reg. US Pat. & TM Off. 30013103017 7118-1131 07/06

Documents

Surgical Technique International Version · prophylactic nailing of impending pathologic fractures; reconstruction following tumor resection and grafting; bone lengthening and shortening;