Including - Smith & Nephew
Contents
1. sss 30 Skin incision with TRIGEN SURESHOT sse 3l Targeting the locking hole sse 32 Drilling the distal hole sss 33 SCEN Mc quon T E E 34 Instruments for proximal locking distal locking and freehand distal locking of Proximal 16cm Humeral Nails 35 Distal locking screws for TRIGEN Proximal 16cm Humeral Nails 36 mier Mee duces T 37 Distal locking screws without the use of TRIGEN SURESHOT 40 SI Al Removal of the nail Al TRIGEN SURESHOT Trauma Interface ssssuss 42 TRIGEN SURESHOT Troubleshooting sse eee eee 46 Catalog information sss 48 Nota Bene The technique description herein is made available to the healthcare professional to illustrate the authors suggested treatment for the uncomplicated procedure In the final analysis the preferred treatment is that which addresses the needs of the patient Z Introduction Uncover an easier and more advanced nailing system The TRIGEN Humeral Nail provides new possibilities for the treatment of proximal humeral fractures and humeral shaft fractures With multiplanar screws that are threaded into the nail to inhibit proximal screw back out and effective simple instrumentation that helps protect soft tissues the TRIGEN system now offers an effective intramedullary nail for humeral fra2. ensure proper orientation of the nail on the Nail Drill Guide Note The metal threads on the proximal locking holes should always be lateral Tighten the Humeral Nail Guide Bolt using the Guide Bolt Wrench 7175 1134 The Impactor 7175 1133 is then attached to the Humeral Nail Guide Bolt To complete the assembly attach the Proximal Drop 7175 1131 to the lateral arm of the Nail Drill Guide Tighten the Proximal Drop to the Guide using the knurled knob Verify targeting accuracy by inserting a Gold Outer Sleeve 7175 1128 and 3 2mm Silver Inner Drill Sleeve 7175 1116 into the drop and passing a 3 2mm Long Graduated Two Flute Drill 7175 1149 through the assembly An incorrectly attached nail will not target The Proximal Drop should be used to target the proximal screws on all Humeral Nails and the distal screws on the 16cm Proximal Nails Distal locking screws for the 18cm or longer Humeral Nails should be targeted using the TRIGEN SURESHOT Distal Targeting System or a freehand technique Note See page 24 for the field accuracy Note Remove Targeter prior to Nail insertion Check with the TRIGEN SURESHOT Distal Targeting System 22 The Humeral Nail and Nail Drill Guide are keyed to ensure proper orientation of the nail on the Nail Drill Guide Surgical Technique TRIGEN SURESHOT system set up continued Locking hole accuracy check in the operative field Insert the SURESHOT Humeral Drill Guide Prob
3. from TRIGEN SURESHOT Targeter The 4 7mm 4 0mm step drill will not fit through the drill sleeve Possible cause Incorrect drill sleeve length selected Metal interference within the TRIGEN SURESHOT electromagnetic field Probe not inserted correctly within set stop Damaged probe Metal interference within the TRIGEN SURESHOT electromagnetic field Probe not inserted correctly within set stop Damaged probe Over tightening of drill sleeve Not compatible with the TRIGEN SURESHOT Distal Targeting System Suggested action Verify the correct drill sleeve length is selected from the software menu Remove any metal objects from the targeting field Verify probe is oriented and seated correctly in the notches of the set stop Verify probe accuracy with Field Accuracy Gauge Remove any metal objects from the targeting field Verify probe is oriented and seated correctly in the notches of the set stop Verify probe accuracy with Field Accuracy Gauge Use the Slotted Hammer from the instrument tray as a wrench to unscrew the drill sleeve counter clockwise from the Targeter Only use the long 7169 2811 short 7169 2810 or 3 2mm SURESHOT Humeral Drill 7169 1155 drills designated for use with the TRIGEN SURESHOT Distal Targeting System 47 Catalog information TRIGEN Humeral Nail Implants a G GHL a OTT All 48 TRIGEN Humeral Nail Cap Not Shown Cat No 7176 0000
4. wall outlet One or both mains power fuses are blown Touchscreen is de calibrated VGA port not activated on Trauma Interface Damaged VGA cable Video monitor not on correct input Error reading data from Targeter Damaged Targeter Error reading data from probe Damaged probe Obstruction within the nail cannulation Metal interference within the TRIGEN SURESHOT electromagnetic field TRIGEN SURESHOT Targeter and probe not within range of each other Suggested action Insert mains power plug into reliable power supply Try other power outlet Replace mains fuses Access Calibration software by selecting Maintenance from the About option under the Menu options password required Connect VGA cable to both Trauma Interface and video monitor before powering on Trauma Interface Replace VGA cable Select proper input on video monitor Unplug Targeter wait 10 seconds plug back in Replace Targeter with new unit Unplug probe wait 10 seconds plug back in Replace probe with new unit Re insert the ball tip guide rod into the nail cannulation to clear any obstruction Remove any metal objects from the targeting field Move the TRIGEN SURESHOT Targeter closer to the sensor end of the probe TRIGEN SURESHOT Troubleshooting Problem Red and Green targeting circles representing the drill sleeve appear incorrect Targeting missed the intended hole Drill sleeve cannot be removed
5. 05 2 0mm Graduated Ball Tip Guide Rod Cat No 7175 1146 Ruler Cat No 7175 1126 on Straight entry reamer Cat No 7175 1103 Straight Ratcheting Driver Cat No 7175 1141 Obturator Cat No 7175 1145 Fixed Endcutting Reamers image not shown Cat No 7111 8220 to 7111 8230 w Cannulated Awl Cat No 7175 1102 17 Surgical Technique Prepare proximal section Insert the Straight Entry Reamer 7175 1103 over the 3 2mm Tip Threaded Guide Pin 7175 1147 or the Trocar 7175 1136 through the Entry Cuff Guard 7175 1100 and or the Disposable Cuff Guard 7175 1101 to prepare the humerus for the proximal section of the nail Ream until the cutting teeth are just below the articular surface of the humeral head The depth indicator on the reamer should be level with the top of the Cuff Guard Alternatively the Cannulated Awl 7175 1102 can be used with the Straight Ratcheting Driver 7175 1141 Surgical Technique Fracture reduction After removing the Straight Entry Reamer 175 1103 and 3 2mm Tip Threaded Guide Pin 7175 1147 or Trocar 7175 1136 insert the Straight Reducer 7175 1105 attached to the Straight Ratcheting Driver 7175 1141 with the slot oriented toward the lateral cortex and reduce the fracture Place the tip of the finger off CN the medial cortex to help reduce the fracture To maintain reduction introduce the 2 0mm Graduated Ball Tip Guide Rod 7175 1146 th
6. 175 1140 AO Mini Connector Cat No 7175 1153 Mini Connector Cat No 7163 1186 Trinkle Connector Cat No 7163 1187 Screw Head Trephine Cat No 7175 1144 Proximal Nail Trephine Cat No 7175 1143 Extractor Cat No 7175 1142 Cannulated Awl Cat No 7175 1102 N s ddp S th nh Wh s ipo aL mo n Mn LI Rn nut n 5l Catalog information TRIGEN Humeral Nail Instruments Screw Length Sleeve Cat No 11 0238 Top Instrument Tray Cat No 7175 1151 Bottom Instrument Tray Cat No 7175 1152 Case Cat No 7112 9400 Case Lid Cat No 7112 9402 Reamer Cassette Cat No 7175 1154 52 Catalog information TRIGEN SURESHOT Instruments TRIGEN SURESHOT Targeting Interface Cat No 7165 7000 Cat No Device Case Oty 7169 2802 Trauma Interface 1 TRIGEN SURESHOT Targeting Instrument Set Set No 7165 7001 Cat No 7169 2801 7169 2804 7169 2805 7169 2806 7169 2807 7169 2808 7169 2809 7169 2816 7169 2830 7169 2831 TRIGEN SURESHOT Humeral Instrument Set Set No 7165 1100 Cat No Description Qty 7169 1151 7169 1153 7169 1154 7169 1156 TRIGEN SURESHOT Humeral Disposable Set Description Targeter Drill Sleeve Long Drill Sleeve Short META Set Stop TAN Set Stop Field Accuracy Gauge Hexdriver TAN Anteversion Locking Guide Targeting Instrument Tray Targeting Instrument Tray Lid Tray Qty SURESHOT Humeral Set Stop 1 SURESHOT Humeral 3 5mm Hexdrive
7. N SURESHOT Targeter 7169 2801 needs to be verified This procedure can also be performed during surgery to verify all components are working correctly prior to their use on a patient Field accuracy check steps Attach TRIGEN SURESHOT Field Accuracy Gauge 169 2808 to TRIGEN SURESHOT Targeter The knob on the Field Accuracy Gauge should be hand tightened only NO Attach the TRIGEN SURESHOT META Set Stop 7169 2806 to the end of the Field Accuracy Gauge insert a TRIGEN SURESHOT probe into the set stop and set the depth to the REF mark on the probe body 3 From the software Menu button select Field Check option 24 Surgical Technique TRIGEN SURESHOT field accuracy check optional 4 A software window will appear informing Menu pua Check Gauge META the user if the TRIGEN SURESHOT Targeter 7169 2801 and SURESHOT Humeral Drill Guide Probe 7169 1152 combination is within the predefined accuracy parameters Pass or Fail message 5 If the field accuracy check fails check the Troubleshooting section of this document for possible solutions Note This step should be performed at least once a year to ensure that the device is working properly 25 Surgical Technique Nail insertion At this point the nail is ready to be inserted Care should be taken to insert the nail with the correct amount of retroversion and depth in order to maximize locking screw fixation while a
8. No 7175 1129 G Gold Outer Sleeve Cat No 7175 1128 3 2mm Long Graduated Two Flute Drill Cat No 7175 1149 3 5mm Hex Driver Cat No 7175 1140 Screw Length Sleeve Cat No 11 0238 35 Surgical Technique Distal locking screws for TRIGEN Proximal 16cm Humeral Nails Note The Proximal Drop 7175 1131 only targets the distal holes for the 16cm nails Nails longer than 16cm will be targeted using the freehand technique or TRIGEN SURESHOT Distal Targeting System With the Proximal Drop connected to the lateral arm of the Nail Drill Guide 7175 1129 place the 3 2mm Silver Inner Drill Sleeve 7175 1116 into the Gold Outer Sleeve 7175 1128 Insert the sleeve unit into the targeting hole in the Proximal Drop which corresponds to the superior M L distal locking hole in the nail While applying compression at the condyles of the elbow to reduce shaft fractures as needed make a stab incision and push the sleeve unit down to the bone The Trocar 7175 1136 in combination with the drill sleeve unit may be used to dimple the cortex Drill through both cortices using the 3 2mm Long Graduated Two Flute Drill 7175 1149 A length measurement can be taken from the calibrations on the drill against the 3 2mm Silver Inner Drill Sleeve or the Screw Depth Gauge 175 1139 can be used through the Gold Outer Sleeve to measure for distal locking screws Once the appropriate length 4 0mm Self Tapping Cortical Screw is sel
9. TRIGEN Humeral Nail System Including TRIGEN SURESHOT Distal Targeting System Surgical Technique for the TRIGEN Humeral Nail System using the TRIGEN SURESHOT Distal Targeting System Table of contents ATO QUI CTO serisinin nennen 3 TRIGEN Humeral Nail indications ssssssssss 4 TRIGEN SURESHOT indications sss 5 TRIGEN Humeral Nail design rationale sssssss 6 TRIGEN Humeral Nail soecihcahons 7 Warnings and cautions for TRIGEN SURESHOT see 8 Surgical Technique Devices for system set UO 10 OR ORE Al ANON Los omit Quee ub m ERE M mI M ENIM DUM 11 Patient ea Ten T 12 Instruments for opening the humerus sss 14 ges m 15 Entry Tool and Guide Pin placement ssssssssss 16 Instruments fracture reduction and reaming 17 Prepare proximal section 18 Fracture reduction sese e 19 Measuring implant engi 20 Additional limited reaming sese 20 Instruments for nail assembly and insertion 2 Nail Drill Guide assembly 22 TRIGEN SURESHOT system set UD 23 TRIGEN SURESHOT field accuracy check optional 24 PSIG NS gio eA E EE 26 Final version adjustment 27 TRIGEN SURESHOT system set up continued 28 Devices to lock distally
10. TRIGEN Humeral Nail Instrument Set Set No 7175 1150 Entry Cuff Guard Cat No 7175 1100 Disposable Cuff Guard Cat No 7175 1101 3 2mm Tip Threaded Guide Pin Cat No 7175 1147 Trocar Cat No 7175 1136 Mini Connector with Handle Cat No 7175 1137 Straight Entry Reamer Cat No 7175 1103 Small Hammer Cat No 7175 1135 Humeral Nail Guide Bolt Cat No 7175 1108 Nail Drill Guide Cat No 7175 1129 Guide Bolt Wrench Cat No 7175 1134 49 Catalog information TRIGEN Humeral Nail Instruments Impactor Cat No 7175 1133 Straight Reducer Cat No 7175 1105 Straight Ratcheting Driver Cat No 7175 1141 o P 0mm x 600mm Graduated 3 2mm Ball Tip Guide Rod Cat No 7175 1146 Obturator Cat No 7175 1145 Ruler Cat No 7175 1126 Fixed Endcutting Reamers size Cat No 6 0mm 7111 8220 7 0mm 7111 8222 8 0mm 7111 8224 9 0mm 7111 8226 10 0mm 7111 8228 11 0mm 7111 8230 image not shown Proximal Drop Cat No 7175 1131 Anterior Stylus Cat No 7175 1130 3 2mm Silver Inner Drill Sleeve Cat No 7175 1116 Dedicated to Humeral nail only cannot be used with other TRIGEN systems HFN 50 Catalog information TRIGEN Humeral Nail Instruments ee Gold Outer Sleeve Cat No 7175 1128 3 2mm Graduated Two Flute Drill Description Cat No Short 7175 1148 Long 7175 1149 Screw Depth Gauge Cat No 7175 1139 3 5mm Hex Driver Cat No 7
11. TRIGEN Proximal Straight Humeral Nail Cat No 7176 0816 TRIGEN Proximal Bent Humeral Nail Cat No 7177 0816 Size 8 mm Size 8 mm Length 16cm Length 16cm TRIGEN Long Bent Humeral Nail Cat No Size Length 7177 0818 7177 0820 7177 0822 7177 0824 7177 0826 7177 0828 7177 0918 7177 0920 7177 0922 8 7mm 8 7mm 8 7mm 8 7mm 8 7mm 8 7mm 9 7 5mm 9 7 5mm 9 7 5mm 18cm 20cm 22cm 24cm 26cm 28cm 18cm 20cm 22cm Cat No Size Length 7177 0924 7177 0926 7177 0928 7177 1018 7177 1020 7177 1022 7177 1024 7177 1026 7177 1028 9 7 5mm 9 7 5mm 9 7 5mm 10 8 5mm 10 8 5mm 10 8 5mm 10 8 5mm 10 8 5mm 10 8 5mm 5 0mm Self Tapping Cancellous Screw Cat No Length Cat No Length 7175 5024 7175 5026 7175 5028 7175 5030 7175 5032 7175 5034 7175 5036 7175 5038 7175 5040 7175 5042 7175 5044 4 0mm Self Tapping Cortical Screw 24mm 26mm 28mm 30mm 32mm 34mm 36mm 38mm 40mm 42mm 44mm 7175 5046 7175 5048 7175 5050 7175 5052 7175 5054 7175 5056 7175 5058 7175 5060 7175 5062 7175 5064 46mm 48mm 50mm 52mm 54mm 56mm 58mm 60mm 62mm 64mm Cat No Length Cat No Length 7175 4020 7175 4022 7175 4024 7175 4026 7175 4028 7175 4030 20mm 22mm 24mm 26mm 28mm 30mm 7175 4032 7175 4034 7175 4036 7175 4038 7175 4040 32mm 34mm 36mm 38mm 40mm 24cm 26cm 28cm 18cm 20cm 22cm 24cm 26cm 28cm Catalog information TRIGEN Humeral Nail Instruments
12. al Menu options Toggle back view This view may be used in cases where the Trauma Interface cannot be placed in front of the surgeon It is intended to be used similar to the mirror option commonly available on C arm machines Implant When choosing an implant several options are given Tap on screen to select Drill sleeve The 3 2mm Humeral Drill Sleeve appears on the screen of the Interface ic DD Wen ILU Ip A per m e e 43 TRIGEN SURESHOT Trauma Interface Field check Fail screen meaning that something is not targeting correctly See Troubleshooting section for further information Pass screen When targeting correctly a pass screen will occur About The About screen provides more information about the software used Shutdown Tap on screen to shut down the system before flipping the power switch 44 TRIGEN SURESHOT Trauma Interface Error message An error message will occur if a probe sensor is invalid or broken 45 TRIGEN SURESHOT Troubleshooting Problem Trauma Interface unit is without power Buttons or items are difficult to select on the touchscreen VGA video out not functioning TRIGEN SURESHOT Targeter not recognized Probe not recognized Probe will not insert to the proper depth in the nail Nail not visible on the screen 46 Possible cause Mains power plug is not inserted properly or there is no mains power No power on the
13. cture management e e B D A D OO D D BO D amp E E E m s eo E amp B fa e co pe E E P J 7 4 smith amp nephew Humeral Nail System d ep pe 5B 5B ot tb 9 E E B E E P 9 5 5 EDF Introduction TRIGEN Humeral Nail indications Two part fractures of the humerus Three part fractures of the humerus Midshaft Diaphyseal Fracture s Segmental Humerus Fracture s Introduction TRIGEN SURESHOT indications Legend Important warnings appear in orange Tips tricks and important information appear in blue Indications contraindications intended use and training The Smith amp Nephew TRIGEN SURESHOT Distal Targeting System is intended to be an intraoperative image guided localization system It is a computer assisted orthopaedic surgery tool to aid the surgeon with drill positioning for screws during intramedullary nail implantation It provides information to the surgeon that is used to place surgical instruments during surgery utilizing intraoperatively obtained electromagnetic tracking data The Smith amp Nephew TRIGEN SURESHOT Targeting System V2 1 is indicated for long bone fractures treated with intramedullary nails in which the use of stereotactic surgery may be appropriate An example of a surgical procedure includes but is not limited to locating and drilling the distal holes in an intramedullary nail Contraindications The screw targeting s
14. drivers are made from magnetic stainless steel that will cause interference with the system and cannot be used Insert a 4 0mm Self Tapping Cortical Screw into the pre drilled hole through the nail and through the far cortex Before fully inserting the screw remove power drill and Targeter Final screw seating must be done by hand by attaching the Straight Ratcheting Driver 7175 1141 to the SURESHOT Humeral 3 5mm Hexdriver 7169 1153 The depth of the screw can be verified by placing a Gold Outer Sleeve 7175 1128 down to bone over the hexdriver There is a profile of the screw head and a groove on the hexdriver that may be used as an indicator for the position of the screw head relative to the near cortex Positioning of the screw can be verified with the C arm Repeat with other distal screws Note Remove SURESHOT Humeral Drill Guide Probe 7169 1152 before proceeding to proximal locking Remove the probe from the SURESHOT Humeral Set Stop 7169 1151 Detach set stop from the Nail Drill Guide 7175 1129 Do not pull the cable to remove probe 34 Surgical Technique Instruments for proximal locking distal locking of Proximal 16cm Humeral Nails and freehand distal locking Proximal Drop Cat No 7175 1131 3 2mm Silver Inner Drill Sleeve Cat No 7175 1116 Trocar Cat No 7175 1136 Screw Depth Gauge Cat No 7175 1139 Straight Ratcheting Driver Cat No 7175 1141 Nail Drill Guide Cat
15. e 169 1152 with the assembled SURESHOT Humeral Set Stop 7169 1151 through the Nail Drill Guide 7175 1129 and cannulation of the TRIGEN IM nail Picture shown with TRIGEN META NAIL Tip The back of a standard AO Mini Connector 7175 1153 may be used as a lever to release the set stop from the drill guide if overtightened Note Verify the set stop position and nail length match align the drill sleeve with one of the distal holes of the nail Verify on the display that the representation of the nail drill sleeve is true Remove the probe from inside the nail and begin nail insertion Take off set stop before inserting the nail and place the impactor Note Verify the probe is oriented correctly in the set stop notches should face anteriorly If the probe is rotated 180 it will not be accurate Note The probe is bent for easier insertion Do not straighten it as this may cause inaccuracy or even missing the lock Note All tool cables should be uncoiled completely and any excess cables should be kept out of the targeter measurement volume Note To guarantee system accuracy the accuracy check has to be performed directly in the operative field aire R FEL T 2mm Geen 23 Surgical Technique TRIGEN SURESHOT field accuracy check optional A field accuracy check procedure should be performed at least once a year or whenever the accuracy of a TRIGEN SURESHOT Humeral Drill Guide Probe 7169 1152 or TRIGE
16. e skin of the patient The drill sleeve inserts will be used in the incision and have direct bone contact Note Verify that the Targeter housing is not damaged holes tears cracks If the housing or the connector is damaged the Targeter is no longer safe to use Note If the Targeter is not recognized after connection to the system the Targeter is defective and must be exchanged See also instrument connection Note Broken or damaged instruments must be exchanged immediately and sent back to Smith amp Nephew Inc Note This device is provided non sterile and must be cleaned and sterilized per Cleaning and Sterilization Smith amp Nephew document 7138 1339 prior to use Surgical Technique OR preparation TRIGEN SURESHOT system set up Note This procedure will cover only the specific steps of freehand targeting of intramedullary locking holes using the TRIGEN SURESHOT Distal Targeting System For the full surgical procedure please refer to the specific surgical technique for the TRIGEN IM Nail System being implanted Trauma Interface setup Tip If the Trauma Interface does not power on After the sterile areas have been established make sure the switch is in the on position place the Trauma Interface 7169 2802 in the desired non sterile location and turn on the power switch Note No other electrical devices should be placed near the Trauma Interface See the Guidance and Manufacturer s Declaration Separa
17. eating different fracture patterns Straight Humeral Nail 5 0mm Cancellous Proximal Locking Screws 24mm 64mm lengths 2mm increments Four multiplanar proximal locks improve fracture stability 4 degree proximal bend Long Bent Humeral Nail 4 0mm Cortical Distal Locking Screws 20mm 40mm lengths 2mm increments Proximal locking holes have innovative threaded design Screws thread into the nail to help prevent screw back out Introduction TRIGEN Humeral Nail specifications TRIGEN TRIGEN Humeral Nail 8 7mm x 16cm Humeral Nail 8 7mm x 16cm Proximal Bent Humeral Nail Proximal Straight Humeral Nail Trapezoidal 12mm x 10 5mm cross section 35mm 80mm 30mm Proximal taper First diameter 20mm measurement 8mm Second diameter Measurement 7mm Proximal Taper TRIGEN Long Bent Humeral Nail 8 7mm 9 7 5mm 10 8 5mm Diameter 18cm 28cm lengths by 2cm increments Trapezoidal 12mm x 10 5mm cross section Proximal Taper First diameter measurement 8mm 9mm or 10mm 20mm 10mm E Second diameter measurement 7mm 7 5mm or 8 5mm Warnings and cautions for TRIGEN SURESHOT Accessibility of documentation Please ensure that all instructions are kept in an easily accessible place for operating personnel The operator checks and decides All the information provided by the TRIGEN SURESHOT Distal Targeting System is to help the operator make decisions during the op
18. ected it is attached to the 3 5mm Hex Driver The screw is inserted through the Gold Outer Sleeve using the 3 5mm Hex Driver 7175 1140 The head of the screw should be nearly seated when the laser marked ring on the Hex Driver is even with the Gold Outer Sleeve Final tightening of the screw should always be performed manually using the Straight Ratcheting Driver 7175 1141 Repeat this process for the interior distal screw 36 Surgical Technique Proximal locking screws Caution Do not countersink the nail such that proximal locking screws are below the level of the humeral head to avoid damage to the axillary nerve In order to avoid impingement of the biceps tendon it is a good idea to start with the proximal anterolateral locking screw Place the 3 2mm Silver Inner Drill Sleeve 7175 1116 into the Gold Outer Sleeve 7175 1128 Insert the sleeve unit into the Proximal Drop 7175 1131 The Trocar 7175 1136 can be inserted into the sleeve unit to determine the exact location for the insertion of the locking screw If the Trocar tip indicates the proximal anterolateral screw is in line with the bicipital groove reorient the nail to avoid impingement Once proper alignment has been achieved make a stab incision and push the sleeve unit down to the bone Use the Trocar to dimple the cortex Remove the Trocar from the sleeve unit and drill through the near cortex stopping at the articular surface of the far cortex using
19. eration The operator must check all the suggestions made by the system and is responsible for all decisions taken Responsibility of Smith amp Nephew Orthopaedics In the event of improper use Smith amp Nephew accepts no responsibility or liability whatsoever for the functioning or utility of the TRIGEN SURESHOT Distal Targeting System when used in the operating theatre Cleaning and sterilization All instruments must be sterilized before use Detailed information on the cleaning and sterilization of components is contained in the separate Cleaning and Sterilization Instructions Smith amp Nephew document 7138 1339 Repair or modifications to the system The user is not permitted to modify or service the equipment There are no serviceable parts inside the unit Refer all service to authorized personnel Modifications additions to the software The user is not permitted to install or uninstall software Any new software must be installed by the manufacturer or by authorized personnel It is only allowed to connect equipment to the interface and power supply connections of the TRIGEN SURESHOT Distal Targeting System which are IEC60601 1 approved and which are approved by Smith amp Nephew Orthopaedics Do not modify this equipment without authorization of the manufacturer Electrical safety warning To avoid risk of electric shock this equipment must only be connected to a supply mains with protective earth ground Avoid spilli
20. eter is properly connected to the system and the application remains in this screen for more than 30 seconds the Targeter may have been damaged during cleaning sterilization In this case another Targeter has to be used Tip It is possible at any time to disconnect and reconnect tools when the application is running The display will show a screen reporting the missing instrument Surgical Technique Patient positioning Supine position Position the patient supine with three liter bags of saline between scapulas Tilt the patient on the fluoroimage table so that the humerus may be extended posteriorly The C arm may be positioned either superior to the shoulder or opposite the shoulder if the C arm modus is large enough Alternative position Position the patient in a slight beach chair position The arm of the semi recumbent patient is left to hang near the trunk thus its weight helps reposition the humeral head anterior to the acromion The C arm is placed above the head of the table at 30 extending distally over the shoulder This will allow an anteroposterior view of the humerus The arm should be placed in reverse pushing position to clear the entry point anatomically located at the superior margin of the articular surface just medial to the greater tuberosity Once the correct positioning and imaging are assured the shoulder and arm are prepped and draped Surgical Technique Instruments for opening the hume
21. ews 39 Surgical Technique Distal locking screws without the use of TRIGEN SURESHOT Freehand locking Distal locks on all nails 18cm and longer should be done using the freehand technique The Screw Length Sleeve 11 0238 can be used with the 3 2mm Graduated Two Flute Drill 7175 1149 to drill for the A P distal locks Length measurements can be made by using A the graduations on the drill against the Screw Length Sleeve The Screw Depth Gauge 7175 1139 could also be used to determine the appropriate screw length Once the appropriate length 4 0mm Self Tapping Cortical Screw is selected it is attached to the 3 5mm Hex Driver 175 1140 The screw is inserted through the Gold Outer Sleeve 7175 1128 using the 3 5mm Hex Driver Final tightening of the screw should always be performed manually using the Straight Ratcheting Driver 7175 1141 Repeat this process for the inferior distal screw 40 Surgical Technique Closure Close the wound in layers use nonresorbable sutures in the rotator cuff repair Close the remainder of the incision in a standard fashion Removal of the nail The Screw Head Trephine 7175 1144 the Proximal Nail Trephine 7175 1143 and the Extractor 7175 1142 are included in the instrument set to facilitate nail removal 4 TRIGEN SURESHOT Trauma Interface Overview mode When the Targeter is greater than 5cm from the interlocking holes the Trauma Interface screen wi
22. g insertion of the nail Begin with the 6 0mm Fixed Endcutting Reamer 7111 8220 to 7111 8230 and insert it over the 2 0mm Graduated Ball Tip Guide Rod Ream the intramedullary canal sequentially Be careful not to push the guide rod distally during reaming Never insert a nail that has a larger diameter than the last reamer used It is recommended that templating is done for all cases to estimate the size of the implant needed The diameter of the last reamer used will help determine the diameter of the implant needed Keep in mind that all of the nail sizes taper and the canal should be reamed to 1mm over the implant diameter 20 OA ITE Surgical Technique Instruments for nail assembly and insertion Humeral Nail Guide Bolt Cat No 7175 1108 ee Guide Bolt Wrench Cat No 7175 1134 Proximal Drop Cat No 7175 1131 3 2mm Silver Inner Drill Sleeve Cat No 7175 1116 Anterior Stylus Cat No 7175 1130 Nail Drill Guide Cat No 7175 1129 Impactor Cat No 7175 1133 Gold Outer Sleeve Cat No 7175 1128 3 2mm Long Graduated Two Flute Drill Cat No 7175 1149 Trocar Cat No 7175 1136 Humeral Nail Drill Guide Probe Cat No 7175 1151 2 Surgical Technique Nail Drill Guide assembly Once the implant selection is complete use the Humeral Nail Guide Bolt 7175 1108 to attach the Nail Drill Guide 7175 1129 to the nail The nail and Nail Drill Guide are keyed to
23. l Entry portal is made at the apex of the humeral head and centered midway between the biceps groove anteriorly and the posterior humeral head Central Portal Lateral Portal Surgical Technique Entry Tool and Guide Pin placement The rotator cuff is divided to expose the superior portion of the humeral head The Entry Cuff Guard 7175 1100 protective device should be used to retract the soft tissue of the rotator cuff for visualization of the bone The Cuff Guard provides a visual working channel while protecting the rotator cuff and soft tissue during the procedure Attach the 3 2mm Tip Threaded Guide Pin 7175 1147 or Trocar 7175 1136 to the Mini Connector with Handle 7175 1133 Place through the Cuff Guard into the superior margin of the humeral head just medial to the greater tuberosity avoiding the rotator cuff insertion Verify position on the C arm to confirm guide pin placement is aligned in the medullary canal by oblique pictures at 45 with internal and external rotation of the shoulder Note The Disposable Cuff Guard 7175 1101 may be used to protect the rotator cuff while preparing the humerus for the nail The Nail can be inserted through the Disposable Cuff Guard A Drill Guide comes packaged with the Disposable Cuff Guard to facilitate the placement of the guide pin in the precise position Surgical Technique Instruments fracture reduction and reaming Straight Reducer Cat No 7175 11
24. ll display the IM nail in the overview mode This provides the user with a larger field of view in order to help find the general location of the interlocking holes The view in the upper right corner is the profile view It is collinear to the drill sleeve axis and the position is aligned with the tip of the drill sleeve Drilling mode When the targeter is moved within 5cm of the interlocking holes the Trauma Interface screen will display the IM nail in the drilling mode This provides the user with a smaller field of view that automatically zooms in to the interlocking holes Blitz EAE Drilling mode manual rotation Each IM nail has several predefined views that are automatically selected depending on the position of the Targeter to the IM nail Depending on the operating environment these predefined views might not be appropriate and can be manually adjusted To rotate the view Touch the screen near the outside and drag the view in a clockwise or counterclockwise direction To flip the view Touch the Menu button and select Toggle Maru HEr 8 7 mm Back View All changes made for a view are temporarily stored for that view until program exit To reset the view The default view settings can be restored by touching the Menu button and selecting Reset View or double tapping the center of the screen 42 TRIGEN SURESHOT Trauma Interface Menu Tapping on the Menu button will open up sever
25. n to bone where the green circle is aligned directly over the hole on the screen Note No X Rays are necessary 3 Surgical Technique Targeting the locking hole With the TRIGEN SURESHOT Humeral 3 2mm AO Drill 7169 1155 inserted into the TRIGEN SURESHOT Targeter 7169 2801 insert the tip of the SURESHOT Humeral 3 2mm Drill Sleeve 7169 1154 represented by the green circle through the incision and down to bone Tibia shown in image Perfect circles Align the tip of the drill sleeve over the desired hole in the nail This will be represented on the screen when the green circle is centered in the hole as shown Push the serrated tip firmly against bone to keep the green circle static on the screen Adjust the trajectory represented by red line between two circles of the red circle until both circles are concentric and centered with the desired hole on the screen Then start drilling 32 Critical Verify there are no other metal objects including metal triangles in the field Metal interference will cause the system to be inaccurate surreal Sf rg 2 run Seeve MU uis S m FALLI egve Note The green circle must be fully within the hole of the IM nail displayed on the Trauma Interface screen to ensure accurate drilling Surgical Technique Drilling distal hole Drill through near cortex and the nail using the TRIGEN SURESHOT Humeral 3 2mm AO Drill 7169 1155 Before drilling through far cor
26. ng screws will not be inserted into the bicipital groove potentially injuring the biceps tendon Figure 16b Note When using the TRIGEN SURESHOT Distal Targeting System move the Anterior Stylus 7175 1130 to the lateral side of the Proximal Drop 7175 1131 after the final version is determined and insert a 3 2mm Tip Threaded Guide Pin 7175 1147 to provisionally secure the nail 2 Surgical Technique TRIGEN SURESHOT system set up continued Connect probe to Trauma Interface 7169 2802 unit Make sure to use the SURESHOT Humeral Drill Guide Probe Dark Green 7169 1152 Connect the probe to either of the probe sensor ports on the Trauma Interface Note For assembly screw on SURESHOT Humeral Set Stop 7169 1151 to Nail Drill Guide 7175 1129 then insert probe Note The probe will be used as an intramedullary tool inside the nail placed in the patient s bone Note If the probe is not recognized after connection to the system the probe is defective and must be exchanged See also instrument connection Dark green probe Use only with TRIGEN Humeral Nail Proximal Drop 7175 1151 Note Broken or damaged instruments must be exchanged immediately and sent back to Smith amp Nephew Note This device is provided sterile by ethylene oxide gas and is single use There will be a confirmation in the screen of the Trauma Interface that implies that the probe has been connected Tip When
27. ng water or other liquids on electronic electrical equipment Use only Smith amp Nephew disposables and accessories with the Smith amp Nephew TRIGEN SURESHOT Distal Targeting System Maintenance To verify accurate functionality the device should be checked per the Maintenance Instructions contained in a separate Smith amp Nephew document 7118 1927 This accuracy check must be performed at least once every 12 months If this accuracy check is not performed as defined in the previous paragraph all warranty claims expire and the device is operated at the user s own risk Recycling Old electrical and electronic equipment must be disposed separately and may not be included in the regular domestic waste Alternatively the unit can be handed over to Smith amp Nephew Orthopaedics for correct recycling Warnings and cautions for TRIGEN SURESHOT Note Do not unplug the power while the system is running Note Danger of damage and tipping over Tip Place the unit on a firm level surface capable of holding at least TOkg 22 lbs Note To avoid the risk of electric shock this equipment must only be connected to a supply mains with protective earth Devices for TRIGEN SURESHOT system set up aea Ta Trauma Interface Cat No 7169 2802 Power Cord Cat No 6680 0193 TRIGEN SURESHOT Targeter Cat No 7169 2801 Note The Targeter will be operated within the sterile field and may have contact with th
28. oftware application for this system is contraindicated for all IM nails other than Smith amp Nephew TRIGEN META NAIE TAN FAN Humeral Pediatric and Adolescent nails Do not operate the TRIGEN SURESHOT Targeter within 200mm of an installed pacemaker The magnetic field produced by the Targeter may interfere with the operation of the pacemaker Intended use The TRIGEN SURESHOT Distal Targeting System is only designed for use with the indicated implants and instruments Implants and instruments must be used in accordance with the instructions as described in this manual and or in the non navigated surgical procedure Training Only trained operators are allowed to use the TRIGEN SURESHOT Distal Targeting System The various operating instructions must be fully read and understood as part of the training If any part of the instructions is unclear please contact your local representative Plausibility check As with all technical equipment malfunctions may occur due to improper use or more rarely technical failure To reduce the risks involved with such technical malfunction the operation can be completed using manually controlled instruments providing the malfunction is detected without delay It is therefore important to check the plausibility of the steps as indicated by the system and to carry out verification of the software targeting particularly when using the system for the first time Should there be any doubt regarding co
29. ord SURESHOT Humeral 3 2mm AO Drill Cat No 6680 0193 Cat No 7169 1155 v c SURESHOT Humeral Drill Guide Probe TRIGEN SURESHOT Humeral Drill Sleeve Cat No 7169 1152 Cat No 7169 1154 mS L Note When the targeter is out of the preferred San d oa PST range or there is metal or electrical interference the green and red targeter circles on the Trauma Interface screen may become unstable and or a warning message will be displayed If the interference is excessive the IM nail image on the Trauma Interface screen will disappear CO If interference cannot be avoided a standard X Ray technique must be used Straight Ratcheting Driver Note All tool cables should be uncoiled Cat No 7175 1141 completely and any excess cables should be kept out of the targeter measurement volume SURESHOT Humeral Set Stop Cat No 7169 1151 30 Surgical Technique Skin incision with TRIGEN SURESHOT Detach the Impactor 7175 1133 from the Nail Drill Guide 7175 1129 Reattach the SURESHOT Humeral Set Stop 7169 1151 and insert the SURESHOT Humeral Drill Guide Probe 7169 1152 in the nail Adjust the probe to nail length Skin incision Meu eerie Use the serrated tip of the SURESHOT Humeral 3 2mm Drill Sleeve 7169 1154 to identify where to make the incision The tip is at the right position when the green circle is aligned with the desired hole on screen Make the incision and place the tip of the drill sleeve dow
30. oriented as shown the connector should assemble easily Do not force the connector into the port Note If the probe is properly connected to the system and the application reports Probe not found for more than 10 seconds the probe may be damaged or defective In this case the probe has to be exchanged Tip It is possible at any time to disconnect and reconnect tools when the application is running The display will show a screen reporting the missing instrument 28 Surgical Technique TRIGEN SURESHOT system set up continued After the TRIGEN SURESHOT Targeter 7169 2801 and SURESHOT Humeral Drill Guide Probe 7169 1152 have been connected attach SURESHOT Humeral 3 2mm Drill Sleeve 7169 1154 to targeter Drill sleeve attachment Tip The drill sleeve 7169 1154 can be loosened Tightly secure the selected drill sleeve to from the targeter using the slot in the Small the targeter Hammer 7175 1135 Select the TRIGEN Humeral nail size that will be used Tip A different TRIGEN Humeral Nail size can be selected at any time during the procedure by choosing the implant option from the drop down menu The selected implant and diameter will be noted on the Trauma Interface screen 29 Surgical Technique Devices to lock distally 7t smith amp nephew TRIGEN SURESHOT Distal Targeting System TRIGEN SURESHOT Targeter e e e Cat No 7169 2801 Trauma Interface Cat No 7169 2802 Power C
31. r 1 SURESHOT Humeral 3 2mm Drill Sleeve 2 SURESHOT Humeral Instrument Caddy 1 Set No 7165 1101 Cat No Description Qt 7169 1152 SURESHOT Humeral Drill Guide Probe 2 7169 1155 SURESHOT Humeral 3 2mm AO Drill 2 53 Catalog information TRIGEN SURESHOT Instruments TRIGEN SURESHOT Country Kit North America Cat No 7165 7003 Cat No Description Qty 6680 0193 Power Cord 125 Volt 10 Amp North America Hospital Grade 7118 1927 User Manual English 1 Additional Country Kits TRIGEN SURESHOT Country Kit Australia Cat No 7165 7004 Cat No Description Qty 6680 0303 Power Cord 250 Volt 10 Amp 1 Australia NZ 7118 1927 User Manual English 1 TRIGEN SURESHOT Country Kit Continental Europe Cat No 7165 7005 Cat No Description Qty 6680 0291 Power Cord 250 Volt 10 Amp 1 Continental Europe 7118 1927 User Manual English 1 TRIGEN SURESHOT Country Kit Germany Cat No 7165 7006 Cat No Description Qty 6680 0291 Power Cord 250 Volt 10 Amp 1 Continental Europe 7118 1538 User Manual German 1 TRIGEN SURESHOT Country Kit Spain Cat No 7165 7007 Cat No Description Qty 6680 0291 Power Cord 250 Volt 10 Amp 1 Continental Europe 7118 1539 User Manual Spanish 1 54 Catalog information TRIGEN SURESHOT Instruments TRIGEN SURESHOT Country Kit Italy Cat No 7165 7009 Cat No Description Qty 6680 0291 Power Cord 250 Volt 10 Amp 1 Con
32. rough the Straight Reducer Center the Guide Rod 1 2cm proximal to the olecranon fossa in the distal end of the humerus Once the Guide Rod is in place carefully remove the Straight Reducer using the Obturator 7175 1145 as needed to ensure the Guide Rod stays in place Surgical Technique Measuring implant length To measure the length of the implant needed ensure that the distal tip of the 2 0mm Graduated Ball Tip Guide Rod 7175 1146 is located at the desired position of the distal tip of the nail Slide the Ruler 7175 1126 over the proximal end of the 2 0mm Graduated Ball Tip Guide Rod and advance the open end of the Ruler to where the proximal portion of the implant will be seated just below the articular surface of the proximal humerus Read the nail length from the calibrations exposed at the other end of the Ruler The 2 0mm Graduated Ball Tip Guide Rod has graduated markings and can be used to determine required implant length The Straight Reducer 7175 1105 can also be used to determine implant length by using the markings on the reducer shaft Both options are used to directly measure to the articular surface taking care to ensure the nail will be slightly countersunk Additional limited reaming Necessary for Proximal Nails longer than 8mm X 16cm After the nail length has been determined additional limited reaming can be performed to avoid nail incarceration and distraction at the fracture site durin
33. rrect functioning the targeting should be verified or a switch made to a traditional X Ray technique Introduction TRIGEN Humeral Nail design rationale The TRIGEN Humeral Nailing System product offering includes a 16cm Proximal Straight Nail a 16cm Proximal Bent Nail and a full line of Long Bent Nails Nails with a proximal bend are best suited for simple two part fractures of the proximal humerus involving the surgical neck of the humerus and proximal third humeral fractures without comminution In these scenarios the proximal bend facilitates an easier entry portal attainment and nail insertion with an incision just medial to the rotator cuff insertion The Long Bent Humeral Nail is primarily indicated for humeral shaft fractures which are inherently not prone to varus malposition The lateral portal design allows insertion just medial to the rotator cuff insertion and facilitates easier portal attainment and nail insertion The 16cm Proximal Straight Humeral Nail offers the option of a medialized entry site If the greater tuberosity is fractured or compromised a straight centralized starting point avoids fracture extension from the tuberosity fracture into the entry portal and resultant loss of nail stability The entry portal for the straight nail is slightly more difficult to attain than the curved nail entry portal Locking holes TRIGEN 8 7mm X 16cm Proximal Straight Humeral Nail offers an alternate choice in tr
34. rus Entry Cuff Guard Cat No 7175 1100 3 2mm Tip Threaded Guide Pin Cat No 7175 1147 Mini Connector with Handle Cat No 7175 1137 Cannulated Awl Cat No 7175 1102 14 _ Disposable Cuff Guard Optional may be used in place of 7175 1100 Entry Cuff Guard Cat No 7175 1101 Trocar Cat No 7175 1136 Straight Entry Reamer Cat No 7175 1103 Straight Ratcheting Driver Cat No 7175 1141 Surgical Technique Incision The incision approach that is recommended and most often used for antegrade humeral nailing is the lateral deltoid splitting incision For complete fractures or nonunions a traditional deltopectoral approach may be used A 2 3cm incision is made from the edge of the acromion to the edge of the head of humerus anterolateral to the tip of the acromion The deltoid is divided down to the sub deltoid bursa The deltoid muscle is then retracted Visualize the rotator cuff insertion into the greater tuberosity The biceps tendon is palpated anteriorly The rotator cuff supraspinatus tendon is incised 15 20mm in line with its fibers exposing the humeral head Insert suture into the rotator cuff interval to retract the rotator cuff and facilitate its repair after insertion of the nail Lateral portal Entry portal is made just medial to the tendon insertion and centered midway between the biceps groove anteriorly and the posterior humeral head Central portal straight proximal nai
35. tex obtain the screw measurement Picture shown with TRIGEN META NAIL Note Important if standard 3 2mm Graduated Two Flute Drill is used magnetic metal can adversely affect accuracy causing the drill to miss Verify there is no other magnetic metal object in area other than the items shown A note will appear on screen warning of compromised targeting field if magnetic metal is close If it is in the field image disappears Screw measurement With the tip of the drill against the far cortex measure for length then drill through the far cortex Ensure the serrated tip of the SURESHOT Humeral 3 2mm Drill Sleeve 7169 1154 is pushed against the bone Example Measure 35mm add approximately 3mm the screw length would be 38mm Alternative screw measurement with Screw Depth Gauge 7175 1139 After successfully drilling through the screw hole of the nail with the SURESHOT Humeral 3 2mm AO Drill remove the drill bit being careful not to move the arm 33 Surgical Technique ocrew insertion Detach the SURESHOT Humeral 3 2mm Drill Sleeve 7169 1154 from the TRIGEN SURESHOT Targeter 7169 2801 Introduce the SURESHOT Humeral 3 5mm Hexdriver 7169 1153 with the screw attached through the Targeter TRIGEN SURESHOT Targeter is backed away from bone by sleeve length approximately 80mm for the sleeve Picture shown with TRIGEN META NAIL Note Image disappears if too close Note The standard TRIGEN Hex
36. the 3 2mm Graduated Two Flute Drill 7175 1149 Take the length measurement from the calibrations on the drill or the Screw Depth Gauge 7175 1139 The 3 2mm Silver Inner Drill Sleeve must be removed from the Gold Outer Sleeve in order to use the Screw Depth Gauge 37 Surgical Technique Proximal locking screws Remove the 3 2mm Silver Inner Drill Sleeve 7175 1116 and insert the 3 5mm Hex Driver 175 1140 with the appropriate length 5 0mm Cancellous Screw attached The head of the screw should be nearly seated when the laser marked ring on the 3 5mm Hex Driver is even with the Gold Outer Sleeve 7175 1128 Final seating of the screw should always be under manual control using the Straight Ratcheting Driver 7175 1141 to avoid over insertion of the screw in soft bone Insert the remaining two proximal locking SCrews 38 Surgical Technique Proximal locking screws To target the proximal anterior locking hole remove the Anterior Stylus 7175 1130 and attach the Proximal Drop 7175 1131 on the anterior arm of the Nail Drill Guide 7175 1129 Caution Locate biceps tendon prior to beginning placement of the anterior screw Insert the 3 2mm Silver Inner Drill Sleeve 7175 1116 into the Gold Outer Sleeve 7175 1128 Insert the sleeve unit into the hole marked Anterior on the Proximal Drop Follow the same procedure described previously to drill measure and insert the Anterior and Posterior Proximal Scr
37. tinental Europe 7118 1536 User Manual Italian 1 TRIGEN SURESHOT Country Kit United Kingdom Cat No 7165 7011 Cat No Description Qty 6680 0213 Power Cord 250 Volt 10 Amp UK 1 7118 1927 User Manual English 1 TRIGEN SURESHOT Country Kit South Africa India Cat No 7165 7012 Cat No Description Qty 6680 0302 Power Cord 250 Volt 10 Amp 1 So Africa India 7118 1927 User Manual English 1 55 Orthopaedics Smith amp Nephew Inc 7135 Goodlett Farms Parkway Cordova TN 38016 www smith nephew com USA Telephone 1 901 396 2121 Information 1 800 821 5700 Orders and Inquiries 1 800 238 7538 Trademark of Smith amp Nephew Certain marks Reg US Pat amp TM Off 2011 Smith amp Nephew Inc The color Pantone 151 Orange for medical instruments is a U S registered trademark All rights reserved of Smith amp Nephew 7118 1802 REVO 2 08 11
38. tion Distances table contained in Smith amp Nephew document 7118 1927 Pressing the power button will bring up the Menu start up screen Starting up SURESHOT Targeting When start up screen disappears before the Menu display prompts for tool connections a warning SURESHOT Probe SURESHOT Targeter screen will appear Do not operate the TRIGEN Humeral connected SURESHOT Targeter within 200mm of an installed pacemaker Note The magnetic field produced by the Targeter may interfere with the operation of the pacemaker Surgical Technique OR preparation TRIGEN SURESHOT System set up TRIGEN SURESHOT Targeter connection When the display prompts for tool connections connect the TRIGEN SURESHOT Targeter 169 2801 to the Targeter port on the Trauma Interface 7169 2802 Targeter and probe have not been connected Menu SURESHOT Targeter Confirmation that the Targeter tool has been connected when the center of the Targeter lights up orange SURESHOT Targeter connected Note The Targeter body may have contact with the patient and must remain in the sterile field at all times Only the cable and connector may be removed from the sterile field Note This step needs to be performed at least ten minutes prior to targeting in order to ensure proper accuracy Tip When oriented as shown the connector should assemble easily Do not force the connector into the port Note If the Targ
39. voiding critical soft tissues such as the biceps tendon axillary and radial nerves Insert the nail attached to the Nail Drill Guide Assembly over the 2 0mm Graduated Ball Tip Guide Rod 7175 1146 and through the Entry Cuff Guard 7175 1100 with the lateral arm of the drill guide oriented with approximately 30 35 of retroversion Adjustments to this version can be made so that the anterior arm of the drill guide is in line with the lesser tuberosity avoiding alignment with the bicipital groove Proper depth is achieved when the lateral ledge on the drill guide is above the lateral cortex and the nail is seated just below the articular surface Remove the Guide Rod from the top of the Nail Drill Guide 7175 1129 Confirm that the fracture is compacted and not distracted 26 Surgical Technique Final version adjustment Final and rigid version adjustment to the nail can be performed prior to inserting the proximal locking screws by attaching the Anterior Stylus 175 1130 to the anterior arm of the Nail Drill Guide 7175 1129 Insert the Trocar 7175 1136 through the Anterior Stylus and position the nail so that the Trocar can be inserted into the lesser tuberosity at the location of the anterior locking hole Leave the Trocar in place to maintain fracture reduction and rotational stability during the insertion of the proximal lateral screws This step ensures that the proximal anterior and proximal anterolateral locki
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