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Surgical Technique

1. Instrument Set Set No 7165 4002 Cat Item 7165 4501 7165 4502 7165 4503 7165 4505 7165 4506 7165 4520 7165 4554 7163 1025 Description META NAIL Anterior Drop META NAIL Drill Guide META NAIL Extension Drill Guide Extension Guide Bolt 23mm Guide Bolt Long 51mm Long Screw Length Sleeve Cannulated Impactor Short Large Nail Extractor META NAIL Disposables Set No 7165 4003 Cat Item 7163 1110 7163 1117 7163 1626 7167 4130 or 7163 1436 7165 4528 7163 1320 Description 4 0mm Long Pilot Drill 4 0mm Short Drill 3 0mm x 1000mm Ball Tip Guide Rod 3 2mm Brad Point Guide Pin Universal Compression Driver Disposable Nail Extractor f Qty Blocking Screw Instrument Set Optional Set No 7165 4001 Cat Item 7165 4515 7165 4509 7165 4522 7165 4511 7165 4513 7165 4514 7165 4523 7163 4508 Description Blocking Screw Device Tibial Blocking Screw Attachment 11 0mm T handle Awl 8 5mm 10mm Blocking Screw Cartridge 11 5mm 13mm Blocking Screw Cartridge Offset Blocking Screw Cartridge Blocking Screw Alignment Pin Retrograde Femoral Blocking Screw Attachment The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with 4 0mm AO Long Drill 7163 1121 The 4 0mm Short Drill 7163 1117 is interchangeable with 4 0mm AO Short Drill 7163 1123 The Disposable Nail Extractor 7163 1320 is interchangeable with the Large Nail Extractor 7163 1278 located in the origin
2. 2 Distal Bend Location 60mm Note These views are not to scale and should set does not include all sizes be used as a pictorial representation only Most distal hole threaded 4 CD Surgical Technique Patient positioning Position the patient supine on a radiolucent table with the unaffected limb extended away from the affected limb Figure 1 Alternatively a fracture table may be used with a pin inserted through the calcaneus to place the leg in traction Flex the affected limb 80 90 and check for length and rotation by comparison to the unaffected limb Use a bolster or radiolucent triangle to maintain limb position Figure 2 Caution If using the TRIGEN SURESHOT Distal Targeting System do not use a metal triangle Verify that there are no other metal objects including metal triangles in the immediate targeting area Metal interference will cause the SURESHOT System to be inaccurate Rotate the C Arm to ensure optimal AP anteroposterior and lateral visualization of the entire tibia A distraction device may also be applied to obtain and or maintain traction Establish the incision and entry portal Assemble the Honeycomb 7167 4075 Entry Portal Handle 7167 4092 and Entry Portal Tube 7167 4060 Figure 3 The pieces will lock in place securely at either 0 or 180 Optional Suction can be applied to the Entry Portal Handle Figure 1 Figure 2 En
3. Cap So JB BR 2 2 2 amp 4S ap Egl S 22 8 8 3 8 8 8 98 S BB s lt REE eee eee eee eee ee luul NO CD a ON Nail assemblv Use the Guide Bolt 7165 4506 to attach the META NAIB Drill Guide 7165 4502 to the nail Tighten with the Guide Bolt Wrench 7163 1140 and T handle The nail is correctly aligned when The vertical black line on the posterior side of the insertion barrel aligns with the line on the posterior side of the nail The A on the anterior side of the nail aligns with the A on the anterior side of the insertion barrel Figure 19 The apex of the nail s proximal Herzog Bend faces posteriorly and the Drill Guide is oriented anteriorly Figure 20 Note The bevel on the front of the nail marks the connection to the Drill Guide and can be seen in the lateral view as a means to determine proximal insertion depth Note The standard META NAIL Drill Guide and Guide Bolt are recommended for use for compression or dynamic locking When compared to using the META NAIL Extension Drill Guide the longer insertion barrel of the standard META NAIL Drill Guide facilitates countersinking of the nail Note The assembly and insertion of the grey 8 5mm diameter META NAIL Tibial Nail follows the same technique as the 10mm 11 5mm and 13mm diameter nails Attach the Cannulated Impactor Medium 7167 5081 to the Drill Guide Figure 21 Attach the Anterior Dr
4. at the site of screw entry and insert the gold 9 0mm Drill Sleeve and Figure 29 silver 4 0mm Drill Sleeve through the dynamic slot on the Anterior Drop down to bone Figures 29 and 30 10 Drill both cortices with the 4 0mm Long Pilot Drill 11 Use the techniques described in the Lock the Screw section to measure and insert the screw Note If the screw is left in the dynamic mode a nail cap cannot be used as it will push against the locking screw Figure 30 The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with 4 0mm AO Long Drill 7163 1121 Ln ON Co Proximal locking Compression One of two compression locking methods can be used Compression Driver method Countersink the nail a minimum of 10 mm Figure 31 Lock the nail distally Reduce the fracture as much as possible to maximize the advantage of the compression driver Insert a screw through the proximal side of the dynamic slot as previously described Remove the gold 9 0mm Drill Sleeve and Medium Hexdriver Attach the Universal Compression Driver 7165 4528 to the T handle and thread it through the guide bolt into the top of the nail until it contacts the most proximal 5 0mm locking screw Figure 32 Advance the Compression Driver by turning it clockwise to drive the locking screw distally which will compress the fracture up to 7mm Figure 32 Note If there are screws in the other proxima
5. 0mm 5 0mm x 32 5mm 5 0mm x 35mm 5 0mm x 37 5mm 5 0mm x 40mm 5 0mm x 42 5mm 5 0mm x 45mm 5 0mm x 47 5mm 5 0mm x 50mm 5 0mm x 52 5mm 5 0mm x 55mm 5 0mm x 57 5mm 5 0mm x 60mm 5 0mm x 62 5mm 5 0mm x 65mm 5 0mm x 67 5mm 5 0mm x 70mm 5 0mm x 72 5mm 5 0mm x 75mm 4 5mm 5 0mm TRIGEN META NAIL 10mm Tibial TRIGEN META NAIL 11 5mm Tibial Set No 7165 3000 Set No 7165 3001 Cat Item Length Cat Item Length 7165 5124 24cm 7165 5224 24cm 7165 5126 26cm 7165 5226 26cm 7165 5128 28cm 7165 5228 28cm 7165 5129 29cm 7165 5229 29cm 7165 5130 30cm 7165 5230 30cm 7165 5131 31cm 7165 5231 31cm 7165 5132 32cm 7165 5232 32cm 7165 5133 33cm 7165 5233 33cm 7165 5134 34cm 7165 5234 34cm 7165 5135 35cm 7165 5235 35cm 7165 5136 36cm 7165 5236 36cm 7165 5137 37cm 7165 5237 37cm 7165 5138 38cm 7165 5238 38cm 7165 5139 39cm 7165 5239 39cm 7165 5140 40cm 7165 5240 40cm 7165 5141 41cm 7165 5241 41cm 7165 5142 42cm 7165 5242 42cm TRIGEN META NAIL 13mm Tibial Nail Cap Set Screw i Cat Item 7165 6000 Cat Item Length 7165 5318 18cm 7165 5320 20cm 7165 5322 22cm j 7165 5324 24cm I 11 my 7165 5326 26cm H Hi Hi H 7165 5328 28cm A Aah TRIGEN Nail Caps 7165 5330 30cm 7165 5331 31cm Cat Item Length 7165 5332 32cm 7163 4000 Omm 7163 4005 5mm 7163 4010 10mm 7163 4015 15mm 7163 4020 20mm 7165 5333 33cm 7165 5334 34cm 7165 5335 35cm 7165 5336 36cm 7165 5337 37cm 7165 5338 38cm 7165 5339 39cm 716
6. 5 5340 40cm 7165 5341 41cm 7165 5342 42cm 7165 5343 43cm 7165 5344 44cm 7165 5346 46cm 7165 5348 48cm 7165 5350 50cm Contained in the standard implant set Caution U S Federal law restricts these devices to sale by or on the order of a physician Smith amp Nephew Inc www smith nephew com 1450 Brooks Road Telephone 1 901 396 2121 Memphis TN 38116 Information 1 800 821 5700 USA Orders Inquiries 1 800 238 7538 2015 Smith amp Nephew Trademark of Smith amp Nephew Certain marks Reg US Pat amp TM Off 01359 V3 71181610 REVC 04 15
7. TRIGEN META NAIL Tibial Nail System Table of contents T vaie Tele 3 TRIGEN NETA NAIL Tibial Nail Specifications 4 Surgical Technique pp 5 Patient positioning see ee jattesta ve gost 5 Establish the incision and entry portal pp 5 Alternative technique Entry Gorig 7 Reduce the ee 8 Determine the implant length 0 ss eee ee 9 Unreamed technique L eenennnnnnznnnnenz nn enn nn nn nn 10 Reamed technique sse eennnnznnnznnnznn ena nn nn nn nara n nn na 10 Nail assembly 11 Nall SCION aseene a E E E 12 Check nail deoh 13 LEN 14 Proximal locking ss sem eee 15 Proximal locking Compression pp 16 Blocking screw technique sese esse sees 18 Incision and entry GOI 18 Establish the entry portal 18 AP blocking screw insertion ss seseeennenznnnnzzzentenzznntintinini 18 ML blocking Screw insertion eee 19 Blocking screw insertion with a reducer pp 20 Final view AP and ML blocking screw insertion 0000 20 Stability blocking screw insertion pp 20 Final view Stability blocking SCrEWS pp 21 TRIGEN nail cap insertion optional eeeemmmeenezzzznznzzzznnzzzznzzzzznenzzzzzznzzzz 21 Nail extraction phong 22 An alternative method for extraction 0 semen 23 Catalog information pp 24 Nota Bene The technique description herein is made available to the healthcare professional to illustrate the authors sugg
8. al TRIGEN Instrument Set 7163 1326 and the HFN Instrument Set 7170 0001 Qtv 25 Implants TRIGEN Internal Captured Screws 4 5mm and 5 0mm Set No 71642005 Cat Item 7164 5420 7164 5422 7164 2125 7164 2127 7164 2130 7164 5432 7164 2135 7164 5437 7164 2140 7164 5442 7164 2145 7164 5447 7164 2150 7164 5452 7164 5455 7164 5457 7164 5460 7164 5462 7164 5465 Length 4 5mm x 20mm 4 5mm x 22 5mm 4 5mm x 25mm 4 5mm x 27 5mm 4 5mm x 30mm 4 5mm x 32 5mm 4 5mm x 35mm 4 5mm x 37 5mm 4 5mm x 40mm 4 5mm x 42 5mm 4 5mm x 45mm 4 5mm x 47 5mm 4 5mm x 50mm 4 5mm x 52 5mm 4 5mm x 55mm 4 5mm x 57 5mm 4 5mm x 60mm 4 5mm x 62 5mm 4 5mm x 65mm Set No 7164 2000 Cat Item 7164 5020 7164 5022 7164 5025 7164 5027 7164 5030 7164 5032 7164 5035 7164 5037 7164 5040 7164 5042 7164 5045 7164 5047 7164 5050 7164 5052 7164 5055 7164 5057 7164 5060 7164 5062 7164 5065 7164 5067 7164 5070 7164 5072 7164 5075 TRIGEN META NAIL 8 5mm Tibial Set No 7165 3002 Cat Item 7165 5024 7165 5026 7165 5028 7165 5029 7165 5030 7165 5031 7165 5032 7165 5033 7165 5034 Length Cat Item 24cm 7165 5035 26cm 7165 5036 28cm 7165 5037 29cm 7165 5038 30cm 7165 5039 31cm 7165 5040 32cm 7165 5041 33cm 7165 5042 34cm Contained in the standard implant set 26 Length 35cm 36cm 37cm 38cm 39cm 40cm 41cm 42cm Length 5 0mm x 20mm 5 0mm x 22 5mm 5 0mm x 25mm 5 0mm x 27 5mm 5 0mm x 3
9. cture into the region of the distal epiphyseal scar The guide rod should be center center in the AP and lateral views Once the guide rod is at the desired depth detach the Gripper and prepare to remove the Reducer from the tibial canal During extraction slide the Obturator 7167 4078 into the T handle in order to maintain guide rod position within the canal Figure 14 10 Remove the Reducer from the tibial canal Figure 11 Gripper Reducer Reducer Connector Figure 12 Figure 13 eS Figure 14 Determine the implant length Confirm that the Ruler opens easily If it does not adjust the thumb wheel connection at the end to ensure free movement After the Reducer has been removed reconfirm the guide rod placement within the distal tibia Slide the Ruler 7167 4079 over the guide rod until the metal tip contacts the proximal tibia Figure 15 Confirm the guide rod position in the window at the opposite end of the Ruler as shown in order to ensure accurate implant measurement Figure 16 Figure 15 Push down on the top of the Ruler until it contacts the 3 0mm Ball Tip Guide Rod Window Ass Note Ensure that the ruler is in contact A with the Ball Tip Guide Rod Read the implant length from the exposed calibrations at the end of the Ruler Confirm fracture reduction to ensure that the implant length is not underestimated Reference the fibula for acc
10. d position in the ML plane Figure 41 A Tighten the device to the awl and insert the appropriate Blocking Screw Cartridge Figure 42 Adjust the cartridge proximally or distally within the Blocking Screw Device to determine blocking screw position Insert the blocking screw as previously described The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with 4 0mm AO Long Drill 7163 1121 Figure 42 NO a O Ln ON Once blocking screw insertion is complete Obtain both AP and lateral radiographic images Confirm proper screw placement Figure 44 With the nail inserted attach the Tibial Blocking Follow the previouslv described techniques Blocking screw insertion with a reducer Blocking screws can also be inserted bv attaching the Blocking Screw Device to the Reducer instead of the 11 0mm T handle Awl Figure 43 Follow the previously described blocking screw insertion technique Final view AP and ML blocking screw insertion remove the Blocking Screw Device from the 11 0mm T handle Awl or Reducer to contirm accurate placement Figure 43 Note The Awl or Reducer provides a reliable indication of the nail s insertion trajectory based Figure 44 upon the location of the blocking screws Proceed with tibial nail insertion Stability blocking screw insertion Following nail insertion and confirmation of fracture reduction blocking screws can be placed on eithe
11. em TRIGEN META NAIL Tibial Nail Specifications 10 ae TRIGEN META NAIL Tibia TRIGEN META NAIL Tibia Specifications p 8 5mm 10 11 5 and 13mm 27m Lengths 16 50cm 16 50cm Proximal Diameter 12mm 10 11 5 diameter fi 12mm driving end 13mm 13 diameter Distal Diameter ies 8 5mm 10 11 5 and 13mm non driving end all knee and distal tibial 2 3mm 10 Wall Thickness 1 9mm 3 0mm 11 5 2 3mm 13 Guide Bolt Thread 5 16 24 UNF 5 16 24 UNF Screw Lengths 25 65mm 25 110mm RT Femoral amp Recon RT Femoral amp Recon i l 7 0mm Cannulated Screw Alternative Hexdrivers 7 0mm Cannulated Screw j l PERI LOC 4 7mm Hexdriver c PERI LOC Locking Screw Top view of nail PROFIX 4 7mm Hexdriver Proximal Locking Driving End 17mm 45 Screw Locked w META NAIL Cap Static Lock 23mm 45 Threaded w bushing Locations Orientations 30mm 25 Threaded gu 40mm 25 Threaded Threaded 4 3mm Threaded 4 5mm Static Locking Hole minor diameter minor diameter 60mm Dimensions Threaded 4 7mm Threaded 5 3mm major diameter major diameter Compression Dynamic 10m 10mm Slot Location o Compression Dvnamic 2 i 4 7mm 7mm 5 3mm 7mm Slot Diameter Length Non driving end of nail Herzog Distal Locking Non Driving End 25mm ML 25mm ML 15mm AP 15mm AP 5mm ML Threaded 5mm ML Threaded Static Locking Hole l l 4 7mm 5 3mm Dimensions Static Lock Locations Orientations Degree of Distal Bend 2
12. ested treatment for the uncomplicated procedure In the final analysis the preferred treatment is that which addresses the needs of the patient Introduction The following technique is for informational and educational purposes only It is not intended to serve as medical advice It is the responsibility of treating physicians to determine and utilize the appropriate products and techniques according to their own clinical judgement for each of their patients For more information on the TRIGEN META NAIL Tibial Nail System ncluding its Indications for Use REF 81068703 contraindications and product safety information please refer to the product s label the Instructions for Use packaged with the product and if using the TRIGEN SURESHOT Distal Targeting System the TRIGEN SURESHOT Distal Targeting System User Manual REF 7118 1540 The TRIGEN META NAIL Tibial Nail System is designed specifically to repair fractures of the proximal and distal thirds of the tibia including the shaft stable and unstable fractures nonunions malunions and for the prophylactic nailing of impending pathological fractures The META NAIL System can be used with or without the SURESHOT Distal Targeting System If using the SURESHOT Distal Targeting System be sure to read and understand the TRIGEN SURESHOT Distal Targeting System User Manual REF 7118 1540 Only trained operators are allowed to use the TRIGEN SURESHOT Distal Targeting Syst
13. f the Disposable Nail Extractor 7163 1320 11 Thread the assembly into the top of the nail Note It is the flared portion of the Entry Reamer that enters the top of the nail 12 Remove the remaining proximal locking screw 13 Extract the nail with a back slapping motion Figure 52 The Cannulated Impactor Long is located in the original TRIGEN Instrument Set 7163 1326 The Disposable Nail Extractor 7163 1320 is interchangeable with the Large Nail Extractor located in the original TRIGEN Instrument Set 7163 1326 and the HFN Instrument Set 7170 0001 22 An alternative method for extraction Guide rod jamming technique Advance the end of a 3 0mm Ball Tip Guide Rod through the end of the nail Insert the smooth end of a 2 0mm Ball Tip Guide Rod 7175 1146 in the same manner With both guide rods in place attach the Gripper to the end of the 3 0mm Ball Tip Guide Rod Pull the Gripper back so that it wedges the ball tip against the 2 0mm Guide Rod Backslap against the Gripper with the Slotted Hammer to extract the nail Guide rods Cat No Description 7163 1626 3 0mm x 1000mm Ball Tip Guide Rod 7175 1146 2 0mm x 600mm Ball Tip Guide Rod Additional removal items Cat No Description 115074 Large Extractor Hook 115073 Small Extractor Hook Available sterile packed For nail removal only do not use for nail insertion 23 Catalog information TRIGEN Base Instrumen
14. ide are securely connected Hammering can loosen the Guide Bolt Note For information regarding drilling distal holes and distal screw insertion using the TRIGEN SURESHOT Targeting System refer to the TRIGEN SURESHOT Targeting System User Manual 7118 1540 Figure 24 Figure 25 Lock the Screw Determine the Locking Screw length There are three options available to determine the locking screw lengths The Gold 9 0mm Drill Sleeve silver 4 0mm Drill Sleeve and 4 0mm Long Pilot Drill Figure 26 A The Screw Depth Gauge 7163 1189 Figure 26 B The Screw Length Sleeve 7167 4085 and 4 0mm Short Drill 7163 1117 Figure 26 C Note For information regarding Drill Depth Measurement Software DDM using the TRIGEN SURESHOT Targeting System refer to the TRIGEN SURESHOT Targeting System User Figure 26 Manual 7118 1540 The DDM software can be used for distal locking only Insert the Locking Screws Proximal locking options include three statically locked threaded holes and one slot that allows for both fracture compression and or dynamization Figure 27 These are targeted through the orange and blue color coded holes on the Anterior Drop Distal locking options include three statically locked holes two ML mediolateral holes and one AP hole The most distal ML hole is threaded for additional stability Gold 5 0mm locking screws are compatible with 10mm 11 5mm and 13mm diameter na
15. ill Sleeve 7167 4083 into one of the two Blocking Screw holes in the Drop then pass a 4 0mm Long Pilot Drill 7163 1110 through the drill sleeves Note For proximal interlocking with the leg in extension use the Extension Drill Guide 7165 4503 and Extension Guide Bolt 7165 4505 The long insertion barrel of the standard Drill Guide may impinge upon the distal femoral condyles and prevent the nail from interlocking with the tibia in full extension Figure 23 Note The TRIGEN SURESHOT Distal Targeting System cannot be used with the META NAIL Extension Drill Guide Figure 23 Check nail depth Check proximal nail depth In the lateral view confirm nail position by observing the nail Drill Guide junction Each circular groove on the Drill Guide s insertion barrel represents a 10mm depth interval Figure 24 Note If compression or dynamic locking is desired countersink the nail approximately 10mm in order to avoid implant prominence Check distal nail depth In the AP and lateral views confirm that the nail has been inserted to the desired depth Figure 25 Note Optimal insertion depth which will allow room for screw insertion below the fracture is essential Distal third tibial fractures require at least three locking screws to maintain stability _ Remove the Guide Rod once the nail has been fully seated Reattach the Anterior Drop Following nail insertion confirm that the nail and Drill Gu
16. ils Grey 4 5mm locking screws are compatible with 8 5mm diameter nails Note Do not use the 4 0mm Short Step Drill 7164 1123 when drilling for a grey 4 5mm locking screw Its diameter transitions from 4 0mm to 4 7mm and will drill too large a hole in the near cortex which may compromise locking Figure 27 Screw purchase META NAIL Tibial Nail with all four proximal screws inserted The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with 4 0mm AO Long Drill 7163 1121 The 4 0mm Short Drill 7163 1117 is interchangeable with 4 0mm AO Short Drill 7163 1123 14 Proximal locking Static locking 1 Make a small incision at the site of screw entry 2 Insert the gold 9 0mm Drill Sleeve and silver 4 0mm Drill Sleeve through the static slot on the Anterior Drop Figure 28 down to bone 3 Drill both cortices with the 4 0mm Long Pilot Drill 4 Measure for screw length using either the Figure 28 calibrations on the 4 0mm Long Pilot Drill or by removing the 4 0mm Drill Sleeve and using the Screw Depth Gauge 5 Attach the appropriate length screw to the end of the Medium Hexdriver 7163 1066 6 Use power to insert the screw through the gold 9 0mm Drill Sleeve until the laser etched ring on the Hexdriver reaches the back of the Drill Sleeve 7 Attach the T handle to the Hexdriver 8 Tighten the screw by hand Dynamic locking 9 With the nail countersunk approximately 10mm make a small incision
17. l holes the fracture cannot be compressed Note Use flouroscopy to check dynamic screw position when compressing the fracture Once the fracture gap is fully compressed lock the nail with up to three additional proximal Static screws while the Anterior Drop is still attached to the Drill Guide Figure 33 Note If the Compression Driver is progressed after the fracture is fully compressed the locking screw will begin to bend In extreme cases where excess force is applied the screw may break upon removal Figure 31 Figure 32 Figure 33 Nail Cap Set Screw method Lock the nail distally then fully insert the dynamic locking screw as previously described Remove the Drill Guide Anterior Drop assembly Insert the Nail Cap Set Screw 7165 6000 into the top of the nail and advance with the Medium Hexdriver T handle assembly until the fracture is compressed and the Nail Cap Set Screw has fully engaged the locking screw Figures 34a and 34b Note If there are screws in the other proximal holes the fracture cannot be compressed Note Use flouroscopy to check dynamic screw position when compressing the fracture Figure 34a Figure 34b NO Tighten the device to the awl and insert Adjust the cartridge proximally or distally within Blocking screw technique Incision and entry point Make a 2cm incision in line with the intramedullary canal Orient the incision so that it is pa
18. oid penetration of the posterior cortex CO Remove the Entry Reamer and guide pin Alternative technique Entry portal 9 Attach the T handle 7167 4076 or 7167 4576 to the Cannulated Awl 7167 4000 Figure 9 10 Insert the awl into the proximal tibia to a depth of 4 6cm Figure 8 Note The Cannulated Awl is 9 5mm in diameter Additional reaming is required for nail entry 11 Insert the 3 2mm T handle Trocar 7167 4074 Figure 10 into the rear of the assembly prior to insertion in order to prevent awl slippage and cannulated Awl with T handle accumulation of cortical bone within the cannulation Figure 9 3 2mm T handle Trocar Figure 10 Reduce the fracture Open the Gripper 7167 4080 Insert the smooth end of the 3 0mm Ball Tip Guide Rod 7163 1626 into the front of the Gripper Figure 11 Close the Gripper Connect the 8 5mm Reducer and the Reducer Connector 7167 4077 so that the words Slot Orientation on the connector are in line with the opening at the Reducer s tip Figure 12 Complete the assembly by connecting the Reducer and connector to the T handle 7167 4076 or 7167 4576 Note If blocking screws are desired at this point in the procedure refer to the blocking screw technique section of this surgical technique Advance the Reducer into the intramedullary canal Figure 13 Use the curved tip to direct the 3 0mm Ball Tip Guide Rod past the fra
19. op 7165 4501 to the Drill Guide Figure 21 To verify the accuracy of the target insert a gold 9 0mm Drill Sleeve 7163 1152 and silver 4 0mm Drill Sleeve 7167 4083 into the Drop Pass a 4 0mm Long Pilot Drill 7163 1110 through the assembly Note An incorrectly attached nail will not target The 4 0mm Long Pilot Drill 7163 1110 is interchangeable with the 4 0mm AO Long Drill 7163 1121 Guide Bolt META NAIL Drill Guide TRIGEN META NAIL Figure 19 Figure 20 META NAIL Anterior Drop 9 0mm Drill Sleeve Figure 21 Nail insertion 1 Detach and remove the Anterior Drop 2 Attach the Cannulated Impactor Medium 7167 5081 to the Drill Guide Figure 22 3 Orient the Drill Guide assembly in the AP anteroposterior position 4 Use the Slotted Hammer 7167 4082 to tap and advance the nail over the guide rod to the desired depth Figure 22 Note if excessive force is required to insert the nail additional reaming of the intramedullary canal may be required 5 Verify fracture reduction as the nail crosses the fracture site paving close attention to rotation length alignment distraction and or shortening 6 Check the final nail position in both the AP Figure 22 and lateral views for correct alignment Note To obtain provisional fixation of the proximal tibial fragments reattach the Anterior Drop and insert the gold 9 0mm Drill Sleeve 7163 1152 and silver 4 0mm Dr
20. r side of the nail in the metaphyseal region for additional stability Screws may be inserted in both the AP and ML planes Screw Attachment 7165 4509 Figure 45 to the Anterior Drop triangle to triangle for AP screws and square to square for ML screws Figure 45 for cartridge positioning and blocking screw insertion Figure 46 Note The AP blocking screws targeted through the two holes built into the Anterior Drop cannot be used if the most inferior oblique proximal locking screw has been inserted The blocking screws are located 53mm below the proximal tip of the nail Figure 46 20 Final view Stability blocking screws 1 Once stability blocking screw insertion is complete remove the Blocking Screw Attachment and Anterior Drop from the Drill Guide 2 Obtain both AP and lateral radiographic images to confirm accurate screw placement Figures 47 and 48 TRIGEN Nail Cap insertion optional 1 Remove the Drill Guide Anterior Drop assembly 2 Attach the selected Nail Cap Figure 49 to the Medium Hexdriver T handle assembly 3 Insert the Nail Cap into the top of the nail until it is tight Caution A Nail Cap cannot be used if a Nail Cap Set Screw is implanted or if a locking screw is inserted in the dynamic locking position The tip of the Nail Cap will contact the locking screw and prevent complete engagement of the Nail Cap with the nail Note If cross threading occurs rotate the Nail Cap counte
21. rclockwise until its threads line up with those of the nail Proceed with the Nail Cap insertion until it is tight Accurate screw placement Figures 47 and 48 Figure 47 Figure 48 Figure 49 21 Nail extraction optional Standard technique 1 Use the Medium Hexdriver T handle assembly to remove the Nail Cap or Nail Cap Set Screw if implanted all of the distal locking screws and all but one of the proximal locking screws Figure 50 2 Thread the Cannulated Impactor Medium 7167 5081 or Cannulated Impactor Long 7163 1185 into the back of the Disposable Nail Extractor 7163 1320 3 Thread the assembiv into the top of the nail 4 Remove the remaining proximal locking screw 5 Use the Slotted Hammer with a back slapping motion to extract the nail Figure 50 Figure 50 Percutaneous technique In the absence of a Nail Cap or Nail Cap Set Screw 6 Use the Medium Hexdriver T handle assembly to remove all distal locking screws and all but one of the proximal locking screws 7 Under fluoroscopy insert a 3 2mm Brad Point Figure 51 Tip Guide Pin 7167 4130 or 7163 1436 into the top of the nail either using power or bv hand Figure 51 8 Make a 2cm incision around the pin 9 Advance the 12 5mm Entrv Reamer over the pin and into the top of the nail to remove anv bonv ingrowth Figure 52 10 Thread the Cannulated Impactor Medium or Cannulated Impactor Long 7163 1185 into the back o
22. re 38 Figure 38 Lateral 7 h gt K Figure 36 O y T handle awl Insert the gold 9 0mm Drill Sleeve and silver 4 0 mm Drill Sleeve into the desired cartridge hole and down to the bone Figure 39 Drill both cortices with the 4 0mm Long Pilot Drill Note Use caution during drilling and insertion of the blocking screws in the AP plane Do not drill past the posterior cortex or insert a screw that is too long Damage to the neurovascular structures located posterior to the proximal tibia may result Figure 39 Determine the screw length by reading the exposed drill bit calibrations or by removing the 4 0mm Drill Sleeve and measuring with the Screw Depth Gauge Use the Medium Hexdriver T handle assembly to insert the screw until the screw engages the far cortex Following implantation of the proximal blocking screw and reduction of the fracture pass the 11 0mm T handle Awl into the distal fragment Figure 40 Figure 40 Reposition either the Blocking Screw Cartridge or the awl as necessary and follow the previously described technique for blocking screw insertion ML blocking screw insertion To prevent anterior or posterior malalignment of the proximal fragment blocking screws may also be placed in the ML mediolateral plane Attach the Blocking Screw Device to the 11 0mm T handle Awl Figure 41 Rotate the blocking screw device into the desire
23. t Set Set No 7167 4012 Cat Item 7112 9401 7112 9402 7167 4021 7163 1066 7163 1068 7163 1116 7163 1140 7163 1152 7163 1161 7163 1186 7163 1189 7167 4000 7167 4060 7167 4074 7167 4075 7167 4076 or 7167 4576 7167 4077 7167 4077 24 Description Small Outer Case Lid for Outer Case TRIGEN Base Tray Medium Hexdriver Short Hexdriver 12 5mm Entry Reamer Guide Bolt Wrench 9 0mm Drill Sleeve Multipurpose Driver Mini Connector Screw Depth Gauge Cannulated Awl Entry Portal Tube 3 2mm T handle Trocar Honeycomb T handle Reducer Reducer Connector Qty d i d d d O SP Cat Item 7167 4078 7167 4079 7167 4080 7167 4081 7167 4082 7167 4083 7167 4084 7167 4085 7167 4092 7167 1212 7111 8200 7163 1130 7164 1123 7163 1121 7167 1123 7167 4130 7163 1070 7175 1153 7163 1187 Description Obturator Ruler Gripper Impactor Slotted Hammer 4 0mm Drill Sleeve Screwdriver Release Handle Screw Length Sleeve Entry Portal Handle TRIGEN Reamer Set Optional SCULPTOR Flexible Reamer Optional Flexible Reamer Extender Optional TRIGEN 4 0 Diaphyseal Drill 4 0mm Long AO Pilot Drill 333mm Disposable 4 0mm Short AO Pilot Drill 161mm Disposable 3 2mm x 343mm Brad Point Tip Guide Pin Disposable Long Hexdriver Optional AO Mini Connector Optional Trinkle to Mini Connector Optional Qty d O el d TRIGEN META NAIL
24. tellar splitting medial or lateral parapatellar Note Locate the entry point just medial to the lateral tibial eminence in the AP view in line with the anterior cortex and intramedullary canal in the lateral view Figure 35 AP Establish the entry portal dails Insert the 11 0mm T handle Awl 7165 4522 manually to a depth just proximal to the fracture Figure 36 Note When creating the initial entry point pay close attention to the trajectory of the awl and the relationship to the anatomic axis of the tibia Correct awl trajectory in the proximal fragment must be established prior to alignment with the Metal handle anatomic axis of the distal fragment Figure 36 This will ensure accurate fracture reduction when the nail is inserted AP blocking screw insertion In order to prevent varus or valgus malalignment of the proximal fragment blocking screws may be placed in the AP plane Cartridge Attach the Blocking Screw Device 7165 4515 to the 11 0mm T handle Awl and move it into the Fi l ie gure 37 desired position in the AP plane Figure 37 Note The Blocking Screw Alignment Pins 7165 4523 can be screwed into the three threaded holes on the metal handle of the Blocking Screw Device to serve as external points of reference during fracture alignment the appropriate Blocking Screw Cartridge 7165 4511 7165 4513 or 7165 4514 the Blocking Screw Device to determine the blocking screw position Figu
25. try Tube Figure 3 Guide Pin Sleeve Entry Portal Handle 2 Make a 2cm incision in line with the intramedullary canal Figure 4 Orient the incision so that it is patellar splitting medial or lateral parapatellar Note Locate the entry point for the 3 2mm Brad Point Guide Pin just medial to the lateral tibial eminence in the AP view in line with the anterior cortex and intramedullary canal in the lateral view Figure 5 Figure 4 AP Lateral Figure 5 3 Attach a 3 2mm Brad Point Guide Pin l 7167 4130 or 7163 1436 to the drill via Figure 6 the Mini Connector 7163 1186 Note A wire driver can be used in place of the Mini Connector 4 Insert the guide pin into the proximal tibia to a depth of 4 6cm Figure 6 Note The Entry Portal instrumentation serves as a soft tissue protector Note If suboptimal guide pin insertion occurs rotate the Honeycomb within the Entry Tube to the desired location and insert another 3 2mm Brad Point Guide Pin Figure 7 Note Do not over insert the guide pin as this can establish a false trajectory and cause fracture malalignment Figure 7 6 Ln After the guide pin is in place remove the Honeycomb from the Entry Tube along with any other guide pins ON Check the guide pin position via radiographic imaging 7 Advance the 12 5mm Entrv Reamer 7163 1116 over the guide pin through the Entry Tube to a depth of 4 6cm Figure 8 Note Av
26. urate fracture distraction or compression lt Thumb wheel Figure 16 Unreamed technique Use radiographic templating to determine nail size Figure 17 Note The appropriate diameter implant provides translational fill within the isthmus of the intramedullary canal To help avoid implant incarceration during insertion select a nail approximately 1 0 1 5mm less than the narrowest canal measurement on the lateral radiograph Figure 17 TRIGEN META NAIL Tibial Nail Radiographic Template Cat No 7118 0810 Reamed technique Use radiographic templating to determine nail size Use the 9 0mm Front Cutting Reamer Head 7111 8231 and Flexible Reamer Shaft 7111 8200 to ream the intramedullary canal sequentially in half millimeter increments to a size 1 0 1 5mm larger than the selected nail size Figure 18 To ensure Guide Rod placement during reaming insert the Obturator 7167 4078 into the back of the Reamer unit during retraction Continue to confirm Guide Rod placement in the distal tibia throughout reaming Note Periodically move the reamer back and forth in the canal to clear debris trom the cutting flutes 10 T LO 8 5mm Shaft Diameter To a LS tO O w N D T TE BE o e e fe LATERAL VIEW Figure 18 A P VIEW 40mm 50mm 60mm Nail

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