6.5 mm and 7.3 mm Cannulated Screws Technique Guide

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1 6.5 mm and 7.3 mm Cannulated Screws Technique Guide An Integral Part of the SYNTHES Cannulated Screw System Original Instruments and Implants of the Association for the Study of Internal Fixation AO ASIF

2 The 6.5 mm and 7.3 mm Self-drilling, Self-tapping Cannulated Screws Features Cannulated shaft accepts 2.8 mm diameter guide wires (threaded and nonthreaded wires available). Hemispherical head ensures optimal annular contact with Synthes washers and plates when screws are angled. Low-profile head reduces possibility of soft tissue irritation. Reverse-cutting flutes assist in screw removal. Choice of thread lengths offers best fit of threads into far bone fragment, for greater interfragmentary compression. Cancellous thread profile uses deep cutting threads with a large pitch to increase resistance to pullout. The large pitch also accelerates screw insertion and removal. Self-drilling, self-tapping screw tip facilitates screw insertion by eliminating the need for predrilling and tapping in most cases. Self-drilling, self-tapping flutes Cancellous thread design Reverse-cutting flutes 4.8 mm diameter shaft Deeper threads for maximum pullout resistance Hemispherical, low profile head with 4.0 mm hex drive Rigid 2.8 mm guide wire, made of high strength L-605 alloy Thread Lengths 6.5 mm 7.3 mm 16 mm thread Materials 32 mm thread Fully threaded Implant quality 316L stainless steel Titanium alloy Ti-6Al-7Nb

3 Indications For fracture fixation of large bones and large bone fragments, such as: Femoral neck fractures Slipped capital femoral epiphyses As an adjunct to DHS in basilar neck fractures Tibial plateau fractures Other indications include: Ankle arthrodeses Pediatric femoral neck fractures (6.5 mm Cannulated Screws only) Intercondylar femur fractures Sacroiliac joint disruptions Subtalar arthrodeses Miss-A-Nail 6.5 mm and 7.3 mm titanium screws may be used with the Titanium Femoral Nail System. Warning: This device is not approved for screw attachment or fixation to the posterior elements (pedicles) of the cervical, thoracic, or lumbar spine. 1

4 AO Principles In 1958, the AO ASIF (Association for the Study of Internal Fixation) formulated four basic principles, which have become the guidelines for internal fixation: Anatomic Reduction The guide wire inserted prior to the cannulated screw helps to maintain anatomic alignment while the screw is inserted. As the cannulated screw is inserted, it compresses the fragments, eliminating any gaps and achieving anatomic reduction. Stable Fixation Cannulated screws provide interfragmentary compression and absolute stability across the fracture. The screws are available in several different thread lengths, allowing the surgeon to optimize purchase in the far fragment for maximum compression. Preservation of Blood Supply Because the path of cannulated screws is directed by small diameter guide wires, the screws can be precisely placed with percutaneous techniques, thereby minimizing disruption of soft tissue and vascular blood flow. Early Mobilization Cannulated screw features, combined with AO technique, create a focused, load-sharing fixation construct. 2

5 Surgical Technique Technique Tips Cleaning Cannulations Cleaning the cannulation in each instrument is imperative for proper function. Instruments should be cleared intraoperatively with the 2.8 mm Cleaning Stylet [319.46] to prevent accumulation of debris in the cannulation and potential binding of the instruments about the guide wire. Postoperatively, they should be cleaned with both the Cleaning Stylet and Cleaning Brush [319.24]. Drilling and Tapping The self-drilling, self-tapping flutes of the 6.5 mm and 7.3 mm cannulated screws make predrilling and tapping unnecessary in most cases, but in very dense bone, it may be helpful to use the 5.0 mm Cannulated Drill Bit [310.63] and the Cannulated Tap [ ]. Considerations for Selecting the 6.5 mm versus the 7.3 mm Cannulated Screw Dimensionally, the thread and head diameters of the 6.5 mm Cannulated Screw are smaller than those of the 7.3 mm Cannulated Screw. The core and shaft diameters are the same. With regard to screw performance, the deep cutting threads on the 7.3 mm Cannulated Screw give it greater pullout resistance (about 10%), whereas the 6.5 mm screw is optimized for use in a smaller bone space, with multiple adjacent screws, and through plates. Bending strength, insertion torque and torsional strength are essentially equivalent. Percutaneous Technique 1 Insert the guide wire Insert the percutaneous sleeve assembly through a stab incision and through the soft tissue to the bone. Remove the trocar. Under power, insert the 2.8 mm Threaded Guide Wire through the inner sleeve into the bone. Check for appropriate depth under image intensification. Protection Sleeve Note: When using the cannulated instrument shafts over the extra long 450 mm guide wire, a cannulated coupling device or Jacobs chuck is required. Wire Sleeve

6 Surgical Technique (continued) Percutaneous Technique (continued) Option 1a: Insert additional parallel guide wire(s) with Adjustable Parallel Wire Guide Use the 2.8 mm Adjustable Parallel Wire Guide to place parallel wires at various distances from the first wire. Place the fixed sleeve over the previously inserted wire and adjust the movable sleeve to the desired position and distance. Tighten the knurled nut on the adjustable sleeve to lock it in place. Insert the desired number of additional wires. Adjustable Parallel Wire Guide Option 1b: Insert multiple parallel guide wire(s) using Multiple Wire Guide Insert the Multiple Wire Guide and Trocar through a stab incision and through the soft tissue to the bone. Remove the trocar. Select hole pattern and insert 2.8 mm guide wires through the preselected holes. Once all wires are placed, use the protection sleeve to protect the soft tissue while measuring and inserting screws. Multiple Wire Guide Note: The Multiple Wire Guide will allow placement of washers when wires are placed through nonadjacent holes. Placement through adjacent holes will allow clearance for screws but not for washers. 4

7 2 Countersink (optional) When a lower screw profile is necessary, use the Cannulated Countersink to create a recess for the screw head. 3 Measure for screw length Remove wire sleeves or guides and slide the tapered end of the Cannulated Screw Measuring Device over the guide wire and through the protection sleeve to the bone. Read the scale at the end of 300 mm wires, or at the 300 mm calibration marking on 450 mm wires, to determine insertion depth of wire and appropriate screw length. Measuring Device Protection Sleeve Note: The reading indicates the screw length that will place the screw at the tip of the guide wire. Subtract appropriately for any anticipated interfragmentary compression resulting from screw insertion. Note: If planning to countersink, this should be done prior to inserting Measuring Device. 5

8 Surgical Technique (continued) Percutaneous Technique (continued) 4 Insert the screw Using the Cannulated Hexagonal Screwdriver, place the appropriate length screw over the guide wire through the protection sleeve, and insert into the bone. Remove and discard the guide wire. For power insertion of screws, use the Cannulated Hexagonal Screwdriver Shaft [314.23] and Holding Sleeve [314.11]. Always use the Cannulated Hexagonal Screwdriver [314.05] for final, manual seating of the screw. Use of a washer should be considered when using the 7.3 mm drill bit to make a gliding hole, or inserting the screw into osteoporotic bone. Note: In very dense bone, it may be helpful to predrill the cortex with the 5.0 mm drill bit. Cannulated Hexagonal Screwdriver

9 Open Technique 1 Set angle of Variable Angle Wire Guide Prior to inserting guide wires, place the Variable Angle Wire Guide [312.07] directly on the bone and select the insertion angle. Variable Angle Wire Guide Insert guide wires and measure Select a hole pattern and insert the 2.8 mm guide wires through the preselected holes. Once all wires are placed, use the protection sleeve to protect the soft tissue while measuring for screw length. Note: The Variable Angle Wire Guide will allow placement of washers when wires are placed through nonadjacent holes. Placement through adjacent holes will allow clearance for screws but not for washers. 3 Insert screws Using the Cannulated Hexagonal Screwdriver, place the appropriate length screw over the guide wire and through the protection sleeve, and insert into the bone. Remove and discard the guide wire. 7

10 Implants Stainless Steel (316L) 6.5 mm Cannulated Screws, 16 mm thread length mm* mm** 7.3 mm Cannulated Screws, 16 mm thread length mm* 6.5 mm Cannulated Screws, 32 mm thread length mm* mm** 7.3 mm Cannulated Screws, 32 mm thread length mm* 6.5 mm Cannulated Screws, fully threaded mm* mm** 7.3 mm Cannulated Screws, fully threaded mm* [219.99] To prevent screw head from sinking into osteoporotic bone *5 mm increments **10 mm increments Also available 8

11 Titanium (Ti-6Al-7Nb) 6.5 mm Titanium Cannulated Screws, 16 mm thread length mm* mm** 7.3 mm Titanium Cannulated Screws, 16 mm thread length mm* 6.5 mm Titanium Cannulated Screws, 32 mm thread length mm* mm** 7.3 mm Titanium Cannulated Screws, 32 mm thread length mm* 6.5 mm Titanium Cannulated Screws, fully threaded mm* mm** 7.3 mm Titanium Cannulated Screws, fully threaded mm* Titanium [419.99] To prevent screw head from sinking into osteoporotic bone *5 mm increments **10 mm increments Also available 9

12 Instruments 2.8 mm Threaded Guide Wire, 300 mm [292.68] Maintains reduction during drilling and facilitates precise placement of the screw in the bone, 10 per set, packaged individually. (L-605 alloy) Percutaneous Sleeve Assembly: All steps can be performed through the 12.0 mm/8.5 mm Protection Sleeve [312.05] including measuring and screw insertion. The 8.5 mm/2.8 mm Wire Sleeve [312.08] nests in the protection sleeve for placement of a single guide wire. The 2.8 mm Trocar [312.02] nests in the wire sleeve to facilitate passage of the sleeve assembly through the soft tissue. The Washer Sleeve [312.09] is required only when inserting screws with washers. 8.5 mm/2.8 mm Wire Sleeve [312.08] 12.0 mm/8.5 mm Protection Sleeve [312.05] 2.8 mm Trocar [312.02] Multiple Wire Guide Assembly: Multiple Wire Guide [ ] 2.8 mm Trocar for Multiple Wire Guide [ ] Multiple, parallel guide wire placement can be performed through the Multiple Wire Guide [ ]. The 2.8 mm Trocar for Multiple Wire Guide [ ] nests in the Multiple Wire Guide to facilitate passage of the guide through soft tissue mm/13.0 mm Washer Sleeve [312.09] Protects soft tissue during placement of screw with washer. 10

13 2.8 mm Adjustable Parallel Wire Guide [312.01] For parallel placement of guide wires in percutaneous procedures. Cannulated Screw Measuring Device [319.70] Indicates screw length required to reach tip of guide wire. Holding Sleeve [314.11] Cannulated Hexagonal Screwdriver [314.05] Fully cannulated for insertion of any Synthes 6.5 mm or 7.3 mm Cannulated Screw over the guide wire (4.0 mm hex). Used with Holding Sleeve [314.11]. 2.8 mm Cleaning Stylet [319.46] For intraoperative clearing of cannulated instruments. 2.9 mm Cleaning Brush [319.24] For postoperative cleaning of cannulated instruments. Note: Clear instrument cannulations intraoperatively with the cleaning stylet. Clean instruments postoperatively with the stylet and the cleaning brush. 11

14 Instruments (continued) Solid Hexagonal Screwdriver [313.93] Used for removal of 6.5 mm and 7.3 mm Cannulated Screws. (4.0 mm hex) Large Quick Coupling [338.49] For use with Cannulated Drill Bits, hexagonal screwdriver shafts, and quick coupling drills. Screw Forceps [319.97] For removal of screws from the screw rack. 5.0 mm Cannulated Drill Bit, 300 mm, 2.9 mm cannulation [310.63] For use in dense bone. 7.3 mm Cannulated Drill Bit [ ] For drilling gliding hole for 6.5 mm and 7.3 mm Cannulated Screws. 12

15 Cannulated Countersink [310.78] Prepares recess in bone for screw head. Cannulated Tap for 6.5 mm and 7.3 mm Cannulated Screws [ ] For use in dense bone. Variable Angle Wire Guide [312.07] For parallel placement of guide wires in open procedures. Cannulated Hexagonal Screwdriver Shaft [314.23] For power insertion of 6.5 mm and 7.3 mm Cannulated Screws over a 2.8 mm guide wire. (4.0 mm hex) Solid Hexagonal Screwdriver Shaft [314.04] Facilitates power removal of 6.5 mm and 7.3 mm Cannulated Screws. (4.0 mm hex) Also Available: 2.8 mm Guide Wire with flutes (nonthreaded), 300 mm, 150 mm calibration [292.81] 2.8 mm Threaded Guide Wire, 450 mm, 300 mm calibration [ ] 13

16 Instrument and Implant Sets The 6.5 mm and 7.3 mm Cannulated Screws are available in six different instrument and implant sets, three with stainless steel screws and three with titanium. Each set includes the same set of instruments, but a different combination of two screw sets. Stainless Steel Titanium 6.5 mm Cannulated Screw Instrument and Implant Set mm Cannulated Screw Instrument and Implant Set mm and 7.3 mm Combined Cannulated Screw Instrument and Implant Set 6.5 mm Partially 6.5 mm Fully 7.3 mm Partially 7.3 mm Fully Set Name Threaded Screws Threaded Screws Threaded Screws Threaded Screws 6.5 mm Cannulated Screw Instrument and Implant Set 7.3 mm Cannulated Screw Instrument and Implant Set 6.5/7.3 mm Combined Cannulated Screw Instrument and Implant Set X X X X X X Note: If a different mix of screws is preferred, individual screw sets and racks may be ordered and assembled into a customized set with your choice of instruments and graphic case. See Set Contents section for part numbers. 14

17 Set Contents Graphic Case The graphic case consists of a graphic case base, upper instrument tray, lower instrument tray, and case lid. Screw racks are ordered separately from the case to allow hospitals to customize their sets with screw combinations other than those defined in the standard product sets. The upper instrument tray stores the instruments most frequently used during cannulated screw implantation. Under the upper tray are two spaces for screw racks, an auxiliary bin and the lower instrument tray, which sits on top of the auxiliary bin. The auxiliary bin is designed to store screws longer than 150mm, which will not fit into the screw racks. The graphic cases for the different instrument and implant sets are identical except for their lids, which are labeled with each particular set name. The case lids, as well as the case base, screw racks and rack lids are all available separately as additional or replacement items. Graphic Cases Graphic Case for 6.5mm Cannulated Screw Instrument and Implant Set Graphic Case for 7.3mm Cannulated Screw Instrument and Implant Set Graphic Case for 6.5/7.3mm Combined Cannulated Screw Instrument and Implant Set Graphic Case Components Graphic Case Base, for 6.5 mm, 7.3 mm, and combined cannulated screw sets Graphic Case Lid, for 6.5 mm cannulated screw sets Graphic Case Lid, for 7.3 mm cannulated screw sets Graphic Case Lid, for 6.5 and 7.3 mm combined cannulated screw sets Screw Racks and Lids Screw Rack, for 7.3 mm cannulated screws fully threaded (with lid) Screw Rack, for 7.3 mm cannulated screws with 16 mm and 32 mm threads (with lid) Screw Rack, for 6.5 mm cannulated screws fully threaded (with lid) Screw Rack, for 6.5 mm cannulated screws with 16 mm and 32 mm threads (with lid) Lid, for screw rack Lid, for screw rack Lid, for screw rack Lid, for screw rack

18 Instrument and Implant Sets Stainless Steel 6.5 mm Cannulated Screw Instrument and Implant Set [ ] includes: Instruments (listed in blue box) mm Partially Threaded Cannulated Screw Set* 16 mm thread, mm 32 mm thread, mm mm Fully Threaded Cannulated Screw Set* Fully threaded, mm, mm Screw Rack, 16 mm and 32 mm threads mm Screw Rack, fully threaded Graphic Case 7.3 mm Cannulated Screw Instrument and Implant Set [ ] includes: Instruments (listed in blue box) mm Partially Threaded Cannulated Screw Set* 16 mm thread, mm 32 mm thread, mm mm Fully Threaded Cannulated Screw Set* Fully threaded, mm mm Screw Rack, 16 mm and 32 mm threads mm Screw Rack, fully threaded Graphic Case Instruments for 6.5 mm, 7.3 mm, and 6.5 mm/7.3 mm Combined Sets mm Threaded Guide Wire, trocar point, 300 mm, 10 ea mm Cannulated Drill Bit, large quick coupling, 300 mm, 2.9 mm cannulation mm Cannulated Drill Bit, large quick coupling, 300 mm, 2.9 mm cannulation Cannulated Countersink, for 6.5 mm and 7.3 mm Cannulated Screws Cannulated Tap for 6.5 mm and 7.3 mm Cannulated Screws, 275 mm/200 mm tap depth mm Adjustable Parallel Wire Guide mm Trocar mm/8.5 mm Protection Sleeve Variable Angle Wire Guide mm/2.8 mm Wire Sleeve mm/13.0 mm Washer Sleeve Multiple Wire Guide, for use with 2.8 mm guide wires mm Trocar, for Multiple Wire Guide Solid Hexagonal Screwdriver, 4.0 mm hex Solid Hexagonal Screwdriver Shaft, 4.0 mm hex Cannulated Hexagonal Screwdriver, 4.0 mm hex Holding Sleeve Cannulated Hexagonal Screwdriver Shaft, 4.0 mm hex mm Cleaning Brush mm Cleaning Stylet Measuring Device, for 6.5 mm and 7.3 mm Cannulated Screws Screw Forceps Large Quick Coupling 6.5 mm/7.3 mm Combined Cannulated Screw Instrument and Implant Set [ ] includes: Instruments (listed in blue box) mm Partially Threaded Cannulated Screw Set* 16 mm thread, mm 32 mm thread, mm mm Partially Threaded Cannulated Screw Set* 16 mm thread, mm 32 mm thread, mm mm Screw Rack, 16 mm and 32 mm threads mm Screw Rack, 16 mm and 32 mm threads Graphic Case Also Available Extra Long 6.5 mm Cannulated Screws mm thread, 160 mm 180 mm** mm thread, 160 mm 180 mm** Fully threaded, 140 mm 180 mm** 2.8 mm Guide Wires mm Guide Wire with flutes (nonthreaded), 300 mm, 150 mm calibration mm Threaded Guide Wire, trocar point, 450 mm, 300 mm calibration Note: Sets may be customized with various combinations of 6.5 mm and 7.3 mm screws by ordering the instruments, graphic case, screw racks and screw sets separately. *5 mm increments **10 mm increments 16

19 Instrument and Implant Sets Titanium 6.5 mm Titanium Cannulated Screw Instrument and Implant Set [ ] includes: Instruments (listed in blue box) mm Partially Threaded Titanium Cannulated Screw Set* 16 mm thread, mm 32 mm thread, mm mm Fully Threaded Titanium Cannulated Screw Set* Fully threaded, mm mm Screw Rack, 16 mm and 32 mm threads mm Screw Rack, fully threaded Graphic Case 7.3 mm Titanium Cannulated Screw Instrument and Implant Set [ ] includes: Instruments (listed in blue box) mm Partially Threaded Titanium Cannulated Screw Set* 16 mm thread, mm 32 mm thread, mm mm Fully Threaded Titanium Cannulated Screw Set* Fully threaded, mm mm Screw Rack, 16 mm and 32 mm threads mm Screw Rack, fully threaded Graphic Case 6.5 mm/7.3 mm Titanium Combined Cannulated Screw Instrument and Implant Set [ ] includes: Instruments (listed in blue box) mm Partially Threaded Titanium Cannulated Screw Set* 16 mm thread, mm 32 mm thread, mm mm Partially Threaded Titanium Cannulated Screw Set* 16 mm thread, mm 32 mm thread, mm mm Screw Rack, 16 mm and 32 mm thread mm Screw Rack, 16 mm and 32 mm thread Graphic Case Instruments for 6.5 mm, 7.3 mm, and 6.5 mm/7.3 mm Combined Sets mm Threaded Guide Wire, trocar point, 300 mm, 10 ea mm Cannulated Drill Bit, large quick coupling, 300 mm, 2.9 mm cannulation mm Cannulated Drill Bit, large quick coupling, 300 mm, 2.9 mm cannulation Cannulated Countersink, for 6.5 mm and 7.3 mm Cannulated Screws Cannulated Tap for 6.5 mm and 7.3 mm Cannulated Screws, 275 mm/200 mm tap depth mm Adjustable Parallel Wire Guide mm Trocar mm/8.5 mm Protection Sleeve Variable Angle Wire Guide mm/2.8 mm Wire Sleeve mm/13.0 mm Washer Sleeve Multiple Wire Guide, for use with 2.8 mm guide wires mm Trocar, for Multiple Wire Guide Solid Hexagonal Screwdriver, 4.0 mm hex Solid Hexagonal Screwdriver Shaft, 4.0 mm hex Cannulated Hexagonal Screwdriver, 4.0 mm hex Holding Sleeve Cannulated Hexagonal Screwdriver Shaft, 4.0 mm hex mm Cleaning Brush mm Cleaning Stylet Measuring Device, for 6.5 mm and 7.3 mm Cannulated Screws Screw Forceps Large Quick Coupling Also Available Extra Long 6.5 mm Cannulated Screws mm thread, 160 mm 180 mm** mm thread, 160 mm 180 mm** Fully threaded, 140 mm 180 mm** 2.8 mm Guide Wires mm Guide Wire with flutes (nonthreaded), 300 mm, 150 mm calibration mm Threaded Guide Wire, trocar point, 450 mm, 300 mm calibration Note: Sets may be customized with various combinations of 6.5 mm and 7.3 mm screws by ordering the instruments, graphic case, screw racks and screw sets separately. *5 mm increments **10 mm increments 17

20 Individual Screw Sets Stainless Steel Individual screw sets and screw racks may be purchased along with the respective graphic case and insruments to create customized instrument and implant sets. 6.5 mm Partially Threaded Cannulated Screw Set [ ] 6.5 mm Cannulated Screws* 16 mm thread mm, 2 ea mm, 4 ea mm, 2 ea mm, 1 ea. 32 mm thread mm, 2 ea mm, 1 ea. Washer mm, 6 ea. 7.3 mm Partially Threaded Cannulated Screw Set [ ] 7.3 mm Cannulated Screws* 16 mm thread mm, 2 ea mm, 4 ea mm, 2 ea mm, 1 ea. 32 mm thread mm, 2 ea mm, 1 ea. Washer mm, 6 ea. 6.5 mm Fully Threaded Cannulated Screw Set [ ] 6.5 mm Cannulated Screws, fully threaded* mm, 4 ea. Washer mm, 6 ea. 7.3 mm Fully Threaded Cannulated Screw Set [ ] 7.3 mm Cannulated Screws, fully threaded* mm, 4 ea. Washer mm, 6 ea. *5 mm increments 18

21 Individual Screw Sets Titanium Individual screw sets and screw racks may be purchased along with the respective graphic case and insruments to create customized instrument and implant sets. 6.5 mm Partially Threaded Titanium Cannulated Screw Set [ ] 6.5 mm Titanium Cannulated Screws* 16 mm thread mm, 2 ea mm, 4 ea mm, 2 ea mm, 1 ea. 32 mm thread mm, 2 ea mm, 1 ea. Titanium Washer mm, 6 ea. 7.3 mm Partially Threaded Titanium Cannulated Screw Set [ ] 7.3 mm Titanium Cannulated Screws* 16 mm thread mm, 2 ea mm, 4 ea mm, 2 ea mm, 1 ea. 32 mm thread mm, 2 ea mm, 1 ea. Titanium Washer mm, 6 ea. 6.5 mm Fully Threaded Titanium Cannulated Screw Set [ ] 6.5 mm Titanium Cannulated Screws, fully threaded* mm, 4 ea. Titanium Washer mm, 6 ea. 7.3 mm Fully Threaded Titanium Cannulated Screw Set [ ] 7.3 mm Titanium Cannulated Screws, fully threaded* mm, 4 ea. Titanium Washer mm, 6 ea. *5 mm increments 19

22 SYNTHES (USA) 1302 Wrights Lane East West Chester, PA Telephone: (610) To order: (800) Fax: (610) SYNTHES (CANADA) LTD Meadowpine Boulevard Mississauga, Ontario L5N 6P9 Telephone: (905) To order: (800) Fax: (905) Original Instruments and Implants of the Association for the Study of Internal Fixation AO ASIF 2003 SYNTHES (USA) DHS, SYNTHES and ASIF are registered trademarks of SYNTHES (USA) and SYNTHES AG Chur. Printed in U.S.A. 2/05 J4552-B

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