3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP )

Transcription

1 For Minimally Invasive Osteosynthesis 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

2 Table of Contents Introduction 3.5 mm and 4.5 mm Curved Locking Compression 2 Plates (LCP) AO Principles 5 Indications 6 Fixation Principles 7 Minimally Invasive Reduction and 12 Plate Insertion Instruments Surgical Technique Toothed Reduction Handles (Bicortical) 13 for Enhanced Rotational Stability Plate Contouring (optional) 16 Plate Insertion 17 Reduction and Temporary Plate Placement 20 Screw Insertion 21 Screw Placement Verification 26 Implant Removal 28 Product Information Implants 29 Instruments 31 Set Lists 36 MR Information The 3.5 mm and 4.5 mm Curved LCPs has not been evaluated for safety and compatibility in the MR environment. It has not been tested for heating, migration, or image artifact in the MR environment. The safety of the 3.5 mm and 4.5 mm Curved LCPs in the MR environment is unknown. Scanning a patient who has this device may result in patient injury. Image intensifier control 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 1

3 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) The DePuy Synthes Locking Compression Plates (LCP ) are part of a plate and screw system that merges locking screw technology with conventional plating techniques. The Locking Compression Plate System has many similarities to existing plate fixation methods, but with a few important enhancements. Locking screws provide the ability to create a fixed-angle construct while utilizing familiar AO plating techniques. A fixed-angle construct provides advantages in osteopenic bone or multifragment fractures where traditional screw purchase is compromised. Locking screws do not rely on plate-to-bone compression to maintain stability, but function similarly to multiple small angled blade plates. Plate features The Locking Compression Plates (LCP) Uniform hole spacing Load (compression) and neutral screw positions 2 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

4 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP) Combi holes The Combi holes allow placement of standard cortex and cancellous bone screws on one side or threaded conical locking screws on the opposite side of each hole. Dynamic compression unit (DCU) hole section for standard screws Threaded hole section for locking screws Locking screw in threaded side of plate hole Holes in these plates are oriented so that the compression of the hole is always directed toward the middle of the plate. Cortex screw in compression side of plate hole 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 3

5 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP) Locking screws, self-tapping, with StarDrive TM Recess The locking screws mate with the threaded plate holes to form a fixed-angle construct. Locking screw design The screw design has been modified, as compared to standard cortex screws, to enhance fixation and facilitate the surgical procedure. StarDrive Recess The StarDrive Recess provides improved torque transmission to the screw while retaining the screw on the screwdriver without the use of a holding sleeve. Large core diameter The large core diameter improves bending and shear strength, and distributes the load over a larger area in the bone. Self-tapping flutes Conical screwhead The conical head facilitates alignment of the locking screw in the threaded plate hole to provide a secure screw-plate construct. Thread profile The shallow thread profile of the locking screws results from the larger core diameter. This is possible because locking screws do not rely solely on the screw threads to create compression between the plate and the bone to maintain stability. 4 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) 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 1958, the AO formulated 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, active mobilization Early Early and and safe safe mobilization and rehabilitation of of the injured part and and the the patient as as a 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-Verlag; 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 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 5

7 Indications The Synthes 3.5 mm Curved LCP Plates are intended for fixation of fractures, osteotomies and nonunions of the clavicle, scapula, olecranon, humerus, radius, pelvis, distal tibia and fibula, particularly in osteopenic bone for adult patients. The Synthes 4.5 mm Curved LCP Plates are intended for fixation of various long bones, such as the humerus, femur, and tibia. They are also for use in fixation of periprosthetic fractures, osteopenic bone, and nonunions or malunions in adult patients. The 3.5 mm and 4.5 mm Curved LCP Plates are also intended for fracture fixation of diaphyseal and metaphyseal areas of long bones in pediatric patients. 6 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

8 Fixation Principles The following points distinguish treatment using locking compression plate technology: Allows fracture treatment using compression plating with conventional cortex or cancellous bone screws Allows fracture treatment using locked plating with bicortical or unicortical locking screws Permits the combination of conventional and locking screw techniques Note: These LCP Plates are suitable for a large number of fracture types. For that reason, this technique guide does not deal with any specific fracture type. Please refer also to the AO Principles of Fracture Management, 2 and the AO Manual of Fracture Management Internal Fixators. 3 a Unicortical screw fixation Unicortical locking screws provide stability and load transfer only at the near cortex due to the threaded connection between the plate and the screw. Screw stability and load transfer are accomplished at two points along the screw: the screwhead and near cortex. Because the screw is locked to the plate, fixation does not rely solely on the pullout strength of the screw or on maintaining friction between the plate and the bone. Bicortical screw fixation has long been the traditional method of compressing a plate to the bone where friction between the plate and the bone maintains stability. Screw stability and load transfer are accomplished at two points along the screw: the near and far cortices. b a. Unicortical screws utilize the locked screw and the near cortex to achieve stability. b. Bicortical screws require two (2) cortices to achieve stability. 2. Thomas P. Rüedi, et al, ed., AO Principles of Fracture Management, New York: Thieme, M. Wagner and R. Frigg, AO Manual of Fracture Management Internal Fixators, New York: Thieme, mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 7

9 Fixation Principles The following examples show the biomechanical features of conventional plating techniques, locked or bridge plating techniques, and a combination of both. Conventional plating F3 F2 Absolute stability The tensile force (F1) originating from tightening the screws presses the plate onto the bone (F2). The developing friction (F3) between the plate and the bone leads to stable plate fixation. To ensure absolute stability, the friction resistance must be higher than the axial forces (F4) arising during rehabilitation. F4 F1 F2 F4 Lag screw Interfragment compression is accomplished by using a lag screw. This is particularly important in intra-articular fractures which require a precise reduction of the joint surfaces. Lag screws can be angled in the plate hole, allowing placement of the screw perpendicular to the fracture line. Primary loss of reduction In conventional plating, even though the bone fragments are correctly reduced prior to plate application, fracture dislocation will result if the plate does not fit the bone. In addition, if the lag screw is not seated perpendicular to the fracture line (e.g., spiral fracture of the distal tibia), shear forces will be introduced. These forces may cause loss of reduction. 8 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

10 Fixation Principles Secondary loss of reduction Under axial load, postoperative, secondary loss of reduction may occur by toggling of the screws. Since cortex screws do not lock to the plate, the screws cannot oppose the acting force and may loosen, or be pushed axially through the plate holes. Blood supply to the bone The periosteum is compressed under the plate area, reducing or even interrupting blood supply to the bone. The result is delayed bone healing due to temporary osteoporosis underneath the plate. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 9

11 Fixation Principles Bridge/locked plating using locking screws Screws lock to the plate, forming a fixed-angle construct Bone healing is achieved indirectly by callus formation when using locking screws exclusively Maintenance of primary reduction Once the locking screws engage the plate, no further tightening is possible. Therefore, the implant locks the bone segments in their relative positions regardless of degree of reduction. Precontouring the plate minimizes the gap between the plate and the bone, but an exact fit is not necessary for implant stability. This feature is especially advantageous in minimally or less invasive plating techniques because these techniques do not allow exact contouring of the plate to the bone surface. Stability under load By locking the screws to the plate, the axial force is transmitted over the length of the plate. The risk of a secondary loss of the intraoperative reduction is reduced. Blood supply to the bone Locking the screw into the plate does not generate additional compression between the plate and the bone. Therefore, the periosteum will be protected and the blood supply to the bone preserved. 11 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

12 Fixation Principles Combined internal fixation The combination of conventional compression plating and locked plating techniques enhances plate osteosynthesis. The result is a combination, or Combi, hole that, depending on the indication, allows standard compression plating, locked/ bridge plating or a combination of both. Internal fixation using a combination of locking screws and standard screws Note: If a combination of cortex and locking screws is used, a cortex screw should be inserted first to pull the plate to the bone. If locking screws (1) have been used to fix a plate to a fragment, subsequent insertion of a standard screw (2) in the same fragment without loosening and retightening the locking screw is NOT RECOMMENDED. 1 1 Warning: If a locking screw is used first, care should be taken to ensure that the plate is held securely to the bone to avoid spinning of the plate about the bone. Note: Do not lock the screws at full speed to reduce the risk of stripping the head. This can make it difficult to remove the implant. Precaution: For long screws and thick cortical bone, ensure sufficient cooling during insertion. 2 Dynamic compression Once the metaphyseal fragment has been fixed with locking screws, the fracture can be dynamically compressed using standard screws in the DCU portion of the Combi hole. Locked and standard plating techniques First, use lag screws to anatomically reconstruct the joint surfaces The behavior of a locking screw is not the same as that of a lag screw. With the locked plating technique, the implant locks the bone segments in their relative positions regardless of how they are reduced A plate used as a locked/bridge plate does not produce any additional compression between the plate and the bone The unicortical insertion of a locking screw causes no loss of stability 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 11

13 Minimally Invasive Reduction and Plate Insertion Instruments Minimally invasive surgery supports the principles of biological internal fixation by avoiding long incisions and extensive soft tissue stripping associated with conventional techniques. Devascularization of the fragments can be minimized by indirect reduction and an improved healing process can be expected. The Minimally Invasive Reduction Instruments are intended for obtaining intraoperative fixation using minimally invasive, indirect reduction techniques. The Minimally Invasive Plate Insertion Instruments are indicated for plate insertion through minimal incision(s) after temporary reduction has been achieved. The Minimally Invasive Reduction and Plate Insertion Instrument Set includes: Reduction handles to gain and maintain stable intraoperative fixation of a fracture Soft tissue retractors to subcutaneously prepare a plate pathway over long distances through a small incision A plate holder with clamping feet for easy, percutaneous manipulation of a plate along the bone Reduction handles Toothed reduction handles provide rotational stability during manipulation of bone fragments. Soft tissue retractors The offset blade allows easy preparation of a cavity for percutaneous plate insertion. The asymmetric tip allows a choice of insertion angle. The blade length can be adjusted using a combination wrench. The blade can be completely removed for easy cleaning of the cannulated handle. Plate holder The plate holder is for percutaneous insertion of most LCP and LC-DCP Plates. A simple clamping mechanism provides guidance and easy handling of a plate under soft tissue. Nine interchangeable clamping feet are available for use with the plate holder. 11 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

14 Toothed Reduction Handles (Bicortical) for Enhanced Rotational Stability 1 Insert threaded rod Instruments for 3.0 mm threaded rods mm Protection Sleeve, slotted mm/ 3.0 mm Drill Sleeve mm Threaded Rod, self-drilling tip Instruments for 5.0 mm threaded rods mm Protection Sleeve, slotted mm/5.0 mm Drill Sleeve mm Threaded Rod, self-drilling tip Insert a self-drilling threaded rod through the drill sleeve assembly (drill sleeve and protection sleeve) and into the bone so that the self-drilling tip is embedded in the far cortex. Precaution: Do not insert the drill tip into the opposite cortical bone to prevent damage of the opposite side structure and to avoid removal problems. Remove the drill sleeve. Precautions: Instruments and screws may have sharp edges or moving joints that may pinch or tear user s glove or skin. Handle devices with care and dispose of worn bone cutting instruments in an approved sharps container. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 11

15 Toothed Reduction Handles (Bicortical) for Enhanced Rotational Stability 2 Attach reduction handle Instruments for 3.0 mm threaded rods Reduction Handle, toothed, for 3.0 mm Threaded Rod mm Protection Sleeve, slotted Adjusting Nut, for 3.0 mm Threaded Rod mm Threaded Rod, self-drilling tip Instruments for 5.0 mm threaded rods Reduction Handle, toothed, for 5.0 mm Threaded Rod mm Protection Sleeve, slotted Adjusting Nut, for 5.0 mm Threaded Rod mm Threaded Rod, self-drilling tip Slide the toothed reduction handle over the threaded rod and through the slotted protection sleeve to the bone. Slide the adjusting nut over the threaded rod and tighten it onto the reduction handle. Note: Tightening the adjusting nut excessively may cause the threaded rod to strip out of the bone. Remove the protection sleeve by sliding back the release. A second toothed reduction handle can be attached using the same technique. 11 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

16 Toothed Reduction Handles (Bicortical) for Enhanced Rotational Stability 3 Reduce fracture Instruments for 3.0 mm threaded rods Medium Combination Clamp, MR Safe mm Carbon Fiber Rod Instruments for 5.0 mm threaded rods Large Combination Clamp, MR Conditional mm Carbon Fiber Rod If needed, apply combination clamps and a carbon fiber rod without tightening the construct. Reduce the fragments. 4 Temporary fixation Instrument mm/ 11 mm Wrench Using the 8 mm/11 mm wrench, firmly tighten the combination clamps to temporarily hold the reduction. After definitive treatment of the fracture, remove the reduction instruments. The large reduction instruments are shown in these illustrations. Use the same technique for the small reduction instruments. Note: Reduction instruments, including threaded rods, are not indicated for postoperative use. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 11

17 Plate Contouring (optional) Use the AO preoperative planner template for the 3.5 mm and 4.5 mm curved LCP Plates. Note: Templates are available in two sizes: actual size and 115% magnification in which the image is enlarged 15% to correspond to typical radiological magnification; however, variations in magnification levels are common. Required sets Small Fragment LCP Instrument and Implant Set or Large Fragment LCP Instrument and Implant Set or Periarticular LCP Plating System, with 5.0 mm Locking Screws Bending instruments */ Bending Irons * * Bending Pliers * Plate Bending Press Use the bending instruments to contour the locking compression plate to the anatomy. Note: The plate holes are designed to accept some degree of deformation. When bending the plate, place the bending irons on two adjacent holes. This ensures that the threaded holes will not be distorted. Significant distortion of the locking holes will reduce locking effectiveness. Please refer to the AO Principles of Fracture Management, 4 and the AO Manual of Fracture Management Internal Fixators. 5 Precautions: Reverse bending or using the incorrect instrumentation for bending may weaken the plate and lead to premature plate failure (e.g. breakage). Do not bend the plate beyond what is required to match the anatomy. Do not bend the plate at the level of the holes. 4. Rüedi. 5. Wagner. *Also available. 11 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

18 Plate Insertion 1 Insert soft tissue retractors Instruments mm/ 11 mm Wrench Soft Tissue Retractor, small, extendible Optional instrument Small Soft Tissue Retractor Blade, long To adjust the length of the soft tissue retractors, loosen the clamping sleeve with the 8 mm/11 mm wrench. Use the 8 mm wrench for the small retractor. Slide the blade within the handle to an appropriate length and tighten the clamping sleeve. Warning: Do not over tighten the clamping sleeve as this could lead to breakage. Do not extend the blade beyond the line marked MAX. Insert the soft tissue retractor through an incision to prepare a cavity for percutaneous plate insertion. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 11

19 Plate Insertion 2 Assemble plate holder 3 Instruments for 3.5 mm narrow plates Large Hexagonal Key, for large screws Clamping Foot, for , for 3.5 mm LCP and 3.5 mm LC-DCP Plate Holder, for Minimally Invasive Plating Osteosynthesis Instruments for 3.5 mm broad and 4.5 mm narrow plates Clamping Foot, for , for 4.5 mm/5.0 mm Narrow LCP and 4.5 mm Narrow LC-DCP Connecting Screw, for Plate Holder 4 2 Push the connecting screw through the plate holder until it clicks into place (1). Insert a clamping foot into the plate holder (2). Engage the connecting screw into the clamping foot, but do not fully tighten (3). Slide the selected plate into the clamping foot (4). Firmly tighten the connecting screw with the large hexagonal key. 11 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

20 Plate Insertion 3 Insert plate 4 Remove plate holder Instrument Large Hexagonal Key, for large screws Use the large hexagonal key to remove the connecting screw from the plate holder. Remove the plate holder from the clamping foot. Slide the clamping foot from the plate. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 11

21 Reduction and Temporary Plate Placement 1 Reduce and position plate Instruments for 3.5 mm plates Push-Pull Reduction Device Threaded Plate Holder or Threaded Plate Holder, long Instruments for 4.5 mm plates Push-Pull Reduction Device Threaded Plate Holder The plate may be temporarily held in place with standard plate holding forceps, a push-pull reduction device or a K-wire. Note: The middle of the plate should be positioned over the fracture site if compression of the fracture fragments is desired. The push-pull reduction device is designed to temporarily hold the plate to the bone through a plate hole. The device is self-drilling and connects with the DePuy Synthes quick coupling for power insertion. Insert into the near cortex only. After power insertion, turn the collet clockwise until it pulls the plate securely to the bone. Note: Take care to avoid inserting this device in a hole that will be needed immediately for plate fixation. However, the device may be removed and a screw inserted through the same plate hole. A threaded plate holder can also be used as an aid to position the plate on the bone. The plate holder may also function as an insertion handle for use with minimally invasive plating techniques. 22 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

22 Screw Insertion 1 Insert screws Determine whether standard cortex screws, cancellous bone screws or locking screws will be used for fixation. A combination of all may be used. Note: If a combination of cortex, cancellous and locking screws is used, a standard screw should be used first to pull the plate to the bone. Warning: If a locking screw is used first, care should be taken to ensure that the plate is held securely to the bone to avoid spinning of the plate about the bone. Insertion of a cortex or cancellous bone screw Instruments for 3.5 mm cortex or cancellous bone screws mm Drill Bit Small Hexagonal Screwdriver Depth Gauge, for small screws mm Universal Drill Guide Instruments for 4.5 mm cortex or cancellous bone screws mm Drill Bit Large Hexagonal Screwdriver Depth Gauge, for large screws mm Universal Drill Guide Predrill both cortices using the universal drill guide for an eccentric (compression) or neutral (buttress) insertion of cortex screws. Note: The LC-DCP Drill Guide and the DCP Drill Guide are NOT suitable for use with LCP Plates. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 22

23 Screw Insertion 1 Insert screws continued Neutral insertion of a standard screw When pressing the universal drill guide into the DCU portion of the LCP Plate, it will center itself and allow neutral predrilling. Dynamic compression, eccentric insertion of a cortex screw To drill a hole for dynamic compression, place the universal drill guide eccentrically at the edge of the DCU portion of the LCP Plate hole, without applying pressure. Tightening of the cortex screws will result in dynamic compression corresponding to that of the LC-DCP Plate. Measure for screw length using the depth gauge and insert the appropriate length cortex or cancellous bone screw. 22 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

24 Screw Insertion Insertion of locking screws Instruments for 3.5 mm locking screws mm Drill Bit mm Threaded Drill Guide StarDrive Screwdriver, T15 or StarDrive Screwdriver Shaft, T Depth Gauge, for small screws * Torque Limiting Attachment, 1.5 Nm or * Torque Limiting Attachment, 1.5 Nm, quick coupling Instruments for 5.0 mm locking screws mm Drill Bit mm Threaded Drill Guide StarDrive Screwdriver, T25 or StarDrive Screwdriver Shaft, T Depth Gauge, for large screws * Torque Limiting Attachment, 4 Nm or * Torque Limiting Attachment, 4 Nm, for AO Reaming Coupler Note: The locking screw is not a lag screw. Use standard screws when a precise anatomical reduction (e.g., joint surfaces) or interfragmentary compression is required. Before inserting the first locking screw, perform anatomical reduction and fix the fracture with lag screws, if necessary. After the insertion of locking screws, an anatomical reduction will no longer be possible without loosening the locking screw. Screw the threaded drill guide into an LCP Plate hole until fully seated. *Also available. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 22

25 Screw Insertion 1 Insert screws continued Insertion of locking screws continued Note: Since the direction of a locking screw is determined by plate design, final screw position may be verified with a K-wire prior to insertion. This becomes especially important when the plate has been contoured or applied in metaphyseal regions around joint surfaces (refer to Screw Placement Verification on page 26). Warning: Do not try to bend the plate using the threaded drill guide because damage may occur to the plate hole threads. Use the drill bit to drill the desired depth. Remove the threaded drill guide. Use the depth gauge to determine screw length. Precautions: The use of the threaded drill guide is mandatory in order to ensure that the locking screw is drilled in the proper perpendicular angle and correctly locked in the plate. Always irrigate during drilling to avoid thermal damage to the bone. For Long screws and thick cortical bone, ensure sufficient cooling during insertion. Do not insert the drill tip into the opposite cortical bone to prevent damage of the opposite side structure and to avoid removal problems. 22 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

26 Screw Insertion Insert the locking screw under power using a torque limiting attachment and StarDrive Screwdriver shaft. Note: Recheck each locking screw before closing to verify that the screws are securely locked to the plate. Screwheads must be flush with the plate in the locked position before they can be considered fully seated. Warning: Always use a torque limiting attachment (TLA) when using power to insert locking screws. Alternative method of locking screw insertion Use the StarDrive Screwdriver to manually insert the appropriate length locking screw. Carefully tighten the locking screw, as excessive force is not necessary to produce effective screw-to-plate locking. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 22

27 Screw Placement Verification 2 Verify screw placement Instruments for 3.5 mm locking screws mm Kirschner Wire with Thread mm Wire Sleeve Direct Measuring Device Instruments for 5.0 mm locking screws mm Non-Threaded Guide Wire Direct Measuring Device mm Wire Sleeve Since the direction of a locking screw is determined by plate design, final screw position may be verified with a K-wire before insertion. This becomes especially important when the plate has been contoured or applied in metaphyseal regions around joint surfaces. With the threaded drill guide in place, insert the wire sleeve into the threaded drill guide. Insert a threaded Kirschner wire through the wire sleeve and drill to the desired depth. Verify K-wire placement under image intensification to determine if final screw placement is acceptable. Notes: The K-wire position represents the final position of the locking screw. If the angle of the locking screw is not optimal, it can be corrected. Bend the plate as needed, or move it in a proximal or distal direction. This technique is also suitable to preliminarily fix the plate to the bone. 22 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

28 Screw Placement Verification Measurement may be taken by sliding the tapered end of the direct measuring device over the K-wire down to the wire sleeve. Remove the direct measuring device, K-wire and wire sleeve, leaving the threaded drill guide in place. Use the drill bit to drill the near cortex. Remove the threaded drill guide. Insert the appropriate length locking screw. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 22

29 Implant Removal 1 Unlock and remove screws To remove the plate, unlock all screws from the plate, then remove the screws completely from the bone. This prevents simultaneous rotation of the plate when removing the last locking screw. 2 Insert extraction chisel Instruments Extraction Chisel Shaft Extraction Chisel Tip mm/ 11 mm Wrench Soft Tissue Retractor, small, extendible Insert the extraction chisel shaft into the tip, by aligning the etched lines. Rotate 90 to lock the extraction chisel into place. Insert the extraction chisel into the handle of the soft tissue retractor, with the large flat surface of the tip facing up. Tighten the clamping sleeve with the 8 mm/11 mm wrench. Place the extraction chisel over the exposed end of the plate and slide it along the entire length of the plate. Precaution: The chisel tip is sharp. Use extreme caution when using the chisel in areas where it can come into contact with vascular and neurovascular structures. The chisel tip can be used with 3.5 mm narrow and broad and 4.5 mm narrow LCP Plates. Remove the chisel and plate. 22 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

30 Screws Used With the 3.5 mm and 4.5 mm Curved Locking Compression Plates 3.5 mm Cortex Screws, self-tapping May be used in the DCU portion of the Combi holes Compress the plate to the bone or create axial compression 3.5 mm Locking Screws, self-tapping Create a locked, fixed-angle screw-plate construct Used in the locking portion of the Combi holes Threaded conical head 4.0 mm Cancellous Bone Screws May be used in the DCU portion of the Combi hole Compress the plate to the bone or create axial compression Fully or partially threaded shaft 4.0 mm Locking Screws, self-tapping** Create a locked, fixed-angle screw-plate construct Used in the locking portion of the Combi holes Threaded conical head 4.5 mm Cortex Screws, self-tapping** May be used in the DCU portion of the Combi holes Compress the plate to the bone or create axial compression 4.5 mm Cannulated Screws** May be used in the DCU portion of the Combi holes Compress the plate to the bone or create axial compression Self-drilling, self-tapping Fully or partially threaded shaft 5.0 mm Locking Screws, self-tapping** Create a locked, fixed-angle screw-plate construct Threaded conical head Note: All screws are available in implant-quality 316L stainless steel. For use with 3.5 mm LCP Plates. **For use with 4.5 mm LCP Plates. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 22

31 Screws Used With the 3.5 mm and 4.5 mm Curved Locking Compression Plates 5.0 mm Periprosthetic Locking Screws, self tapping** Blunt tip allows unicortical fixation of fractures when an intramedullary implant is present 6.5 mm Cancellous Bone Screws** May be used in the DCU portion of the first and last Combi holes of the 4.5 mm narrow and broad LCP Plates Compress the plate to the bone or create axial compression Fully or partially threaded shaft (16 mm, 24 mm and 32 mm thread lengths) Note: All screws are available in implant-quality 316L stainless steel. **For use with 4.5 mm LCP Plates. Curved LCP Plates Limited-contact plate design Tapered plate ends for submuscular plate insertion 3.5 mm Curved Narrow LCP Plates Available with 10 to 22 Combi holes 3.5 mm Curved Broad LCP Plates Available with 10 to 30 staggered Combi holes 4.5 mm Curved Narrow LCP Plates Available with 10 to 22 Combi holes 4.5 mm Curved Broad LCP Plates* Available with 12 to 26 staggered Combi holes Note: All plates are available in implant-quality 316L stainless steel. *Also available. 33 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

32 Instruments Extraction Chisel Shaft Extraction Chisel Tip mm/ 11 mm Wrench Large Hexagonal Key Soft Tissue Retractor, small, extendible Reduction Handle, toothed, for 3.0 mm Threaded Rod Clamping Foot for the , for 3.5 mm LCP and 3.5 mm LC-DCP 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 33

33 Instruments mm Protection Sleeve, Slotted mm/ 3.0 mm Drill Sleeve Adjusting Nut, for 3.0 mm Threaded Rod mm Threaded Rod, self-drilling tip, 270 mm Small Soft Tissue Retractor Blade, long Reduction Handle, toothed, for 5.0 mm Threaded Rod 33 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

34 Instruments Plate Holder, for Minimally Invasive Plating Clamping Foot, for 4.5 mm/5.0 mm Narrow LCP and 4.5 mm Narrow LC-DCP Connecting Screw, for mm Protection Sleeve, slotted mm/ 5.0 mm Drill Sleeve 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 33

35 Instruments Adjusting Nut, for 5.0 mm Threaded Rod mm Threaded Rod, self-drilling tip, 380 mm */ Bending Irons * * Bending Pliers * Plate Bending Press Large Combination Clamp, MR Conditional *Also available. 33 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

36 Instruments Medium Combination Clamp, MR Safe mm Carbon Fiber Rod, 350 mm mm Carbon Fiber Rod, 240 mm * Torque Limiting Attachment, 1.5 Nm * Torque Limiting Attachment, 4 Nm * Torque Limiting Attachment, 1.5 Nm, Quick coupling * Torque Limiting Attachment, 4 Nm, for AO reaming coupler *Also available. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 35

37 3.5 mm/4.5 mm Curved LCP Instrument Set ( ) Graphic Case mm/4.5 mm Curved LCP Instrument Graphic Case Instruments Extraction Chisel Shaft Extraction Chisel Tip mm/ 11 mm Wrench Large Hexagonal Key Soft Tissue Retractor, small, extendible Reduction Handle, toothed, for 3.0 mm Threaded Rod Clamping Foot for the , for 3.5 mm LCP and 3.5 mm LC-DCP mm Protection Sleeve, Slotted mm/ 3.0 mm Drill Sleeve Adjusting Nut, for 3.0 mm Threaded Rod mm Threaded Rod, self-drilling tip, 270 mm Small Soft Tissue Retractor Blade, long Reduction Handle, toothed, for 5.0 mm Threaded Rod Plate Holder, for Minimally Invasive Plating Clamping Foot, for 4.5 mm/5.0 mm Narrow LCP and 4.5 mm Narrow LC-DCP Connecting Screw, for mm Protection Sleeve, slotted mm/5.0 mm Drill Sleeve Adjusting Nut, for 5.0 mm Threaded Rod mm Threaded Rod, self-drilling tip, 380 mm Large Combination Clamp, MR Conditional Medium Combination Clamp, MR Safe mm Carbon Fiber Rod, 350 mm mm Carbon Fiber Rod, 240 mm For detailed cleaning and sterilization instructions, please refer to or sterilization instructions, if provided. Note: For additional information, please refer to package insert. 33 DePuy Synthes 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique

38 3.5 mm/4.5 mm Curved Narrow LCP Implant Set ( ) Graphic Case mm/4.5 mm Curved LCP Implant Graphic Case Implants 3.5 mm Curved Narrow LCP Plates Holes Holes mm Curved Narrow LCP Plates Holes Holes mm Curved Broad LCP Plates Holes Holes Also available mm Curved Broad LCP Plates, holes S 4.5 mm Curved Broad LCP Plates, S holes / Bending Irons Bending Pliers Plate Bending Press Torque Limiting Attachment, 1.5 Nm Torque Limiting Attachment, 4.0 Nm Torque Limiting Attachment, 1.5 Nm Torque Limiting Attachment, 4.0 Nm Note: For additional information, please refer to package insert. Available nonsterile or sterile-packed. Add S to catalog number for sterile product. 3.5 mm and 4.5 mm Curved Locking Compression Plates (LCP ) Surgical Technique DePuy Synthes 33

39 Limited Warranty and Disclaimer: DePuy Synthes products are sold with a limited warranty to the original purchaser against defects in workmanship and materials. Any other express or implied warranties, including warranties of merchantability or fitness, are hereby disclaimed. Please also refer to the package insert(s) or other labeling associated with the devices identified in this surgical technique for additional information. CAUTION: Federal Law restricts these devices to sale by or on the order of a physician. Some devices listed in this surgical technique may not have been licensed in accordance with Canadian law and may not be for sale in Canada. Please contact your sales consultant for items approved for sale in Canada. Not all products may currently be available in all markets. Manufactured or distributed by: Synthes USA Products, LLC 1302 Wrights Lane East West Chester, PA Synthes USA, LLC 1101 Synthes Avenue Monument, CO To order (USA): To order (Canada): Note: For recognized manufacturer, refer to the product label. DePuy Synthes All rights reserved. DSUS/TRM/1016/1164 6/17 DV