Surgical Technique

1 TFN Titanium Trochanteric Fixation Nail System. For intramedullary fixation of proximal femur fractures. Surgical Technique This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation. Image intensi er control This description alone does not provide sufficient background for direct use of DePuy Synthes products. Instruction by a surgeon experienced in handling these products is highly recommended. Processing, Reprocessing, Care and Maintenance For general guidelines, function control and dismantling of m ulti-part instruments, as well as processing guidelines for i mplants, please contact your local sales representative or refer to: For general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, as well as processing of Synthes non-sterile implants, please consult the Important Information leaflet (SE_023827) or refer to: Table of Contents Introduction TFN Titanium Trochanteric Fixation Nail System 2.

2 Biomechanical Features 3. AO Principles 6. Indications and Contraindications 7. Clinical Cases 8. Surgical Technique Preoperative Implant Selection 9. Open Proximal Femur 10. Insert Nail 17. Proximal Locking 21. Distal Locking Short Nails 35. SureLock Distal Targeting Device Long Nails 39. Freehand Distal Locking Long Nails 40. Insert End Cap 44. Implant Removal 45. Instrument Cleaning 50. Locking Mechanism Assembly 51. Product Information I mplants for Titanium Cannulated Trochanteric Fixation Nails 52. Titanium Trochanteric Fixation Nails (green) Short 55. Titanium Trochanteric Fixation Nails (green) Long 57. Instruments 60. Also Available 73. MRI Information 74. TFN Titanium Trochanteric Fixation Nail System Surgical Technique DePuy Synthes 1. TFN Titanium Trochanteric Fixation Nail System. For intramedullary fixation of proximal femur fractures. The Synthes Titanium Trochanteric Fixation Nail (TFN) System permits an intramedullary approach for the xation of frac- tures of the femur.

3 The TFN System consists of a series of cannulated nails, cannulated helical blades, cannulated fem- oral neck screws, cannulated end caps, and locking bolts and screws. All of the implants in the TFN System are made of ti- tanium alloy.*. The helical blade provides improved resistance to varus col- lapse and rotational control of the medial fracture segment compared to single screw xation ( , lag screws). The result is superior life-to-cut-out versus single screw xation. This is accomplished through the use of the mm helical blade. In addition, the use of the mm helical blade results in reduced bone removal versus use of a traditional hip These helical blade features are especially advantageous in osteoporotic fracture xation. However the TFN system also offers a lag screw xation using an mm femoral neck * Titanium-6% aluminum-7% niobium 1. Sommers, M. Bottlang, C. Roth, H. Hall, Krieg (2004) A laboratory model to evaluate cutout resistance of implants for pertrochanteric fracture fixation.

4 Journal of Orthopaedic Trauma, Vol 18(6): 361 368. 2. Amir A. Al-Munajjed, Joachim Hammer, Edgar Mayr, Michael Nerlich and Andreas Lenich. Biomechanical characterization of osteosyntheses for proximal fractures: helical blade versus screw. Medicine Meets Engineering. 2008. 2 DePuy Synthes TFN Titanium Trochanteric Fixation Nail System Surgical Technique Biomechanical Features Greater resistance to cut-out Proximal femur fixation device cut-out 3. The helical blade of the Titanium Trochanteric Fixation Nail (Unstable pertrochanteric fracture using simulated cancellous bone). (TFN) System provides increased resistance to (405 lbs.). (360 lbs.). The innovative helical blade design was proven to provide (315 lbs.). Load [kN (lbs)]. superior resistance to migration and subsequent cut-out (270 lbs.) TFN. failure. 2 (225 lbs.). (180 lbs.). IM Device Fixation life curves: number of load cycles to cut-out at (135 lbs.)

5 With Lag Screw varying loads. (90 lbs.). (45 lbs.). When tested at a load of kN, the lag screw cut-out 0. 1 10 100 1,000 10,000 100,000. before 1,000 cycles whereas the helical blade cut-out after Cycles to cut-out 10,000 cycles. 1. Sommers, M. Bottlang, C. Roth, H. Hall, Krieg (2004) A laboratory model to evaluate cutout resistance of implants for pertrochanteric fracture fixation. Journal of Orthopaedic Trauma, Vol 18(6):361 368. 2. lbid. 3. lbid. TFN Titanium Trochanteric Fixation Nail System Surgical Technique DePuy Synthes 3. Biomechanical Features Improved resistance to varus collapse Varus rotation of femoral head at 1000 N4. (Unstable pertrochanteric fracture using simulated cancellous bone). 25 . 20 . Varus rotation TFN. IM Device 15 with Lag Screw 10 . 5 . 0. 1 10 100 1,000 10,000 100,000. Cycles Improved resistance to femoral head rotation Rotation of femoral head around implant axis at 1000 N5.

6 (Unstable pertrochanteric fracture using simulated cancellous bone). 80 . 70 . 60 IM Device Varus rotation with Lag Screw TFN. 50 . 40 . 30 . 20 . 10 . 0. 1 10 100 1,000 10,000 100,000. Cycles 4. Sommers, M. Bottlang, C. Roth, H. Hall, Krieg (2004) A laboratory model to evaluate cutout resistance of implants for pertrochanteric fracture fixation. Journal of Orthopaedic Trauma, Vol 18(6):361 368. 5. lbid. 4 DePuy Synthes TFN Titanium Trochanteric Fixation Nail System Surgical Technique The mm helical blade reduces amount of bone removed6. By using the mm helical blade, significantly less bone is removed than with a predrilled lag screw. The helical blade compacts trabecular bone around the blade as it advances into the femoral head. The amount of bone removed by an implant is directly re- lated to its cross-sectional area. The helical blade's cross- Example of bone removal Example of bone removal with standard lag screw with helical blade sectional area is only 38% that of a standard lag screw.

7 Longer fatigue life in mechanical testing7. Fatigue life (1011 lbs). (899 lbs). (787 lbs). Load [kN (lbs)]. (674 lbs) TFN. (562 lbs). (449 lbs). (337 lbs). IM Device (225 lbs). with Lag Screw (112 lbs). 0. 1000 10,000 100,000 1,000,000 10,000,000. Cycles 6. Data on file 7. Data on file TFN Titanium Trochanteric Fixation Nail System Surgical Technique DePuy Synthes 5. AO Principles AO PRINCIPLES. In 1958, the AO formulated four basic principles, which have In 1958, the guidelines become AO formulated four basic for internal principles, fixation1,2.. which have become the guidelines for internal xation1, 2. 1 12:08. Anatomic Anatomic reduction fixation Stable fixation Fracture reduction Fracture reduction and and fixation xation to Fracture Fracture fixation xationproviding providingabsolute abso- to restore restore anatomical anatomical relationships. relationships. or relative lute stability, or relative as required stability, as by the prequired atient, theby injury, and thethe the patient, personality injury, 1 2 of andthethe fracture.

8 Personality of the fracture. Early, Early, active mobilization mobilization Preservationof Preservation of blood blood supply supply Early and Early and safe mobilization mobilizationand and 4 3 Preservation Preservationof ofthe theblood bloodsupply supply rehabilitation the injured partand rehabilitation of the injured part to to soft tissues and bone bygentle soft tissues and bone by the patient and as a whole. the patient as a whole. reduction techniques gentle reduction and careful techniques and handling. careful handling. 1. M ller ME, M Allg wer, R Schneider, H Willenegger. Manual of Internal Fixation. 3rd ed. Berlin Heidelberg New York: Springer. 1991. 2. R edi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme. 2007. 1. M ller ME, Allg wer M, Schneider R, Willenegger H. Manual of Internal Fixation. 3rd ed. Berlin, Heidelberg, New York: Springer.

9 1991. 2. R edi TP, Buckley RE, Moran CG. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme. 2007. 4 DePuy Synthes Expert Lateral Femoral Nail Surgical Technique 6 DePuy Synthes TFN Titanium Trochanteric Fixation Nail System Surgical Technique Indications and Contraindications Indications tures associated with shaft fractures, pathologic fractures of The Synthes Titanium Trochanteric Fixation Nail (TFN) is osteoporotic bone (including prophylactic use) in both tro- intended to treat stable and unstable pertrochanteric chanteric and diaphyseal regions, long subtrochanteric frac- fractures, intertrochanteric fractures, basal neck fractures, tures, proximal or distal nonunions, malunions, and revisions. and combinations thereof. The Long TFN is additionally indicated for subtrochanteric fractures, pertrochanteric frac- Long (300 mm 460 mm) Short (170 mm and 235 mm) Long (300 mm 460 mm) Short (170 mm and 235 mm).

10 Trochanteric Fixation Nails Trochanteric Fixation Nails Trochanteric Fixation Nails Trochanteric Fixation Nails with helical blade with helical blade with screw with screw Contraindications No speci c contraindications. TFN Titanium Trochanteric Fixation Nail System Surgical Technique DePuy Synthes 7. Clinical Cases Case 1. Preoperative AP Preoperative lateral Postoperative AP Postoperative lateral Case 2. Preoperative AP Preoperative lateral Postoperative AP Postoperative lateral 8 DePuy Synthes TFN Titanium Trochanteric Fixation Nail System Surgical Technique 420 = 400. * Magnification factor may vary views of the femoral head. (magnification factor )*. mated nail length and implant size. Measured nail length is 420 mm Estimated nail length is 400 mm Example (for 0% magnification planner ruler): Typical femoral x-ray image is enlarged by 5%. Preoperative Implant Selection pattern, patient anatomy, and postoperative protocol.