VARIABLE ANGLE LOCKING HAND SYSTEM

Transcription

1 VARIABLE ANGLE LOCKING HAND SYSTEM For fragment-specific fracture fixation with variable angle locking and locking technology SURGICAL TECHNIQUE

2 TABLE OF CONTENTS INTRODUCTION Variable Angle Locking Hand System Overview 2 AO Principles 5 Indications 6 Featured Plates & Technique Highlights 7 Screws in the System 18 Featured Instruments 20 SURGICAL TECHNIQUE Preoperative Planning and Reduction 27 Lag Screw Insertion (Optional) 29 Prepare and Insert Plate 37 Insert Screw 50 Implant Removal 51 PRODUCT INFORMATION Implants 54 Instruments 63 Graphic Cases 70 Set Lists 77 Image intensifier control Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies

3 VARIABLE ANGLE LOCKING HAND SYSTEM OVERVIEW The DePuy Synthes Variable Angle Locking Hand System consists of plates that are anatomic, procedure-specific, and available in both stainless steel and titanium. The Variable Angle Locking Hand System offers instrumentation to aid in: x fracture reduction x provisional fixation x plate adaptation x construct creation Designed for the Surgeon and Patient A dedicated, global surgeon team was integral to the design of this system through extensive consultation and participation in multiple design labs. Surgeon interviews, design and development meetings, and collaboration with key opinion leaders determined the clinical components necessary for the DePuy Synthes Variable Angle Locking Hand System. DePuy Synthes Companies are dedicated to improving patient care. System Snapshot Extensive system of anatomically precontoured plates First to the market with 1.3 mm locking screws for hand plating 1 Forceps that aid in fracture reduction and lag screw application Forceps that aid in plate fixation Self-retaining screwdrivers Plates available in 316L stainless steel and titanium Color-coded instruments 1 DePuy Synthes Companies market analysis of leading orthopaedic companies, conducted May DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

4 Variable Angle Locking Hand System Overview SYSTEM TECHNOLOGY Variable Angle Locking Technology 1.5 mm and 2.0 mm plates feature variable angle locking coaxial holes. Four columns of threads in the variable angle locking hole provide four points for threaded locking between the plate and the Variable Angle Locking Screw to create a fixed-angle construct at the desired screw angle. x 1.5 mm variable angle plate holes accept: 1.5 mm variable angle locking screws 1.5 mm cortex screws 1.5 mm locking screws. These screws can only be used on-axis x 2.0 mm variable angle plate holes accept: 2.0 mm variable angle locking screws 2.0 mm cortex screws 2.0 mm locking screws. These screws can only be used on-axis x Variable Angle Locking Screws can be angled anywhere within a 30 cone x 1.5 mm and 2.0 mm cortex screws can be used in the plate positioning slots, if present, for traditional compression and fixation Locking Technology 1.3 mm plates feature locking, coaxial holes. Fully threaded locking holes provide threaded locking between the plate and the locking screw to create a fixed-angle construct 1.3 mm locking plate holes accept: 1.3 mm locking screws 1.3 mm cortex screws Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 3

5 Variable Angle Locking Hand System Overview SYSTEM FEATURES FEATURES Extensive range of implant options Anatomically contoured plates Plates designed for lateral and direct dorsal application Low-profile, anatomically precontoured plates Recessed screw heads Variable Angle Locking Technology BENEFITS Accommodates a variety of fractures and patient sizes Designed with contour to adapt to bony anatomy Accommodates plate placement to help avoid tendon insertion points Designed to reduce soft tissue irritation Designed to sit flush with the plate surface Offers screw placement options in a variety of fragment patterns and around the joint Provides fixed angle stability for metaphyseal and osteopenic bone Elongated plate holes Modular, color-coded system Comprehensive instrumentation Implants offered in both stainless steel and titanium T4 and T6 self-retaining screwdriver shafts Hex coupling screwdriver handle Reduction Forceps Plate Holding Forceps Facilitate plate positioning Aids in clear identification of instruments for Operating Room staff and Central Processing Facilitates proper instrumentation usage by size Aids surgeon in all aspects of procedure: plate adaption, provisional fixation, and bone preparation Allows options for surgeon preference and patient need Aid in screw handling, measuring, and delivery Ergonomic connection mechanism in a handle design that disassembles for cleaning Aids reduction and lag screw application via forceps Holds plate intraoperatively 4 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

6 AO PRINCIPLES AO PRINCIPLES In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation. 1, 2 In Those 1958, principles the AO formulated are: four basic principles, which have become the guidelines for internal fixation 1, 2. 4_Priciples_03.pdf :08 Anatomic Anatomic reduction reduction Fracture Fracture reduction reduction and and fixation fixation to to restore restore anatomical anatomical relationships. relationships. 1 2 Stable Stable fixation fixation Fracture Fracture fixation fixation providing providing absolute absolute or relative or relative stability, stability, as required as by the required patient, by the the injury, patient, and the the injury, personality and the personality of the fracture. of the fracture. Early, Early, active active mobilization Early Early and and safe safe mobilization and rehabilitation rehabilitation of of the the injured part and and the the patient patient as as a whole. whole. 4 3 Preservation Preservation of of blood blood supply supply Preservation Preservation of of the the blood blood supply supply to to soft soft tissues tissues and and bone bone by by gentle reduction gentle reduction techniques techniques and and careful careful handling. handling. 1. Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation. 3rd ed. Berlin, Heidelberg, New York: Springer; Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 1 Müller ME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal 2nd ed. Stuttgart, New York: Thieme; Fixation. 3rd ed. Berlin Heidelberg New York: Springer Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 5

7 INDICATIONS The DePuy Synthes Variable Angle Locking Hand System is intended for fracture fixation of the hand and other small bones and small bone fragments, in adults and adolescents (12 21 years) particularly in osteopenic bone. System indications include the following: Open reduction and internal fixation of fractures, mal-unions, and non-unions Following excision of benign bone tumors Replantations and reconstructions Arthrodeses of joints involving small bones Osteotomies, including deformity correction such as rotation, lengthening, shortening Pathological fractures, including impending pathologic fractures Caution: When using this system to treat skeletally immature patients, physiological status of the physes and individual stature of the patient should be assessed before considering treatment options as damage to the physes may occur, leading to potential growth arrest. MR SAFETY INFORMATION These devices have not been evaluated for safety and compatibility in the MR environment. The devices have not been tested for heating or migration in the MR environment. 6 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

8 FEATURED PLATES & TECHNIQUE HIGHLIGHTS The plates contained in this section are featured implants of the DePuy Synthes Variable Angle Locking Hand System. Refer to the product information section for a complete list of all plate configurations offered as part of this system. Phalangeal Head Plate Designed with an anatomic contour and hole configuration to facilitate fixation of fractures of the middle and proximal phalangeal head. x Elongated hole for adjustment of plate position x Ulnar or radial plate placement x Curved plate designed to follow the natural curve of the phalanx x Screw configuration in the head is designed to span the attachment of the collateral ligament x Available in Right and Left orientations x Designed for periarticular fractures and articular fractures of the distal phalanx Available sizes: Left Right 1.3 mm mm = Stainless Steel 04 = Titanium Left Right Surgical Approach Ulnar Radial Right Hand Right Plate Left Plate Left Hand Left Plate Right Plate Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 7

9 Featured Plates & Technique Highlights When implanting this plate, the following screw order placement is suggested. 1 x Place a cortex screw in the elongated hole (1), leaving the screw slightly loose. Screw placement is at the midaxial line. Place plate prior to the K-wire so that the cortex screw can be positioned at the midaxial line x Provisionally fix the condyles. Place a K-wire in the center of the condyle, so the wire is located between the two distal holes (2). The K-wire should be placed in the center of the axis of the joint. K-wire placement is relative to the fan-shaped, central collateral ligament. Note that the footprint of the ligament is larger than the center of the axis. Make small adjustments to K-wire placement to avoid intra-articular placement of screws, while still creating a stable construct. Variations in K-wire placement are at surgeon s discretion, considering periarticular tissue and fracture size. For 1.3 mm plates, use a 0.6 mm K-wire. For 1.5 mm plates, use a 0.8 mm K-wire x Adjust the plate along the bone shaft, as necessary, so that the K-wire abuts the plate. Tighten the cortex screw in the elongated hole x Place a screw in most distal hole (3) x Place screw in most volar hole (4) x Confirm placement and depth of screws under radiographic imaging x Place remaining screws in the head and plate shaft, depending on fracture pattern Refer to surgical technique section for general plate and screw application techniques where this suggested screw insertion order can be applied. 8 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

10 Featured Plates & Technique Highlights Phalangeal Base Plate Designed with an anatomic contour and hole configuration to facilitate fixation of fractures at the base of the middle and proximal phalanx. x Elongated hole for adjustment of plate position x Lateral or dorsal placement x Designed for metaphyseal transverse, oblique, or comminuted fractures of the phalanx When implanting this plate, the following screw order placement is suggested. x Place cortex screw in elongated hole (1), leaving screw slightly loose. Check alignment and adjust plate as necessary x Tighten screw in the elongated hole x Place a Variable Angle Locking Screw in one of the head holes (2). For 1.3 mm plates, place a locking screw. Confirm screw placement and depth under radiographic imaging x Place remaining screws in the head and plate shaft as needed, depending on fracture pattern Available sizes: 1.3 mm 1.5 mm 2.0 mm = Stainless Steel 04 = Titanium 2 1 Refer to surgical technique section for general plate and screw application techniques where this suggested order can be applied. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 9

11 Featured Plates & Technique Highlights Condylar Plate Straight plate with hole configuration designed to facilitate fixation of the middle and proximal phalanx, and the metacarpals. x Elongated hole for adjustment of plate position x Lateral or dorsal placement x Designed for metaphyseal transverse, oblique, or comminuted fractures of the phalanx and metacarpals Position the head of the plate on the condyles. Available sizes: 1.5 mm 2.0 mm = Stainless Steel 04 = Titanium 2 1 When implanting this plate, the following screw order placement is suggested. x Place a cortex screw in the elongated hole (1), leaving screw slightly loose. Check alignment and adjust plate, as necessary x Tighten the screw in the elongated hole. Place a Variable Angle Locking Screw in one of the head holes (2). Confirm screw placement and length using radiographic imaging x Place remaining screws in the head and plate shaft as needed, depending on fracture pattern Refer to surgical technique section for general plate and screw application techniques where this suggested order can be applied. 11 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

12 Featured Plates & Technique Highlights First Metacarpal Plate, Dorsal Designed with an anatomic contour and hole configuration to facilitate fixation in fractures of the base of the first metacarpal. x Elongated hole for adjustment of plate position x Dorsal placement on the first metacarpal with the wide end of the plate placed proximally x Three 1.0 mm K-wire holes accept k-wires, 1.0 mm or smaller, for provisional fixation x 4 variable angle screw holes in head designed to facilitate capture of fracture fragments x 1.5 mm Variable Angle Locking Plate has higher strength than a 2.0 mm non-locking straight plate* Available sizes: 1.5 mm 2.0 mm = Stainless Steel = Titanium 3 1 Proximal 2 Distal Position plate on the metacarpal. During plate placement, consider the curve in the base of the metacarpal. Place a K-wire in any of the three K-wire holes, if needed, to hold the plate in place and obtain provisional fixation of the fragments around the joint (1). When implanting this plate, the following screw order placement is suggested. x Place cortex screw in the elongated hole (2), leaving the screw slightly loose. Adjust plate position, as necessary. Tighten cortex screw in the elongated hole x Place a Variable Angle Locking Screw in the most proximal, metaphyseal head hole (3). The screw in the most proximal head hole is placed first since it is closest to the joint. Confirm screw placement and length under radiographic imaging x Place remaining screws in the head and plate shaft as needed, depending on the fracture pattern Refer to surgical technique section for general plate and screw application techniques where this suggested order can be applied. * Benchtop testing may not be indicative of clinical performance. Testing on file at DePuy Synthes Companies. Testing was completed comparing the 1.5 mm First Metacarpal Plate, Dorsal to the DePuy Synthes 2.0 mm non-locking straight plate. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 11

13 Featured Plates & Technique Highlights First Metacarpal Plate, Lateral Designed with a shape and hole configuration to facilitate fixation in fractures of the first metacarpal. This plate is designed to be contoured to fit the dorsal and radial periarticular surfaces. x Elongated hole for adjustment of plate position. Elongated hole is positioned on the shaft x Designed for palmar approach to the first metacarpal x Lateral placement on the first metacarpal (radiopalmar) x Plate adaptation is recommended to ensure correct fit of plate to the bone (see technique section related to plate contouring) x Available in Left and Right orientations x Y-shape with contourable arms to fit varying anatomy and address fracture fragments x Designed for T- or Y-shaped fractures in the sagittal plane and comminuted intra-articular fractures of the base of the first metarcarpal Available size: 1.5 mm Left Right = Stainless Steel 04 = Titanium Left 2 2 Right Placement of the plate is fracture-dependent. When implanting this plate, the following screw order and placement is suggested. x Ensure plate is contoured to fit anatomy, prior to implantation. The more contoured arm of the plate is positioned so that it wraps around the bone palmarly. This contoured arm follows the curve of the shaft of the plate x Place a cortex screw in the elongated hole (1), leaving the screw slightly loose. Adjust plate position, as necessary. Tighten cortex screw in the elongated hole x Place a Variable Angle Locking Screw in the arms of the plate (2). Confirm screw placement and length under radiographic imaging x Place remaining screws in the plate, depending on fracture pattern Refer to surgical technique section for general plate and screw application techniques where this suggested order can be applied. 11 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

14 Featured Plates & Technique Highlights Metacarpal Neck Plate Designed with an anatomic contour and hole configuration to facilitate fixation of the head and neck of the metacarpals. x Elongated hole for adjustment of plate position x MC V: ulnar placement x MC II-IV: dorsolateral placement x 1.0 mm K-wire hole accepts K-wires 1.0 mm or smaller, for provisional fixation x 4 diverging screws for secure fixation x Designed for unstable subcapital and comminuted head and neck fractures of the metacarpals Available size: 1.5 mm = Stainless Steel = Titanium When implanting this plate, the following screw order placement is suggested. x Place a cortex screw in the elongated hole (1), leaving the screw slightly loose. Adjust plate position, as necessary. Tighten cortex screw in the elongated hole x Additionally, a K-wire can be placed in the K-wire hole (2) in the distal portion of the plate to hold the plate in place, as necessary x Place a Variable Angle Locking Screw in the either of the most distal holes of the plate head (3). Avoid wire and screw interference when placing screws in a variable angle hole. If necessary, the K-wire can be bent slightly to facilitate placement of the Variable Angle drill guide into a plate hole in the head of the plate Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 11

15 Featured Plates & Technique Highlights x Confirm screw placement and length under radiographic imaging x Place remaining screws in the plate, depending on fracture pattern. Fracture pattern will dictate the order of screw placement Refer to surgical technique section for general plate and screw application techniques where this suggested order can be applied. Variable angle screws at nominal angle in head of plate. Variable angle screws at 15 angulation in head of plate. 11 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

16 Featured Plates & Technique Highlights Rotation Correction Plate Designed with an anatomic contour and hole configuration to facilitate fixation of the metacarpals and phalanges. x Elongated transverse hole for intraoperative adjustment of the reduction, including correction of the fragment rotation of the bone, if necessary. Elongated hole allows 2.5 mm of travel x Design of the plate head facilitates contouring to the anatomy of the condyles x Designed for fractures and osteotomies of the metacarpals and phalanges Available sizes: 1.5 mm 2.0 mm = Stainless Steel = Titanium 1 2 When implanting this plate, the following screw order placement is suggested. x Position the plate with the T-shaped section of the plate near the joint x Insert 2 Variable Angle Locking Screws into the T-shaped section of the plate (1), ensuring that the elongated hole (2) is on the side of the osteotomy away from the joint, near a section of intact bone. Confirm screw placement and length under radiographic imaging x Adjust the position of the bone x Place a cortex screw into the elongated transverse hole (2), leaving the screw loose. Release and tighten the cortex screw while adjusting plate position, as necessary x Check result of repositioning with the wrist at maximum extension. Tighten cortex screw x Place remaining screws distal or proximal to the elongated transverse hole. Confirm screw placement and depth using radiographic imaging Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 11

17 Featured Plates & Technique Highlights Refer to surgical technique section for general plate and screw application techniques where this suggested order can be applied. 11 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

18 Featured Plates & Technique Highlights Fracture Plate Designed for indirect reduction techniques where bridging or in-situ reduction is desired. x Allows adjustment of rotation and angulation before fixed angle construct is applied. Consistent with AO indirect reduction techniques of external fixation 1,2 x Two elongated holes for intra-operative correction in 2 planes x Dorsal placement x Staggered shaft x Designed for crushed, multifragmented, and/or periarticular fractures of the metacarpals and phalanges Available sizes: 1.5 mm 2.0 mm = Stainless Steel = Titanium 1 2 When implanting this plate, the following screw order placement is suggested. x Insert a cortex screw into the head of the plate (1) into the condyle, ensuring that the elongated hole (2) is on the side of the osteotomy away from the joint, near a section of intact bone. Provisional fixation in either adjacent hole may be helpful x Correct the position of the bone. Place a cortex screw in the elongated transverse hole (2) x Continue to adjust the position of the bone, as necessary x Check result of repositioning x Place remaining screws distal or proximal to the elongated transverse hole Refer to surgical technique section for general plate and screw application techniques where this suggested order can be applied. 1. Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation. 3rd ed. Berlin, Heidelberg, New York: Springer; Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme; Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 11

19 SCREWS IN THE SYSTEM 1.3 mm Screws 1.3 mm Locking Screws Only for on-axis insertion in the locking holes Threaded, conical head locks securely into the locking hole Self-retaining,T4 STARDRIVE Recess Self-tapping tip facilitates insertion 1.3 mm Cortex Screws Can be used in locking holes to compress the plate to the bone Self-retaining,T4 STARDRIVE Recess Self-tapping tip facilitates insertion 1.5 mm Screws 1.5 mm Variable Angle Locking Screws Threaded, rounded head locks securely into the variable angle locking hole Purple, color-coded head to easily distinguish as Variable Angle Locking Screw Self-retaining, T4 STARDRIVE Recess Blunt self-tapping tip 1.5 mm Cortex Screws Can be used in the variable angle locking holes to compress the plate to the bone Self-retaining, T4 STARDRIVE Recess Self-tapping tip facilitates insertion Also Available 1.5 mm Locking Screws only used on-axis Compatible with 1.5 mm Variable Angle Locking Plates 11 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

20 Screws in the System 2.0 mm Screws 2.0 mm Variable Angle Locking Screws Threaded, rounded conical head locks securely into the locking hole Purple, color-coded head to easily distinguish as a Variable Angle Locking Screw Self-retaining, T6 STARDRIVE Recess Blunt, self-tapping tip 2.0 mm Cortex Screws Can be used in the variable angle locking holes to compress the plate to the bone Self-retaining, T6 STARDRIVE Recess Self-tapping tip facilitates insertion Also Available 2.0 mm Locking Screws only used on-axis Compatible with 2.0 mm Variable Angle Locking Plates Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 11

21 FEATURED INSTRUMENTS Reduction Forceps ( ) This instrument is designed to hold reduced metacarpal and phalangeal bone fragments in place, while allowing insertion of a lag screw through the barrel of the forceps. Colors on the drill sleeves indicate the screw size and color bands indicate the threaded and gliding hole. Plate Holding Forceps ( ) The Plate Holding Forceps is designed to hold the plate in the desired position against the bone. x The ball on the upper portion of the jaws inserts through the plate hole to the bone, and the lower arm is inserted beneath the soft tissue against the underside of the bone x The forceps can then be closed to the desired tightness to hold the plate, and is designed to remain in place after the handles are released 22 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

22 Featured Instruments Plate Holder ( ) The Plate Holders are designed to hold the plates. The arms are squeezed together and inserted into a single plate hole. Once the arms are released, they hold the plate via tension The arms of the plate holders can also be placed in two adjacent holes The forceps can also be used to hold the outside edges of the plate. If used to hold the outside of the plate, releasing the arms of the holder will allow the plate to disengage. Alternative Instrument Mini Plate Holder, Long Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 22

23 Featured Instruments Plate Cutter for 1.3 mm to 2.0 mm Plates ( ) The Plate Cutter for Plates is designed to cut all plates within the Variable Angle Locking Hand System. A rasp for manual deburring is provided on the plate cutter head, if deburring is needed after cutting Plate Cutter, In-Line for 1.3 mm Locking, 1.5 mm VA Locking, and 2.0 mm VA Locking Plates ( ) The Plate Cutter, In-Line for Plates is designed to cut plates with straight shafts within the Variable Angle Locking Hand System. Variable Angle locking and locking plate holes are inserted over the insertion posts to hold the plate in place A rasp for manual deburring feature is provided on the plate cutter head, if deburring is needed after cutting 22 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

24 Featured Instruments Bending Pliers ( , ) Bending Pliers facilitate additional contouring of the plates, if necessary. Bending Pins ( ) Bending Pins facilitate additional contouring of 1.3 mm plates, if necessary. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 22

25 Featured Instruments Screwdriver Handle with Hex Coupling ( ) The design of the handle reduces the likelihood of rolling on a flat surface. The hex coupling provides a one-step, reliable connection when inserting the screwdriver shaft. The screwdriver handle disassembles into three pieces for cleaning and sterilization. The three parts include the hex coupling with spring, the shaft, and the handle. STARDRIVE TM Screwdriver Shafts ( , ) Self-retaining screwdrivers aid in screw handling, measuring, and delivery. 1.3 mm and 1.5 mm screws feature a T4 STARDRIVE Recess. The tip of the T4 Screwdriver is gold-colored. 2.0 mm screws feature a T6 STARDRIVE Recess. 22 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

26 Featured Instruments Variable Angle Locking Double Drill Guide with Cone ( , ) The double drill guide with cone is designed for variable angle technique and nominal angle technique. Variable Angle Nominal Angle (Coaxial) Variable angle technique using the cone-shaped end. Nominal angle technique using the fixed-angle end marked coaxial. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 22

27 Featured Instruments Variable Angle Locking Double Drill Guide Freehand ( , ) The double drill guide freehand is designed for variable angle technique and nominal angle technique. Variable Angle Nominal Angle (Coaxial) Variable angle technique using the variable angle end, which allows freehand angulation of the drill bit. Nominal angle technique using the fixed-angle end marked coaxial. 22 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

28 PREOPERATIVE PLANNING AND REDUCTION 1 Preparation Complete preoperative radiographic assessment and preoperative planning. Select the implant according to the fracture pattern and anatomy of the bone. Note: Ensure the proper plate selection is available, including L (left) or R (right) plates. Left plates are designed for the left hand. Right plates are designed for the right hand. For clarification on right and left Phalangeal Head Plate application, see information on Page 7. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 22

29 Preoperative Planning and Reduction 2 Reduce Fracture Instruments mm Kirschner Wire, 70 mm, trocar point, (stainless steel) / mm Kirschner Wire, 70 mm, trocar point (stainless steel or titanium) / mm Kirschner Wire, 150 mm, trocar point (stainless steel or titanium) / mm Kirschner Wire, 150 mm, trocar point (stainless steel or titanium) Reduction Forceps Sharp Hook Reduce fracture under imaging using Kirschner wires or reduction forceps if necessary. The reduction method will depend on patient anatomy and fracture pattern. Optional Instrument Reduction Forceps for 1.3 to 2.0 mm Screws/Soft Lock 22 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

30 LAG SCREW INSERTION (OPTIONAL) Lag Screw Insertion Reduction Forceps 1 Select a Drill Sleeve and Drill Bit Lag screws may be inserted using the Reduction Forceps ( ). The associated drill sleeves and drill bits use a color-coded stripe system. The colors on the drill sleeves and drill bits correspond to the screw size. A single stripe indicates that the drill sleeve or drill bit is used for a threaded hole; a double stripe indicates that the drill sleeve or drill bit is used for a gliding hole. Screw Size Color Coding for Instruments Drill Sleeve for Threaded Hole Drill Bit for Threaded Hole (One Color Stripe)* Drill Sleeve for Gliding Hole Drill Bit for Gliding Hole (Two Color Stripes)* 1.3 mm Yellow 1.0 mm mm 1.3 mm mm 1.5 mm Red 1.1 mm mm 1.5 mm mm 2.0 mm Blue 1.5 mm mm 2.0 mm mm * Drill bits are available with various couplings, including Mini Quick Coupling, K-wire, and J-Latch. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 22

31 Lag Screw Insertion (Optional) Lag Screw Insertion Reduction Forceps 2 Assemble Drill Sleeve to Forceps Press the drill sleeve into the barrel of the Reduction Forceps so that the sleeve is fully seated and a click is felt. 3 Attach the Reduction Forceps to the Bone Once in place, close the Reduction Forceps to the desired tightness. The forceps is designed to remain in place after the handles are released. 33 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

32 Lag Screw Insertion (Optional) Lag Screw Insertion Reduction Forceps 4 Drill Threaded and Gliding Hole Gliding Hole Threaded Hole Threaded Hole: Using the drill sleeve, drill the far fragment using a drill bit for the threaded hole. Gliding Hole: Using the drill sleeve, drill the near cortex, so that the thread of the screw does not obtain purchase. Drill so that the lag screw is perpendicular to the fracture plane. An alternative technique is to drill for the gliding hole first and then drill for the threaded hole. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 33

33 Lag Screw Insertion (Optional) Lag Screw Insertion Reduction Forceps 5 Countersink (Optional) Remove the Drill Sleeve from the forceps. Attach the Countersink ( ) to the Screwdriver Handle. Countersink, if desired. 6 Measure Insert the Depth Gauge ( ) through the barrel of the forceps, to determine the screw length needed. The Depth Gauge is designed for one-handed use. 33 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

34 Lag Screw Insertion (Optional) Lag Screw Insertion Reduction Forceps The black line indicates the screw length. Optional Technique: Use the scale on the back of the Depth Gauge to measure for screw length. Note: The depth gauge consists of 2 pieces and is designed to be disassembled for cleaning. Slide the tip of the hook so it is fully inside the black outer body. Press the tab on the back of the sliding hook and remove it from the black outer body. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 33

35 Lag Screw Insertion (Optional) Lag Screw Insertion Reduction Forceps 7 Insert Cortex Screw Instruments STARDRIVE Screwdriver Shaft, T4, 50 mm, Self-Retaining, Hex Coupling STARDRIVE Screwdriver Shaft, T6, 50 mm, Self-Retaining, Hex Coupling Screwdriver Handle with Hex Coupling Assemble the screwdriver shaft to the Screwdriver Handle. For 1.3 mm and 1.5 mm screws, use the T4 STARDRIVE screwdriver shaft ( , with yellow and red bands). The tip of the T4 screwdriver is gold-colored. For 2.0 mm screws, use the T6 STARDRIVE screwdriver shaft ( , with blue band). The screwdriver and screws are designed to be self-retaining. To attach the screw to the screwdriver, position the screwdriver directly in line with the screw with no tilting. Ensure that the screwdriver tip engages the star-shaped recess in the screw. It may be necessary to rotate the screwdriver up to a quarter turn to fully align the star-shaped screwdriver tip into the screw recess. In addition, a tactile sensation may be noticed when the screwdriver shaft is fully aligned with the screw recess. Apply firm axial pressure downwards to ensure that the screw is fully seated before removing the screw from the implant module. Remove the screw from the implant module in a straight vertical position. Using the screwdriver, place the screw on the scale of the implant module, to confirm the length of the screw. Insert the screw through the barrel of the reduction forceps. Confirm screw placement under radiographic imaging. Once the screw has been inserted, remove the forceps from the bone. Note: Prior to sterilization of the Reduction Forceps, Soft Lock, add one drop of DePuy Synthes Autoclavable Oil (519.97) to instrument joints and ratchet mechanisms. 33 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

36 LAG SCREW INSERTION DOUBLE DRILL SLEEVE (OPTIONAL) Instruments mm/1.0 mm Double Drill Sleeve, for 1.3 mm Cortex Screws/Yellow mm/1.1 mm Double Drill Sleeve for 1.5 mm Cortex Screws/Red mm/1.5 mm Double Drill Sleeve for 2.0 mm Cortex Screws/Blue For 1.3 mm, 1.5 mm, and 2.0 mm cortex screws used as independent lag screws, use a double-ended drill sleeve and corresponding drill bit. Drill bits and drill guides are color-coded. Drill bits are available with several different couplings (see item listing). Etch lines on drill bits are spaced 5 mm apart. A K-wire may be used through the double drill sleeve. Screw Size Color Coding for Instruments Double Drill Sleeve Drill Bit For Threaded Hole (One Color Stripe)* Drill Bit for Gliding Hole (Two Color Stripes)* 1.3 mm Yellow mm 1.3 mm 1.5 mm Red mm 1.5 mm 2.0 mm Blue mm 2.0 mm * Drill bits are available with various couplings, including Mini Quick Coupling, K-wire, and J-Latch. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 33

37 Lag Screw Insertion Double Drill Sleeve (Optional) For 1.0 mm cortex screws used as independent lag screws, use a.76 mm drill bit (green band) or 0.8 mm drill bit (green band) and 1.0 mm drill bit. Insert the screws using the 1.0 mm Cruciform Screwdriver Blade with Spring Holding Sleeve ( ). Instruments mm Drill Bit, mini quick coupling with 6 mm stop mm Drill Bit, mini quick coupling with 8 mm stop mm Drill Bit, mini quick coupling with 10 mm stop mm Drill Bit, mini quick coupling with 12 mm stop mm Drill Bit, mini quick coupling with 14 mm stop mm Drill Bit, K-wire attachment, for threaded hole, 64 mm mm Drill Bit, Stryker J-Latch, for threaded hole, 56 mm mm Drill Bit, Mini Quick Coupling, for Threaded Hole, 40 mm mm Cruciform Screwdriver Blade with Spring Holding Sleeve, Hex Coupling 33 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

38 PREPARE AND INSERT PLATE 1 Trim Plate Instrument Plate Cutter for 1.3 mm mm Plates If desired, plate cutters can be used to adjust the length of the plate. The Plate Cutter ( ) is designed to cut all plates within the Variable Angle Locking Hand System. Important: To prevent sharp edges from causing soft tissue irritation, place the plate top side up on the cutters to ensure any sharp edges will angle towards the underside of the plate. Trim the plate to the desired length using the cutters, and remove any burr by using the rasp on the side of the cutters. The Plate Cutter creates a straight cut. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 33

39 Prepare and Insert Plate Optional Instrument Plate Cutter, In-line for 1.3 mm Locking, 1.5 mm VA Locking, and 2.0 mm VA Locking Plates Cut portion of plate The Plate Cutter, In-Line ( ) is designed to cut plates with straight shafts within the Variable Angle Locking Hand System. Note: When using the Plate Cutter, In-Line, insert the plate top side up in its respective color coded area on the cutter. This is to ensure that the plate holes are protected during cutting. Insert the plate so that the section of the plate to be implanted is located on the side that is color-coded. Ensure that the plate is correctly inserted on the post. This cutter is designed to be used to cut straight shafts of plates within the Variable Angle Locking Hand System. Note: The Plate Cutter is designed with 2 silicone inserts in the jaws to hold the cut segment of the plate after cutting. The Plate Cutter, In-Line, is designed with 1 silicone insert. Remove the silicone insert(s) prior to cleaning and sterilization. The Plate Cutter, Inline, creates a cut with a rounded profile. Remove any burr by using the rasp on the side of the cutters. 33 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

40 Prepare and Insert Plate 2 Contour Plate (Optional) If necessary, contour the plate to fit the patient s anatomy. Instruments Plate Bending Pliers for 1.3 mm Locking and 1.5 mm and 2.0 mm Variable Angle Locking Plates, Right Plate Bending Pliers for 1.3 mm Locking and 1.5 mm and 2.0 mm Variable Angle Locking Plates, Left Plate Bending Pins for 1.3 mm Locking Plates Bend using adjacent holes in the plate. Orient the benders so the side etched UP is facing up, with the top of the plate also facing up. Precaution: Avoid reverse bends and sharp bends (sharp bends include a single out-of-plane bend between 2 adjacent holes of >30 ). Reverse or sharp bends may weaken the plate and lead to premature plate failure. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 33

41 Prepare and Insert Plate The Plate Bending Pins ( ) are designed to be used with the 1.3 mm locking plates. Bend adjacent holes in the plates. Precaution: Avoid reverse bends and sharp bends (sharp bends include a single out-of-plane bend between two adjacent holes of >30 ). Reverse or sharp bends may weaken the plate and lead to premature plate failure. 44 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

42 Prepare and Insert Plate 3 Position Plate Instruments mm Kirschner Wire, 70 mm, trocar point (stainless steel) / 0.8 mm Kirschner Wire, 70 mm, trocar point (stainless steel or titanium) / 1.0 mm Kirschner Wire, 150 mm, trocar point (stainless steel or titanium) Reduction Forceps, with points, Ratchet, 130 mm Termite Forceps, 90 mm Reduction Forceps, with points, Broad-Ratchet Position the plate over the reduced fracture using the preferred positioning method. Either K-wires or forceps may be used to hold the plate in place. K-wires can be used in the plate K-wire holes, if present. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 44

43 Prepare and Insert Plate Optional Instrument Plate Holding Forceps, Soft Lock As an alternative, the Plate Holding Forceps may be used to hold the plate to the bone. Insert the ball portion through a plate hole to the bone. The curved arm wraps around the underside of the bone through the incision. Close the forceps to the desired tightness to hold the plate. The forceps is designed to remain in place after the handles are released. Precaution: When using the Plate Holding Forceps, avoid the tendons and avoid applying excessive pressure. Note: Prior to sterilization of the Plate Holding Forceps, Soft Lock, add one drop of DePuy Synthes Autoclavable Oil (519.97) to instrument joints and ratchet mechanisms. For more information, refer to the Featured Instrument section. 44 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

44 Prepare and Insert Plate 4 Determine Screw Type Depending on the individual case, cortex screws or Variable Angle Locking/locking Screws may be inserted. Locking or cortex screws can be used in any of the screw holes, with the exception of the nonthreaded elongated hole, if present. The elongated hole is designed for adjustment of plate position. The elongated hole accepts cortex screws only. Leave the cortex screw slightly loose in the elongated hole while adjusting plate position, as necessary. Tighten the cortex screw once plate placement has been confirmed. If a combination of locking and cortex screws is planned, a cortex screw should be inserted first to pull the plate to the bone. If a locking screw is inserted first, ensure that the plate is held securely to the bone, to avoid spinning the plate as the screw is locked in place. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 44

45 Prepare and Insert Plate 5 Drill Instruments For 1.3 mm Screws mm Drill Bit, K-wire Attachment, for Threaded Hole, 75 mm mm Drill Bit, Stryker J-Latch, for Threaded Hole, 61 mm mm Drill Bit, Mini Quick Coupling, for Threaded Hole, 61 mm For 1.5 mm Screws mm Drill Bit, K-wire Attachment, for Threaded Hole, 70 mm mm Drill Bit, Stryker J-Latch, for Threaded Hole, 65 mm mm Drill Bit, Mini Quick Coupling, for Threaded Hole, 56 mm For 2.0 mm Screws mm Drill Bit, K-wire Attachment, for Threaded Hole, 88 mm mm Drill Bit, Stryker J-Latch, for threaded Hole, 83 mm mm Drill Bit, Mini Quick Coupling, for Threaded Hole, 74 mm Select a drill bit based on the size of the screw. Drill bits are color-coded to the size of the associated screw. Note: The fracture pattern will dictate the optimal screw placement. Fracture pattern will determine the order of screw insertion. In all cases, make sure the plate is in the correct position and flush with the bone. If placing a plate on the condyle, be cognizant of reducing and restoring the articular surface. Screw Size Drill Bit Size/Color Code 1.3 mm 1.0 mm - Yellow 1.5 mm 1.1 mm - Red 2.0 mm 1.5 mm - Blue 44 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

46 Prepare and Insert Plate 6 Select a Drill Guide and Drilling Technique Variable Angle Locking Double Drill Guide with Cone ( , ) Variable Angle Locking Screws can be inserted using 2 different techniques, depending on which end of the drill guide is used: Verify the drill bit angle and depth under radiographic imaging to ensure the desired angle has been achieved. If necessary, drill at a different angle and verify again under imaging. Precaution: Avoid redrilling, especially in osteopenic bone. Variable Angle Nominal Angle (Coaxial) Variable angle technique using the cone-shaped end. Fully insert the variable angle end of the drill guide into the Variable Angle Locking hole. When drilling, the tip of the drill guide should remain fully seated in the hole Nominal angle technique using the fixed-angle end marked coaxial. Fully insert the coaxial end of the drill guide into the Variable Angle Locking hole and drill. Drill the hole with the drill bit at the desired angle within the cone by positioning the drill bit. Precaution: When using the variable angle end of the guide, it is important to not angulate more than 15 from the central axis of the screw hole. Over angulation could result in difficulty locking the screw. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 44

47 Prepare and Insert Plate Drill for Variable Angle Screws Freehand Variable Angle Locking Double Drill Guide Freehand ( , ) Variable Angle Locking Screws can be inserted using 2 different techniques, depending on which end of the drill guide is used: Verify the drill bit angle and depth under radiographic imaging to ensure the desired angle has been achieved. If necessary, drill at a different angle and verify again under imaging. Avoid redrilling, especially in osteopenic bone. Variable Angle Nominal Angle Variable angle technique using the variable angle. Nominal angle technique using the fixed-angle end marked coaxial. Fully insert the variable angle end of the drill guide into the Variable Angle Locking hole. Fully insert the coaxial end of the drill guide into the Variable Angle Locking hole and drill. Drill the hole with the drill bit at the desired angle by positioning the drill guide in the hole. Precaution: When using the variable angle end of the guide, it is important to not angulate more than 15 from the central axis of the screw hole. Over angulation could result in difficulty locking the screw. 44 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

48 Prepare and Insert Plate A 1.0 mm Threaded Drill Guide ( ) is available for use with only the 1.3 mm plates. The drill guide allows drilling in the nominal position in the locking hole. Use a Double Drill Guide ( , , or ) to drill for cortex screws through the plate. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 44

49 Prepare and Insert Plate 7 Determine Screw Length Use the Depth Gauge ( ) to determine screw length. Screw length is indicated by the black line. See pages for additional technique information for the Depth Gauge. 44 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

50 Prepare and Insert Plate 8 Insert Screw Instruments STARDRIVE Screwdriver Shaft, T4, 50 mm, Self-Retaining, Hex Coupling STARDRIVE Screwdriver Shaft, T6, 50 mm, Self-Retaining, Hex Coupling Screwdriver Handle with Hex Coupling Assemble the screwdriver shaft to the screwdriver handle. 1.3 mm and 1.5 mm Screws are inserted with a T4 STARDRIVE Screwdriver (yellow and red bands). The tip of the screwdriver is gold-colored. 2.0 mm Screws are inserted with a T6 STARDRIVE Screwdriver (blue band). The screwdriver and screws are designed to be self-retaining. To attach the screw to the screwdriver, position the screwdriver directly in line with the screw, with no tilting. Ensure that the screwdriver tip engages the star-shaped recess in the screw. It may be necessary to rotate the screwdriver up to a quarter turn to fully align the star-shaped screwdriver tip into the screw recess. In addition, a tactile sensation may be noticed when the screwdriver shaft is fully aligned with the screw recess. Apply firm axial pressure downwards to ensure that the screw is fully seated before removing the screw from the implant module. Remove the screw from the implant module in a straight vertical position. Using the screwdriver, place the screw on the scale of the implant module, to confirm the length of the screw. Insert screw. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 44

51 INSERT SCREW When inserting screws, use a two-finger tightening technique. For Variable Angle Locking and Locking Screws, confirm screw placement and length under radiographic imaging prior to final tightening. For Variable Angle Locking and Locking Screws, screw insertion is complete when the screw is flush to the plate. Confirm screw position and depth under radiographic imaging. Precaution: Avoid penetrating the articular surface. Postoperative Treatment Postoperative treatment with locking plates or variable angle locking plates does not differ from conventional internal fixation procedures. 55 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

52 IMPLANT REMOVAL If removal of the implant is necessary, the following instructions are suggested. 1 Preoperative Planning To ensure that the appropriate screw removal instruments are obtained, the surgeon should have the following information before implant removal: x Implant type x Time of implantation x Material (steel, titanium) x Recess geometry and dimension of screws x Any visible damage to the implant (eg, broken screw shaft) 2 Clean Recess Instrument Sharp Hook Before removing screws, clean the screw recess. Free the screw recess from ingrown bone and tissue using the sharp hook to ensure the screwdriver can be fully inserted. Check the condition and the geometry of the recess of the exposed screwhead. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 55

53 Implant Removal 3 Implant Removal Instruments mm Cruciform Screwdriver Blade with Spring Holding Sleeve, Hex Coupling STARDRIVE Screwdriver Shaft, T4, 50 mm, Self-Retaining, Hex Coupling STARDRIVE Screwdriver Shaft, T6, 50 mm, Self-Retaining, Hex Coupling Screwdriver Handle with Hex Coupling Optional Set Screw Removal Set To remove locking screws, first unlock all screws from the plate; then remove the screws completely from the bone. The last screw removed should be a nonlocking screw on the shaft. This prevents the plate from spinning when locking screws are removed. Note: To remove broken screws or screws with a damaged screw recess, please refer to the DePuy Synthes Screw Removal Set Technique Guide (J8569) for removal instructions. 55 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

54 SUMMARY TABLE INSTRUMENTS Screw Size 1.0 mm Cortex 1.3 mm Cortex 1.5 mm Cortex 2.0 mm Cortex Gliding Hole Threaded Hole Gliding Hole (Two Stripes) 1.0 mm 1.3 mm 1.5 mm 2.0 mm Drill Bit Threaded Hole (One Stripe) 0.76 mm 1.0 mm 1.1 mm 1.5 mm Drill Guide Double Drill Guide for Cortex Screws n/a (1.3 mm/1.0 mm) (1.5 mm/1.1 mm) (2.0 mm/1.5 mm) For Variable Angle Locking or Cortex Screws through the plate 1.0 mm Cortex 1.3 mm Locking or Cortex Screws 1.5 mm Variable Angle Locking or Cortex Screws 2.0 mm Variable Angle Locking or Cortex Screws n/a Drill Bit 1.0 mm 1.1 mm 1.5 mm Variable Angle Double Drill Guide with Cone n/a (1.1 mm) (1.5 mm) Drill Guide Variable Angle Double Drill Guide Freehand (1.1 mm) (1.5 mm) Threaded Drill Guide n/a n/a Double Drill Guide for Cortex Screws n/a (1.3 mm/1.0 mm) (1.5 mm/1.1 mm) (2.0 mm/1.5 mm) Screwdriver Cruciform T4 STARDRIVE T6 STARDRIVE Depth Gauge Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 55

55 IMPLANTS 1.3 mm Locking Plates 316 Stainless Steel and TiCP Titanium Plate Thickness: 0.75 mm Stainless Steel Titanium mm Locking Straight Plate, 6 Holes mm Locking Straight Plate,12 Holes mm Locking T-Plate, 3 Holes Head, 5 Holes Shaft mm Locking Y-Plate, 3 Holes Head, 5 Holes Shaft mm Locking Phalangeal Base Plate, 2 Holes Head, 5 Holes Shaft mm Locking Phalangeal Head Plate, Right mm Locking Phalangeal Head Plate, Left mm Locking Strut Plate, 8 Holes, Oblique, Right mm Locking Strut Plate, 8 Holes, Oblique, Left mm Locking Web Plate, 14 Holes 55 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

56 Implants 1.5 mm Variable Angle Locking Plates 316L Stainless Steel and TiCP Titanium Plate Thickness: 1.0 mm Stainless Steel Titanium mm Variable Angle Locking Straight Plate, 6 Holes mm Variable Angle Locking Straight Plate, 12 Holes mm Variable Angle Locking T-Plate, 3 Holes Head, 7 Holes Shaft mm Variable Angle Locking Y-Plate, 3 Holes Head, 7 Holes Shaft mm Variable Angle Locking Phalangeal Base Plate, 2 Holes Head, 6 Holes Shaft mm Variable Angle Locking Condylar Plate, 2 Holes Head, 6 Holes Shaft mm Variable Angle Locking Phalangeal Head Plate, Right mm Variable Angle Locking Phalangeal Head Plate, Left mm Variable Angle Locking Strut Plate, 8 Holes, Oblique, Right mm Variable Angle Locking Strut Plate, 8 Holes, Oblique, Left mm Variable Angle Locking Strut Plate, 12 Holes mm Variable Angle Locking Web Plate, 14 Holes Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 55

57 Implants Stainless Steel Titanium mm Variable Angle Locking Box Plate, 4 Holes mm Variable Angle Locking First Metacarpal Plate, Dorsal mm Variable Angle Locking First Metacarpal Plate, Lateral, Right mm Variable Angle Locking First Metacarpal Plate, Lateral, Left mm Variable Angle Locking Rotation Correction Plate, 6 Holes mm Variable Angle Locking Fracture Plate, 6 Holes mm Variable Angle Locking Metacarpal Neck Plate 55 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

58 Implants 2.0 mm Variable Angle Locking Plates, 316L Stainless Steel and TiCP Titanium Place Thickness: 1.3 mm Stainless Steel Titanium mm Variable Angle Locking Straight Plate, 6 Holes mm Variable Angle Locking Straight Plate, 12 Holes mm Variable Angle Locking T-Plate, 3 Holes Head, 7 Holes Shaft mm Variable Angle Locking Y-Plate, 3 Holes Head, 7 Holes Shaft mm Variable Angle Locking Phalangeal Base Plate, 2 Holes Head, 6 Holes Shaft mm Variable Angle Locking Condylar Plate, 2 Holes Head, 6 Holes Shaft mm Variable Angle Locking Strut Plate, 12 Holes mm Variable Angle Locking Box Plate, 4 Holes mm Variable Angle Locking First Metacarpal Plate, Dorsal mm Variable Angle Locking Rotation Correction Plate, 6 Holes mm Variable Angle Locking Fracture Plate, 6 Holes Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 55

59 SCREWS 1.0 mm Cortex Screws, Self-Tapping, Cruciform 316L Stainless Steel and TiCP Titanium Stainless Steel Titanium Length (mm) DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

60 Screws 1.3 mm Cortex Screws, Self-Tapping, T4 STARDRIVE Recess 316L Stainless Steel and Titanium* Stainless Steel Titanium Length (mm) mm Locking Screws, Self-Tapping, T4 STARDRIVE Recess 316L Stainless Steel and Titanium* Stainless Steel Titanium Length (mm) *Ti-6Al-7Nb Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 55

61 Screws 1.5 mm Cortex Screws, Self-Tapping, T4 STARDRIVE Recess 316L Stainless Steel and Titanium* Stainless Steel Titanium Length (mm) *Ti-6Al-7Nb 66 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

62 Screws 1.5 mm Variable Angle Locking Screws, Self-Tapping, T4 STARDRIVE Recess 316L Stainless Steel and Titanium* Stainless Steel Titanium Length (mm) *Ti-6Al-7Nb Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 66

63 Screws 2.0 mm Cortex Screws, Self-Tapping, T6 STARDRIVE Recess 316L Stainless Steel and Titanium* Stainless Steel Titanium Length (mm) mm Variable Angle Locking Screws, Self-Tapping, T6 STARDRIVE Recess 316L Stainless Steel and Titanium* Stainless Steel Titanium Length (mm) *Ti-6Al-7Nb 66 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

64 INSTRUMENTS mm Drill Bit, K-wire Attachment, for Threaded Hole, 75 mm mm Drill Bit, Mini Quick Coupling, for Threaded Hole, 61 mm mm Drill Bit, K-wire Attachment, for Gliding Hole, 60 mm mm Drill Bit, Mini Quick Coupling, for Gliding Hole, 46 mm mm Drill Bit, K-wire Attachment, for Threaded Hole, 70 mm mm Drill Bit, Mini Quick Coupling, for Threaded Hole, 56 mm mm Drill Bit, K-wire Attachment, for Gliding Hole, 62 mm mm Drill Bit, Mini Quick Coupling, for Gliding Hole, 48 mm Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 66

65 Instruments mm Drill Bit, K-wire Attachment, for Threaded Hole, 88 mm mm Drill Bit, Mini Quick Coupling, for Threaded Hole, 74 mm mm Drill Bit, K-wire Attachment, for Gliding Hole, 71 mm mm Drill Bit, Mini Quick Coupling, for Gliding Hole, 57 mm Screwdriver Handle with Hex Coupling STARDRIVE Screwdriver Shaft, T4, 50 mm, Self-Retaining, Hex Coupling STARDRIVE Screwdriver Shaft, T6, 50 mm, Self-Retaining, Hex Coupling 66 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

66 Instruments mm Threaded Drill Guide, for 1.3 mm Locking Plates mm / 1.0 mm Double Drill Sleeve, for 1.3 mm Cortex Screws, Yellow Plate Holder, for 1.3 mm to 2.0 mm Plates Plate Bending Pin, for 1.3 mm Locking Plates mm Variable Angle Locking Double Drill Guide, With Cone, for 1.5 mm Variable Angle Locking Plates mm Variable Angle Locking Double Drill Guide, Freehand, for 1.5 mm Variable Angle Locking Plates mm / 1.1 mm Double Drill Sleeve, for 1.5 mm Cortex Screws, Red mm Variable Angle Locking Double Drill Guide, With Cone, for 2.0 mm Variable Angle Locking Plates mm Variable Angle Locking Double Drill Guide, Freehand, for 2.0 mm Variable Angle Locking Plates mm / 1.5 mm Double Drill Sleeve, for 2.0 mm Cortex Screws, Blue Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 66

67 Instruments Depth Gauge for 1.3 mm, 1.5 mm, and 2.0 mm Screws Countersink for 1.3 mm, 1.5 mm, and 2.0 mm Screws Plate Bending Pliers, for 1.3 mm Locking and 1.5 mm and 2.0 mm Variable Angle Locking Plates, Right Plate Bending Pliers, for 1.3 mm Locking and 1.5 mm and 2.0 mm Variable Angle Locking Plates, Left Plate Cutter for 1.3 mm, 1.5 mm, and 2.0 mm Plates Plate Holding Forceps, Soft Lock Reduction Forceps for 1.3 mm to 2.0 mm Screws, Soft Lock 66 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

68 Instruments mm Drill Sleeve, Yellow, for Reduction Forceps mm Drill Sleeve, Yellow, for Reduction Forceps mm Drill Sleeve, Red, for Reduction Forceps mm Drill Sleeve, Red, for Reduction Forceps mm Drill Sleeve, Blue, for Reduction Forceps mm Drill Sleeve, Blue, for Reduction Forceps Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 66

69 Instruments mm Cruciform Screwdriver Blade with Spring Holding Sleeve, Hex Coupling 0.76 mm Drill Bits, mini quick coupling with 6 mm stop with 8 mm stop with 10 mm stop with 12 mm stop with 14 mm stop In Stainless Sets mm Kirschner Wire w/trocar Point 70 mm, 10 each mm Kirschner Wire w/trocar Point 70 mm, 10 each mm Kirschner Wire w/trocar Point 150 mm, 10 each mm Kirschner Wire w/trocar Point 150 mm, 10 each In Titanium Sets mm Ti Kirschner Wire w/trocar Point 70 mm, 10 each mm Ti Kirschner Wire w/trocar Point 150 mm, 10 each mm Ti Kirschner Wire w/trocar Point 150 mm, 10 each 66 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

70 Instruments Reduction Forceps with Points, Broad-Ratchet Termite Forceps, 90 mm Reduction Forceps with Points, Ratchet, 130 mm Sharp Hook Small Hohmann Retractor, 6 mm, Short Narrow Tip, 160 mm Small Hohmann Retractor, 8 mm Short Narrow Tip, 160 mm Periosteal Elevator, 3 mm width, curved blade, round edge Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 66

71 VARIABLE ANGLE LOCKING HAND SYSTEM GRAPHIC CASES Graphic Cases* /3 Instrument Tray, Standard Instruments, for the Variable Angle Locking Hand System /3 Instrument Tray, Cutting and Bending Instruments, for the Variable Angle Locking Hand System /3 Instrument Tray, Reduction Instruments, for the Variable Angle Locking Hand System *Graphic cases shown with instruments, available separately. For detailed cleaning and sterilization instructions, please refer to or sterilization instructions, if provided. 77 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

72 Variable Angle Locking Hand System Graphic Cases mm Locking Implant and Instrument Module with 1.0 mm Screws Compact Set Plate Bin for 1.3 mm Locking Implant and Instrument Module Standard Set Plate Bin for 1.3 mm Locking Implant and Instrument Module Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 77

73 Variable Angle Locking Hand System Graphic Cases mm Variable Angle Locking Implant and Instrument Module Compact Set Plate Bin for 1.5 mm Variable Angle Locking Implant and Instrument Module Standard Set Plate Bin for 1.5 mm Variable Angle Locking Implant and Instrument Module DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

74 Variable Angle Locking Hand System Graphic Cases mm Variable Angle Locking Implant and Instrument Module Compact Set Plate Bin for 2.0 mm Variable Angle Locking Implant and Instrument Module Standard Set Plate Bin for 2.0 mm Variable Angle Locking Implant and Instrument Module Graphic Case, Full Length, 2-High for Variable Angle Locking Hand System Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 77

75 ALSO AVAILABLE K-Wire Insert for Instrument Tray for VA Locking Hand System Drill Insert Module for Reduction Forceps /3 Length Auxiliary Tray mm Drill Bit K-wire Attachment, for Threaded Hole, 64 mm mm Drill Bit, Stryker J-Latch, for Threaded Hole, 61 mm mm Drill Bit, Stryker J-Latch, for Gliding Hole, 55 mm 77 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

76 Also Available mm Drill Bit, Stryker J-Latch, for Threaded Hole, 65 mm mm Drill Bit, Stryker J-Latch, for Gliding Hole, 57 mm mm Drill Bit, Stryker J-Latch, for Threaded Hole, 83 mm mm Drill Bit, Stryker J-Latch, for Gliding Hole, 66 mm Plate Cutter, In-line for 1.3 mm Locking and 1.5 mm and 2.0 mm Variable Angle Locking Plates Silicone Insert for In-line Plate Cutter Silicone Insert for Plate Cutter Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 77

77 Also Available Mini Plate Holder mm Drill Bit, Stryker J-Latch, for threaded hole, 56 mm mm Drill Bit, Mini Quick Coupling, for Threaded Hole, 47 mm mm Drill Bit, Stryker J-Latch, 6 mm Stop, 44.5 mm mm Drill Bit, Stryker J-Latch, 8 mm Stop, 44.5 mm mm Drill Bit, Stryker J-Latch, 12 mm Stop, 44.5 mm mm Drill Bit, Stryker J-Latch, 14 mm Stop, 44.5 mm 77 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

78 VA LOCKING HAND INSTRUMENT AND IMPLANT SET STANDARD STAINLESS STEEL ( ) AND TITANIUM ( ) VA LOCKING HAND INSTRUMENT AND IMPLANT SET COMPACT STAINLESS STEEL ( ) AND TITANIUM ( ) Graphic Cases /3 Instrument Tray, Standard Instruments, for the Variable Angle Locking Hand System /3 Instrument Tray, Cutting and Bending Instruments, for the Variable Angle Locking Hand System /3 Instrument Tray, Reduction Instruments, for the Variable Angle Locking Hand System Screw Length Markers Item Length Item Length Number (mm) Number (mm) Item Number Blank For detailed cleaning and sterilization instructions, please refer to or sterilization instructions, if provided. Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 77

79 VA Locking Hand Instrument and Implant Set Standard Stainless Steel ( ) and Titanium ( ) Standard Sets VA Locking Hand Instrument and Implant Set Standard VA Titanium Locking Hand Instrument and Implant Set Standard Instrument and Implant Modules Included: mm mm mm Implant Bins Included: mm mm mm 77 DePuy Synthes Companies Variable Angle Locking Hand System Surgical Technique

80 VA Locking Hand Instrument and Implant Set Compact Stainless Steel ( ) and Titanium ( ) Compact Sets VA Locking Hand Instrument and Implant Set Compact VA Titanium Locking Hand Instrument and Implant Set Compact Instrument and Implant Modules Included: mm mm mm Implant Bins Included: mm mm mm Variable Angle Locking Hand System Surgical Technique DePuy Synthes Companies 77