Surgical
`Technique
`
`(ATN)
`
`A System of Choices
`• 180 mm Series
`• 200 mm Series
`• Long Nail Series
`
`ZIMMER 1015
`Page 1
`
`

`
`Contents
`
`Design Rationale
`
`Indications/
`Contraindications
`
`ATN Surgical Technique (180 and 200 mm)
`
`Pre-planning and
`Patient Positioning
`
`Nail Insertion
`
`Proximal Locking
`
`Distal Locking
`
`Nail Removal
`
`Long Nail Technique
`
`Steps 1 - 10
`
`Standard and Long Nail
`Ordering Information
`
`ZIMMER 1015
`Page 2
`
`

`
`Design Rationale
`
`Design Rationale
`
`The ACE® Trochanteric Nail (ATN) system treats a wide range of proximal femoral fracture indications using a single set
`
`of user-friendly instruments. The ATN system is designed to provide improved resistance to cut-out and rotational control
`
`as compared to single screw fixation (i.e. one lag screw). The result is true rotational stability.
`
`The nail, which is manufactured from TiMAXTM anodized titanium alloy for high fatigue strength and optimal stress
`
`transfer, can be used in conjunction with a single lag screw and/or an optional anti-rotation screw to maintain true re-
`
`alignment of unstable fractures. The screws are closely spaced so most patient anatomies can accommodate both if
`
`required. An extensive range of neck/shaft angles, distal diameters and nail lengths - combined with the smaller proximal
`
`nail diameter - allow the surgeon to achieve a close match for each patient's anatomy. Reduced proximal nail height,
`
`together with a range of end cap sizes, allows the nail to be correctly seated and remain flush with the greater trochanter.
`
`The instruments for this procedure are color coded and laid out for easy identification and correct selection. The
`
`radiolucent insertion and targeting jig allows good fluoroscopic visualization of the nail and anatomy for proximal lag
`
`screw, anti-rotation screw and distal static and dynamic screw targeting.
`
`TiMAX is DePuy ACE's trademark name for the titanium alloy Ti-6Al-4V treated* with a proprietary surface treatment.
`
`The increased surface hardness of TiMAX permits these components to slide more easily relative to one another. The
`
`surgical goal for hip fixation is to achieve continuous compressive micromotion at the fracture site. The ability of the lag
`
`screw to effectively slide within the hip screw barrel is critical to achieve this goal.
`
`320 mm - 440 mm (Long Nail)
`
`ø16 mm
`
`43 mm
`
`200 mm (Standard Nail)
`180 mm (Short Nail)
`
`40 mm
`
`20 mm
`
`20.25 mm
`
`1 2 5˚
`1 3 0˚
`1 3 5˚
`1 4 0˚
`
`ø 9 mm
`
`ø 11 mm
`ø 13 mm
`
`5˚
`
`1
`
`* TiMAX = Ti-6A1-4V + Proprietary Surface Treatment
`
`Implant Schematic
`
`End Cap
`0 - 25 mm
`Sterile: 9032-08XXX
`
`Solid Cortical Bone Screw ø 4.5 mm
`30 - 60 mm
`Sterile: 8050-45XXX
`
`Anti-Rotation Screw ø 5 mm
`60 - 100 mm
`Sterile: 9032-05XXX
`
`Lag Screw ø 10.5 mm
`60 - 120 mm
`Sterile: 9032-11XXX
`
`ZIMMER 1015
`Page 3
`
`

`
`Indications/Contraindications
`
`The ATN system* is designed for antegrade trochanteric insertion to treat the following fractures:
`
`ATN (180 and 200 mm)
`
`Long ATN (320 - 440 mm)
`
`Indications
`
`Indications
`
`The Trochanteric Nail System is intended to treat stable and
`
`The Trochanteric Long Nail System is additionally indicated
`
`unstable proximal fractures of the femur including
`
`to treat pertrochanteric fractures associated with shaft
`
`pertrochanteric fractures, intertrochanteric fractures, high
`
`fractures, pathologic fractures in osteoporotic bone of the
`
`subtrochanteric fractures and combinations of these fractures.
`
`trochanteric and diaphyseal areas, long subtrochanteric
`
`Contraindications
`
`• Low subtrochanteric fractures
`
`• Femoral shaft fractures
`
`fractures, ipsilateral femoral fractures, proximal or distal
`
`non-unions and malunions and revision procedures.
`
`Contraindications
`
`•
`
`Isolated or combined medial femoral neck fractures
`
`•
`
`Isolated or combined medial femoral neck fractures
`
`Indications/Contraindications
`
`* System includes short, 180 mm; standard, 200 mm;
`and long, 320 - 440 mm nail, in 20 mm increments.
`
`Please note: Bone screws referenced in this material are not approved for screw attachment or fixation to the posterior
`elements (pedicles) of the cervical thoracic or lumbar spine.
`
`2
`
`ZIMMER 1015
`Page 4
`
`

`
`Pre-planning and Patient Positioning
`
`180 mm
`
`200 mm
`
`Preoperative Planning
`
`The ACE Trochanteric Nail System offers the surgeon a
`
`comprehensive set of preoperative templates for use with
`
`radiographs at 15 percent magnification, in the true
`
`anterior/posterior plane. Laid over the uninjured side, these
`
`can be used to predict nail and screw size.
`
`Preoperative templating provides a guide for appropriate
`
`nail length and neck angle, as well as an indication of the
`
`lag screw position, angle and optional AR screw.
`
`Select a template with the appropriate neck angle 125˚,
`
`130˚**, 135˚ or 140˚ and overlay to establish the distal
`
`position of the nail along the long axis of the femur.
`
`Establish the lag screw position by adjusting the
`
`inferior/superior template position so that the lag screw is
`
`in the central to lower third of the femoral neck. Orient the
`
`lag screw in line with the axis of the femoral neck. Position
`
`the lag screw distal tip approximately 5 - 10 mm from the
`
`edge of the subchondral bone of the femoral head. This
`
`will estimate the lag screw length required.
`
`Long Nail
`
`** 130 is the most frequently used neck angle.
`
`3
`
`ZIMMER 1015
`Page 5
`
`

`
`Optimum Position of
`Lag and AR Screws
`
`10 - 150
`Adduction
`
`Preoperative Planning, Continued
`
`Patient Positioning
`
`If an AR screw is required, position the lag screw in the
`
`Place the patient in the supine position on a fracture table
`
`lower third of the femoral neck, with the anti-rotation
`
`or radiolucent imaging table. Lateral access to the proximal
`
`screw within the superior third of the neck. Typically the
`
`femur is required. For the operation, access an image
`
`anti-rotation screw should be 15 – 20 mm shorter than the
`
`intensifier, or ‘C-arm’, to obtain fluoroscopic AP and
`
`lag screw. Take care to ensure that the threaded tip of the
`
`lateral views during preoperative preparation (reduction)
`
`anti-rotation screw is beyond the fracture.
`
`and throughout the procedure for nail insertion and
`
`Distal locking options may be considered pre- or intra-
`
`operatively.
`
`locking, and for anteversion alignment. The affected leg
`
`must be adducted and the trunk securely bent toward the
`
`opposite side. The contralateral leg may be flexed at the hip
`
`or scissored below the affected leg.
`
`Fracture Reduction
`
`Fluoroscopy must be used to verify proper fracture
`
`reduction.
`
`• Anatomic reduction is essential prior to incision.
`
`• Surgeon must avoid varus malreduction.
`
`• Rotation will depend on level of fracture.
`
`Initial Incision
`
`Make an incision proximal to the trochanteric region, in
`
`line with the femoral axis. Place a self-locking retractor to
`
`open the wound. Divide the fascia lata along its fibers.
`
`Access the tip of the greater trochanter.
`
`4
`
`ZIMMER 1015
`Page 6
`
`

`
`Nail Insertion
`
`1
`
`2
`
`Trochanteric
`Entry Point
`
`Femoral Entry Preparation
`
`Femoral Preparation
`
`Opening the Femur Option 1:
`
`Opening the Femur Option 3: Cannulated Awl
`
`Cannulated Entry Reamer (One-step 17 mm)
`
`Attach a standard 3.2 mm guide wire to the guide wire grip
`
`Attach the standard 3.2 mm guide wire to the guide wire
`
`handle or power source and pass it down through the
`
`grip handle or power source and pass it down through the
`
`trochanter into the femoral canal. Pass the cannulated awl
`
`2a
`
`trochanter into the center of the femoral canal. Position
`
`over the guide wire and introduce, with a rotating motion,
`
`entry at or slightly lateral to the tip of the trochanter.
`
`to at least half its blade length.
`
`Verify the position using flouroscopic AP and lateral views.
`* to the
`power source and pass it over the guide wire through the
`
`Attach the one-step cannulated entry reamer
`
`1
`
`tubular skin protector. Use it to create an entry through the
`
`greater trochanter into the femoral canal.
`
`Opening the Femur Option 2: Large Pointed Awl
`
`2
`
`Use the large pointed awl
`
`2
`
`to make an entry point just
`
`lateral to the tip of the greater trochanter – centrally
`
`anterior to posterior. The entry angle should correspond to
`
`the proximal part of the implant: 5 degrees toward the long
`
`axis of the femur. Verify the position and entry angle of the
`
`AP and lateral view using fluoroscopy. Introduce the awl,
`
`with a rotating motion, to at least half its blade length. This
`
`allows the reamer clear passage. Place a standard 3.2 mm
`
`guide wire through the opening into the femur, allowing
`
`introduction of the one-step cannulated entry reamer. 1
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`5
`
`ZIMMER 1015
`Page 7
`
`

`
`n m e
`A li g
`x i m a l T
`P r o
`
`n t o f
`e ti n
`a r g
`
`g
`
`Proximal Reaming
`
`Jig Assembly
`
`AP and lateral fluoroscopy are mandatory to confirm
`
`(1300 neck angle most commonly used)
`
`depth and reaming position.
`
`Select a targeting module
`
`7
`
`that corresponds to the neck
`
`Attach the cannulated entry reamer
`
`1
`
`to the T-handle quick
`
`angle determined during preoperative templating. Attach it
`
`couple
`
`6
`
`or power source and pass it over the guide wire
`
`to the insertion jig
`
`4
`
`and secure it using the targeting
`
`and through the tubular skin protector. It is essential to
`
`module locking nut.
`
`5
`
`Screw the locking bolt
`
`9
`
`and then, using the T-handle
`
`locking wrench , pass it through the insertion jig nose.
`3
`
`ream until at least the reamer’s proximal shaft passes
`
`within the greater trochanter’s cortical bone (the reamer
`
`nose’s cylindrical length matches the implant’s proximal
`
`portion length, above its tapered section). If access for
`
`reaming is inhibited by the soft tissues, attach the quick-
`
`couple power adaptor
`
`8
`
`to the reamer to increase the
`
`shaft length.
`
`The 17 mm-diameter reamer is 1 mm greater in diameter
`
`than the nail to allow free passage of the nail within the
`
`proximal femur.
`
`Using standard reamers
`
`If using standard reamers, reaming stops at the appropriate
`
`depth and is completed with a 17 mm-diameter reamer, at
`
`least to level of lesser trochanter.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`6
`
`ZIMMER 1015
`Page 8
`
`

`
`Nail Insertion
`
`DO NOT HAMMER THE INSERTION JIG
`
`Alignment
`Groove
`
`Nail Flat
`
`Jig Assembly
`
`Nail Introduction
`
`Locate the selected nail on the insertion jig lug. Align the
`
`Introduce the nail, attached to the jig assembly, into the
`
`flat on its proximal tip with the groove on the jig’s outside
`
`proximal femur by hand. Passage over the guide wire is
`
`face so that the distal tip is oriented towards the targeting
`
`optional.
`
`module. Once in place, use the T-handle locking wrench
`
`3
`
`to tighten the locking bolt
`
`9
`
`and secure the implant to the
`
`jig.
`
`Pass the lag screw sheath
`
`10
`
`through the targeting module.
`
`Proper assembly will direct the lag screw drill
`
`14
`
`through
`
`the sleeve and through the proximal lag screw hole in the
`
`assembled nail. Pass the distal sheath
`
`26
`
`and the 3.8 mm
`
`calibrated drill
`
`29
`
`through the targeting module to ensure
`
`Do not hammer the insertion jig. Do not use a sliding
`
`hammer with the short nails. It is only required during nail
`
`extraction.
`
`If the nail is difficult to insert, or if fluoroscopy indicates
`
`impingement between the nail tip and the medial and
`
`anterior cortices, carry out additional proximal reaming to
`
`ease the nail introduction.
`
`correct alignment with the distal locking holes. Check the
`
`If extra distal reaming is required, follow a standard
`
`assembly prior to nail introduction.
`
`reaming technique using a ball nose guide wire and
`
`exchange tube.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`7
`
`ZIMMER 1015
`Page 9
`
`

`
`Nail Introduction
`
`Lag Screw Guide Pin Introduction
`
`As the nail is inserted, check the insertion depth, using
`
`Insert the lag screw sheath
`
`10
`
`through the lag screw hole in
`
`fluoroscopy. This ensures correct lag screw hole alignment
`
`the insertion jig assembly. Pass the trochar
`
`11
`
`through the
`
`with the planned position for the screw in the femoral neck.
`
`sheath and make a suitable incision where the trochar
`
`Maintenance of the reduction must be confirmed. Once the
`
`nail is positioned, introduce the lag screw guide wire.
`
`contacts the skin. Push the trochar and sheath through the
`
`tissue until firm contact is made with the lateral femoral
`
`cortex. Gently tap the trochar tip with a hammer to create a
`
`starting point for the guide wire in the cortex. View its
`
`position under fluoroscopy.
`
`Remove the trochar while the sheath is held against the
`
`cortex. Screw the guide pin sheath
`
`12
`
`into the lag screw
`
`sheath. If the cortical bone is particularly dense, pre-drill
`) to avoid bending
`the guide pin during insertion. Introduce the 3.2 mm guide
`
`the cortices (using the lag screw drill
`
`14
`
`pin under power through the sheath. Centrally align the pin
`
`within the lag screw hole in the nail, and drill into
`
`position under fluoroscopic guidance. Check the guide
`
`pin position within the center of the femoral head and neck
`
`in both AP and lateral planes. Drill the guide pin to
`
`approximately 5 mm from subchondral bone.
`
`Note: If at any time a guide pin is bent, replace it
`
`immediately.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`8
`
`ZIMMER 1015
`Page 10
`
`

`
`Proximal Locking
`
`Correct Sheath
`Orientation
`
`AR Guide Pin Placement
`
`AR Guide Pin Placement
`
`If using the optional anti-rotation screw, leave the lag
`
`Note: The flat sections on the lag screw and
`
`screw sheath and guide pin in place to maintain construct
`
`anti-rotation screw sheaths must face each other (so that
`
`rigidity and ensure parallel screw positioning.
`
`the colored handles are at 180˚) to allow assembly into
`
`Widen the incision and drive the anti-rotation sheath
`
`20
`
`and
`
`the insertion jig.
`
`trochar
`
`21
`
`into firm contact with the lateral cortex. Gently
`
`Remove the trochar and insert the anti-rotation screw guide
`
`tap the trochar tip with a hammer to create a starting point
`
`pin sheath
`
`22
`
`and screw it into the sleeve. If the cortical
`
`for the guide wire in the cortex.
`
`bone is particularly dense, pre-drill the cortices (using the
`
`anti-rotation screw drill
`
`23
`
`) to avoid bending the guide pin
`
`during insertion. Pass the 2.5 mm guide pin through the
`
`sheath and drill into place. Check the guide pin position
`
`during placement in both AP and ML planes, and use
`
`fluoroscopy to ensure that it passes through the anti-
`
`rotation screw hole center in the nail and is correctly
`
`positioned within the femoral neck and head. Insert the
`
`guide pin until its tip is 15 - 20 mm short of the lag screw
`
`guide wire tip and is at least 16 mm beyond the fracture to
`
`allow firm fixation.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`9
`
`ZIMMER 1015
`Page 11
`
`

`
`5 - 10 mm
`
`15 - 20 mm
`
`This difference represents
`the difference between the
`guide pin tip positions
`
`Screw Length Selection
`
`Screw Length Selection
`
`Select the screw length with the lag screw and anti-rotation
`
`Lag Screw Selection
`
`screw sheaths and guide pins in place.
`
`The depth gauge indicates the guide pin length to its tip.
`
`• Firmly seat both sheaths onto the bone
`
`Lag screw length is up to the surgeon’s discretion.
`
`• The depth gauge
`
`13
`
`is located against the
`
`Anti-rotation Screw Selection
`
`proximal face of each sheath with the guide pin
`
`sheaths in place
`
`• The depth gauge measuring face arrow must
`13
`
`point toward the sheath
`
`• Read the protruding length of the guide pin
`
`• System measures to the tip of the guide pin
`
`Determine the anti-rotation screw length using the depth
`
`gauge. No allowance for shortening is required.
`
`Once the lag and anti-rotation screw lengths have been
`
`determined, remove both guide pin sheaths.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`10
`
`ZIMMER 1015
`Page 12
`
`

`
`Proximal Locking
`
`Measurements
`taken here, i.e., 95 mm
`
`Tighten Depth Stop
`
`Depth Stop Assembly
`
`Lag Screw Drilling and Tapping
`
`Assemble the depth stop
`
`15
`
`front and back parts onto the lag
`
`Drive the assembly over the guide wire to its desired depth.
`
`screw drill
`
`14
`
`separately. Pass the front piece over the drill
`
`Use fluoroscopy during drilling to check the position of
`
`first. Then pass the back piece over the drill until it locates
`
`the guide wire and ensure that it is not driven forward by
`
`in the previously decided depth groove. Lock the stop in
`
`the drill.
`
`place by tightening the front piece onto the back piece,
`
`ensuring the depth stop is secured.
`
`The figure in line with and half covered by the front face of
`
`the depth stop assembly, is the set measurement.
`
`Make a final check of the drill position, using fluoroscopy,
`
`before drill removal.
`
`If the bone is particularly dense, use a cannulated tap
`
`16
`
`to
`
`cut a thread for the screw. Assemble the tap with the depth
`
`stop front and back parts in the same way as the lag screw.
`
`Then attach to the quick couple handle and manually insert.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`11
`
`ZIMMER 1015
`Page 13
`
`

`
`Clockwise rotation
`for compression
`
`Lag Screw Insertion
`
`Fracture Compression
`
`Pass the lag screw coupling rod
`
`18
`
`through the lag screw
`
`Fracture compression can only be applied before the anti-
`
`insertion wrench.
`
`17
`
`Position the selected lag screw on the
`
`rotation screw is inserted, without the anti-rotation sheath
`
`20
`
`insertion wrench lugs and then screw the coupling rod to
`
`in place. Clockwise rotation of the compression nut
`
`19
`
`,
`
`the lag screw.
`
`If fracture compression is anticipated, screw the
`
`compression nut
`
`19
`
`onto the lag screw insertion wrench
`
`before the assembly is introduced to the femur. Zero
`
`compression is achieved when the thread on the insertion
`
`wrench aligns with ‘0’ in the compression nut window.
`
`while holding the lag screw insertion wrench handle ,
`17
`
`applies compression. Each full rotation of the compression
`
`nut pulls the lag screw and femoral head 2 mm
`
`distal/lateral. The compression applied is indicated in the
`
`gauge window. Take care to avoid pulling the lag screw
`
`from its engagement in the femoral head. It is
`
`recommended that no more than 4 - 6 mm of compression
`
`Insert the lag screw assembly manually. When the insertion
`
`is applied.
`
`wrench abuts against the sleeve, the lag screw has reached
`
`its planned position.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`12
`
`ZIMMER 1015
`Page 14
`
`

`
`Proximal Locking
`
`Fully inserted guide pin
`
`System drills to start of
`AR screw thread
`
`Anti-rotation Screw Insertion
`
`Anti-rotation Screw Placement
`
`Note: Always insert the anti-rotation screw after the
`
`Place the selected anti-rotation screw on the insertion
`
`lag screw.
`
`Remove both the anti-rotation guide pin sheath
`
`22
`
`and guide
`
`pin. Pass the anti-rotation screw drill
`
`23
`
`through the anti-
`
`rotation sheath
`
`20
`
`and drill into the bone. Stop drilling when
`
`wrench. Attach the T-handle quick couple
`25
`
`6
`
`to the
`
`insertion wrench and manually insert the assembly. When
`
`the shoulder of the insertion wrench abuts the sleeve, the
`
`anti-rotation screw has reached its planned position.
`
`the required depth mark on the drill is aligned with the face
`
`Proximal locking is now complete. Remove both sheaths.
`
`of the anti-rotation sheath. At this point the tip of the drill
`
`will match the start of the threaded portion of the anti-
`
`rotation screw, not the depth to which the 2.5 mm guide
`
`pin tip was inserted. This calibrated depth preserves crucial
`
`bone stock for screw location and should not be exceeded.
`
`Note: Deciding drill depth by fluoroscopy will lead to
`
`incorrect placement and reduction of the bone stock for
`
`the anti-rotation screw.
`
`Again, if the bone is particularly dense, use a tap
`
`24
`
`to cut a
`
`thread for the screw. The anti-rotation tap does not have a
`
`depth stop. Use the depth markings on the shaft to guide
`
`insertion.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`13
`
`ZIMMER 1015
`Page 15
`
`

`
`Distal Locking
`
`Distal Locking: Static
`
`Choose static or dynamic distal locking. Select the
`
`Pass the assembled distal sheath
`
`26
`
`and trochar
`
`27
`
`through
`
`appropriate targeting module hole that corresponds to the
`
`the appropriate static hole for the 180 or 200 mm rod.
`
`nail size implanted (180 or 200 mm). Locking options
`
`Make a small incision at the point of skin contact.
`
`include static, dynamic, both or none.
`
`Push the assembly through the soft tissue until firm contact
`
`is made with the lateral cortex and remove the trochar.
`
`Insert the 3.8 mm drill guide
`
`28
`
`through the distal sheath
`
`and screw into the sleeve.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`14
`
`ZIMMER 1015
`Page 16
`
`

`
`Distal Locking
`
`Measurements
`taken here
`
`Distal Locking: Static
`
`Distal Locking: Dynamic
`
`Advance the 3.8 mm calibrated drill
`
`29
`
`through the drill
`
`Pass the distal sheath
`
`26
`
`through the appropriate 200 or
`
`guide. Stop drilling when the medial cortex is penetrated.
`
`180 mm dynamic hole in the targeting module. Pass the
`
`Note the depth mark on the drill at the level of the drill
`
`trochar through the distal sheath and make a stab incision
`
`guide, and remove the drill. Maintain contact of the distal
`
`at the point of skin contact.
`
`sleeve on bone, especially for depth measurement.
`
`Push the assembly through the soft tissues until firm
`
`An optional depth gauge, which passes through the drill
`
`contact is made with the lateral cortex. Remove the
`
`guide may provide a final depth check. Select a 4.5 mm
`
`trochar. Introduce the drill guide through the distal sheath.
`
`diameter screw, corresponding in length to the depth noted
`
`Introduce the 3.8 mm drill and advance through the lateral
`
`on the drill level. Use the hexagonal screwdriver
`
`30
`
`to
`
`cortex. Stop drilling when the far cortex is penetrated.
`
`introduce the screw through the distal sheath and drive it
`
`Note the depth mark on the drill, at the level of drill guide,
`
`until its tip passes through the far cortex. Remove the
`
`and remove the drill.
`
`sheath.
`
`Distal static or dynamic locking is now complete. Verify
`
`The nail is statically used at the surgeon’s discretion. The
`
`locking screw position of AP and lateral fluoroscopy
`
`second distal (dynamic) screw may also be inserted.
`
`image.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`15
`
`ZIMMER 1015
`Page 17
`
`

`
`End Cap Insertion
`
`Nail Removal
`
`Unscrew the locking bolt
`
`9
`
`on the insertion jig assembly
`
`4
`
`Open the incision and gain clear access to the nail end cap.
`
`using the T-handle locking wrench. Remove the
`3
`
`Unscrew the end cap using the T-handle locking wrench.
`
`3
`
`assembly.
`
`Assemble the insertion jig
`
`4
`
`and the appropriate targeting
`
`To assess the depth of nail insertion from the trochanteric
`
`module
`
`7
`
`and secure using the locking nut. (Use this same
`
`entry site, use fluoroscopy to select the appropriately sized
`
`module for nail insertion. The procedure for selection and
`
`end cap.
`
`assembly is described on pages 6 and 7.)
`
`Use fluoroscopy to assess the depth from the greater
`
`Screw the locking bolt
`
`9
`
`into and pass it through the
`
`trochanter tip to the proximal nail’s tip and select the
`
`insertion jig nose. Use the locking wrench to tighten the
`
`corresponding size end cap.
`
`locking bolt and secure the implant to the jig.
`
`Screw the end cap into the nail’s proximal end using the
`
`Pass the lag screw sheath
`
`10
`
`through the targeting module
`
`T-handle locking wrench.
`
`Rehabilitation
`
`For intertrochanteric fractures, early postoperative weight
`
`bearing is generally allowed.
`
`and make a stab incision at the previous incision scar.
`
`Pass the lag screw trochar
`
`11
`
`through the lag screw sheath
`
`to the lateral cortex. Remove the trochar.
`
`Assemble the lag screw coupling rod
`
`18
`
`and the insertion
`
`wrench . Insert the assembly through the sheath and screw
`17
`
`the coupling rod, clockwise to lock to the lag screw.
`
`Rotate the inserter wrench handle counterclockwise to
`
`extract the lag screw.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`16
`
`ZIMMER 1015
`Page 18
`
`

`
`Nail Removal
`
`ROTATE COUNTERCLOCKWISE
`
`ONLY USE HAMMER FOR NAIL EXTRACTION
`
`AR Screw Removal
`
`Nail Removal
`
`Access the anti-rotation screw head in the same way as the
`
`The nail remains attached to the insertion jig for removal.
`
`lag screw, using the dedicated anti-rotation screw
`
`Extraction should not require excessive force, but, if
`
`instruments. Pass the anti-rotation screw removal wrench
`
`necessary, screw a sliding hammer to the jig at the location
`
`through the sheath and locate it on the distal tip of the
`
`position marked. Ensure that the sliding hammer rod is
`
`anti-rotation screw. Counterclockwise rotation locks the
`
`fully threaded into the insertion jig before applying force.
`
`wrench to the screw. Extract the screw by continued
`
`Do not hammer the insertion jig. Only use
`
`counterclockwise turns.
`
`Distal Screw Removal
`
`Extract the distal screws in the same way as the two
`
`proximal screws, using the dedicated distal screw
`
`instruments.
`
`impact/removal assembly (sliding hammer
`
`31
`
`and
`
`impact/removal rod ) for nail extraction.
`32
`
`If the targeting insertion jig cannot be fitted to the nail,
`
`use the extraction adaptor to remove the nail.
`33
`
`Connect the extraction adaptor to the nail before screw
`
`removal. Locate the proximal and distal screws and
`
`remove without the aid of the insertion jig. Screw the
`
`extraction adaptor into the nail’s proximal end and
`
`then screw the sliding hammer rod into the adaptor.
`
`Apply force to remove the nail.
`
`Once the screws and nail have been extracted, close the
`
`wounds.
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`17
`
`ZIMMER 1015
`Page 19
`
`

`
`Step 2: Determine Nail Length
`
`Position the image intensifier for an AP view of the
`
`proximal femur. Verify fracture reduction. Place the
`
`radiographic ruler over the femur. Read the nail length
`
`directly from the ruler image and select the measurement
`
`that places the nail’s distal end just proximal to the physeal
`
`scar with appropriate location of the lag screw in the
`
`femoral head and neck.
`
`Step 3: Determine Nail Diameter
`
`Position the image intensifier for an AP view of the femur
`
`at the level of the isthmus. Hold the radiographic ruler
`
`perpendicular to the femur and position the diameter tabs
`
`Proximal preparation is the same as for the short nail.
`
`over the isthmus. Read the diameter measurement on the
`
`tab that fills the canal.
`
`Step 1: Guide Wire and
`
`Insertion Point
`
`In the AP view the insertion point is normally found at the
`
`tip or slightly lateral to the tip of the greater trochanter.
`
`The implant’s mediolateral angle is 5 0. This means that the
`
`3.2 mm guide wire with the guide wire grip must be
`
`inserted laterally at a 5 0 angle to the shaft. Insert the guide
`
`wire manually or with power.
`
`Key Features
`
`• Lengths: 320 - 440 mm in 20 mm increments
`
`• Two static distal screw holes
`
`• Radius of curvature: 2.2 m
`
`• Anteversion: 100
`
`• Anatomic 50 ML angle
`
`• Left and right nails
`
`18
`
`ZIMMER 1015
`Page 20
`
`

`
`Long Nail Technique
`
`Step 4: Open Femur
`
`Step 6: Nail Insertion:
`
`Guide the 17 mm cannulated entry reamer
`
`1
`
`through the
`
`(320 - 440 mm in 20 mm increments)
`
`tubular skin protector, over the guide wire or guide rod and
`
`ream manually with the T-handle quick couple
`
`6
`
`or by power
`
`8
`
`.
`
`Remove the tubular skin protector and guide wire.
`
`Do not re-use the guide wire. Cannulated awl may
`2a
`
`be used as an option to open the femur.
`
`Step 5: Reaming Technique
`
`vs. Nonreamed Technique
`
`Standard antegrade femoral reaming is necessary for
`
`Carefully manually insert the nail (can be over the guide
`
`wire or not) as far as possible into the femoral opening.
`
`Slight twisting hand movements help insertion.
`
`If necessary, support insertion by light hammering blows.
`
`Slide the sliding hammer
`
`31
`
`over the impactor/removal
`
`rod for the long nail
`
`32
`
`and insert them into the nail
`
`insertion jig.
`
`Then use the sliding hammer assembly to support the long
`
`nail insertion.
`
`long nails.
`
`The long nail insertion assembly includes:
`
`Over ream 1.0 - 2.0 mm over selected nail diameter.
`
`• Nail Insertion Jig
`
`4
`
`• Targeting Module
`
`7
`
`• Targeting Module Locking Nut
`
`5
`
`• Locking Bolt
`
`9
`
`• Long Nail (320-440 mm in 20 mm increments)
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`19
`
`ZIMMER 1015
`Page 21
`
`

`
`5 - 10 mm
`
`15 - 20 mm
`
`Step 7: Insert Lag Screw and
`Optional AR Screw
`
`Please refer to the ATN standard surgical technique and
`
`choose the appropriate targeting module .
`7
`
`1
`*… Relates to numbered instrumentation on the foldout on page 24 at
`the end of this document.
`
`20
`
`Step 8: Distal Locking:
`
`After proximal fixation, distal locking is usually performed
`
`with two locking bolts. Ensure maintenance of femoral
`
`reduction in length of rotation prior to distal locking.
`
`The long nail includes two static holes. Various techniques
`
`can be used to guide drilling and insertion of screws
`
`through the distal holes. The image intensifier and the
`
`freehand distal target device may be used.
`34
`
`Include the step-by-step reaming technique used for the
`
`two static distal screws.
`
`Perform standard freehand distal locking. Align
`
`fluoroscopy beam parallel to the axis of the distal screw
`
`holes, producing perfect circles. Center the trochar tip drill
`
`in the hole’s center and drill through with intermittent use
`
`of fluoroscopy. If freehand locking is done without the
`
`radiolucent drill, it is usually easiest to gently tap the drill
`
`bit through the proximal hole. Drill the far cortex. The
`
`standard depth gauge is used to measure screw length.
`
`ZIMMER 1015
`Page 22
`
`

`
`Long Nail Technique
`
`ONLY USE HAMMER FOR NAIL EXTRACTION
`
`Step 9: Insert End Cap
`
`Step 10: Implant Removal
`
`(0 - 25 mm in 5 mm increments)
`
`Please refer to the ATN standard surgical technique.
`
`Having made an incision through the old scar, the screws
`
`may be localized using palpation or the image intensifier.
`
`First, remove the end cap and insert the nail insertion jig
`
`or nail extraction adapter into the nail’s proximal end.
`
`Second, remove the lag screw and/or AR screw and distal
`
`screw(s).
`
`21
`
`ZIMMER 1015
`Page 23
`
`

`
`Implants - Product Ordering Information
`
`ACE Trochanteric Nail Lag Screws (10.5 mm)
`Cat. No.
`Sterile
`9032-11-060
`9032-11-065
`9032-11-070
`9032-11-075
`9032-11-080
`9032-11-085
`9032-11-090
`9032-11-095
`9032-11-100
`9032-11-105
`9032-11-110
`9032-11-115
`9032-11-120
`
`Description
`60 mm
`65 mm
`70 mm
`75 mm
`80 mm
`85 mm
`90 mm
`95 mm
`100 mm
`105 mm
`110 mm
`115 mm
`120 mm
`
`ACE Trochanteric Nail Anti-rotation Screws (5 mm)
`Cat. No.
`Sterile
`9032-05-060
`9032-05-065
`9032-05-070
`9032-05-075
`9032-05-080
`9032-05-085
`9032-05-090
`9032-05-095
`9032-05-100
`
`Description
`60 mm
`65 mm
`70 mm
`75 mm
`80 mm
`85 mm
`90 mm
`95 mm
`100 mm
`
`ACE Trochanteric Nail End Caps
`Cat. No.
`Sterile
`9032-08-000
`9032-08-005
`9032-08-010
`9032-08-015
`9032-08-020
`9032-08-025
`
`Description
`0 mm
`5 mm
`10 mm
`15 mm
`20 mm
`25 mm
`
`ACE 4.5 mm Cortical Screws
`Cat. No.
`Cat. No.
`Non-Sterile
`Sterile
`1402230
`8050-45-030
`1402232
`8050-45-032
`1402234
`8050-45-034
`1402236
`8050-45-036
`1402238
`8050-45-038
`1402240
`8050-45-040
`1402242
`8050-45-042
`1402244
`8050-45-044
`1402246
`8050-45-046
`1402248
`8050-45-048
`1402250
`8050-45-050
`1402252
`8050-45-052
`1402254
`8050-45-054
`1402256
`8050-45-056
`1402258
`8050-45-058
`1402260
`8050-45-060
`
`Description
`30 mm
`32 mm
`34 mm
`36 mm
`38 mm
`40 mm
`42 mm
`44 mm
`46 mm
`48 mm
`50 mm
`52 mm
`54 mm
`56 mm
`58 mm
`60 mm
`
`Instruments - Product Ordering Information
`
`Proximal Locking Instruments
`Cat. No.
`Description
`9030-03-001
`Sheath (Lag Screw)
`9030-03-002
`Trochar (Lag Screw)
`9030-03-003
`Guide Pin Sheath (Lag Screw)
`9030-03-004
`3.2 mm Threaded Guide Pin (single use)
`9030-03-005
`Depth Gauge
`9030-03-006
`Cannulated Step Drill (Lag Screw)
`9030-03-007
`Depth Stop
`9030-03-020
`Cannulated Lag Screw Tap
`9030-03-009
`Lag Screw Insertion Wrench
`9030-03-010
`Lag Screw Coupling Rod
`9030-03-013
`Compression Nut
`9030-04-001
`Sheath (Anti-rotation screw)
`9030-04-002
`Trochar (Anti-rotation screw)
`9030-04-003
`Guide Pin Sheath (Anti-rotation screw
`9030-04-004
`2.5 mm Guide Pin (single use)
`9030-04-005
`Drill (Anti-rotation screw)
`9030-04-006
`Tap (Anti-rotation screw)
`9030-04-007
`AR Screw Insertion Wrench
`9030-04-008
`AR Screw Removal Wrench
`
`ACE Trochanteric Nail Instrument Trays
`Cat. No.
`Description
`9030-20-001
`Trochanteric Nail Instrument Tray 1
`9030-20-002
`Trochanter