PRE-OPERATIVE PLANNINGSurgical Technique REDUCTION, ,, It is critical to reduce the fracture before beginning the surgical procedure. An anatomic reduction or a slight valgus reduction

$Page 1: PRE-OPERATIVE PLANNINGSurgical Technique REDUCTION, ,, It is critical to reduce the fracture before beginning the surgical procedure. An anatomic reduction or a slight valgus reduction$
09

操作手册Surgical Technique

Gamma Locking Nail System

OPERATIVE TECHNIQUE

PRE-OPERATIVE PLANNING

X ,以及用C-臂X ,

, X 36

10%〜15%。

A/P and lateral C-arm images should be obtained prior to the surgical procedure. The

suitability of this implant for the patient should be determined prior to surgery by read the

X-ray of the affected femur. An A/P preoperative X-ray should be taken of the contra lateral

hip or of the affected limb once an anatomic reduction has been achieved. X-rays taken at

a 36-inch distance from the source result in 10-15 percent magnification of the bone.

10



患者体位PATIENT POSITIONING

, ,方

,

The patient may be placed in either the supine or the lateral decubitus position. In multiple

trauma patients, the supine position may be used for easier access to the airways as well

as to facilitate the treatment of other injuries. The supine position also facilitates fracture

reduction and rotational alignment of the femur. The disadvantage to the supine position

is that it impairs access to the tip of the greater trochanter for insertion of the nail.

, X ,

,

( 1)。

In order to assist in implants placement, it is essential to obtain excellent quality A/P and

lateral images of the entire femoral head and neck prior to beginning the surgery. It is

essential to obtain excellent A/P and lateral images of the femoral head and neck prior to

beginning the surgery regardless of which patient position is used (Fig.1).

1Fig.1

11



患者体位 ( )PATIENT POSITIONING (CONTINUED)

X ,

, ,

, ( 2)。

The use of image intensification or other x-ray imaging is required. The image intensifier

should be sterile-draped and may be positioned from either the contralateral or ipsilateral

side of the operating table. Confirm visualization of the hip as well as the shaft of the

femur using image intensification before prepping and draping. Bend the patient’s torso

away from the affected extremity to improve access to the greater trochanter. If access to

the greater trochanter is still inadequate, adduct the affected leg. However, to achieve

proper alignment of the fracture, this adducted position must be corrected prior to

insertion of the nail (Fig.2).

2Fig.2

12


REDUCTION

, ,

,

It is critical to reduce the fracture before beginning the surgical procedure. An anatomic

reduction or a slight valgus reduction of the femoral head and neck, should be seen in the

A/P film. Occasionally, a slight sag of the fracture may be seen on the lateral view. This

should be taken into consideration during the surgical procedure. This is most important

for consideration of the starting point of the Steinmann Pins or Pointed Awl into the

Femoral head.


13


INCISION AND EXPOSURE

取大粗隆上方1cm , 5cm, ( 3)。

Begin the skin incision 1 cm proximal to the tip of the greater trochanter, and extend it

proximally for about 5 cm in a longitudinal direction. Continue the incision down through

the subcutaneous tissues and split the iliotibial band (Fig.3).


3Fig.3

14


INSERTION SITE

用C-臂X ( 4),

Place the Pointed Awl at the selected starting point (Fig.4) and

confirm its position in both the A/P and lateral planes on C-arm.

Advance the Awl through the greater trochanter to the lesser

trochanter location.

, ,将 (φ2.5*300)

( 5),使用C-臂X

Locating the correct entry portal in the femur is extremely important. The insertion site for

the nail is usually located at the tip of the greater trochanter. Place the Threaded Guide

Pin (φ2.5*300) at the selected starting point(Fig.5), and confirm its position in both the

A/P and Lateral planes on C-arm.

,

4~5cm, , ,

使用硬 (φ8)

( 6)

Check the position with the C-arm.

Advance the pin down into the

medullary canal approximately

4~5cm. Confirm the position of the

pin using the C-arm with A/P and

lateral views. Remove the Threaded

Guide Pin. Use the Rigid Reamer (φ8)

ream the trochanteric region to open

the medullary canal (Fig. 6). Remove

the Reamer.

4Fig.4

5Fig.5

6Fig.6


15


GUIDE WIRE PLACEMENT

将 (φ3*900)插入 ( 7),

,

C-臂X

On the back table, attach the Guide Wire with

Olive(φ3*900) to the Gripper, and tighten (Fig.7). The

tip of the Guide Wire may be bent, to facilitate

fracture reduction. Insert the Guide Wire through the

entry hole and manipulate it down the proximal femur

across the fracture site. At the fracture site,

manipulate the Guide Wire under C-arm control across

the fracture site.

, ( 8)。如果

, ,

位。

Once in the distal canal, pass the wire to the distal

epiphyseal scar (Fig.8). If reduction of the abducted and

flexed hip is difficult, place pressure on the proximal

fragment, either with the hand or directly with a reduction

rod or other instrument.

,

Once the guide wire with Olive has been fully inserted, the

Gripper is removed.

7Fig.7

8Fig.8


16


9Fig.9

REAMING PROCEDURE

切口近端放置 ,

The Soft Tissue Protector is now positioned at the proximal end of the incision to protect

the soft tissue, and secured with tape or a skin clamp.

, ,

X , ,一般从

7.5mm ( 9) 9mm之前, 0.5mm ,之后,

1.0mm , 1〜2 , ,粗

14mm

The medullary canal is now reamed by passing reamer over the Guide Wire. Each reamer is

composed of a Flexible Reamer Head, a Flexible Shaft and a quick-connect drive end. The

quick-connect end can be connected to a powered driver. The width of the isthmus of the

medullary canal is determined by preoperative x-ray examination. The instrument with the

smallest possible diameter is used for initial reaming into the medullary canal, always

starting with the 7.5mm reamer (Fig.9). Reaming should be continued in 0.5 mm

increments before the medullary canal is reamed to 9mm. After that, the reaming should

be continued in 1.0mm increments, Over-reaming the canal by one or two millimeters may

facilitate preparation of the bone to accommodate the implant. The trochanteric region

should be reamed to14mm in diameter in hard bone to accommodate the implant, using

the Rigid Reamer. Use caution in advancing the Rigid Reamer.

注意: ,以及股骨干的最小直径和股骨的的弯曲度。

, ,

Note: Reaming amounts will depend on the quality of the bone

present, the minimum diameter of the femoral shaft, and the

amount of femoral curvature present. Reaming should be

immediately stopped and the reamer retracted when there is too

much resistance. If the reamer becomes lodged, stop reaming

immediately. Reverse the direction of rotation of the handpiece

and back the reamer out of the canal.


17


( )REAMING PROCEDURE (CONTINUED)

, , ,插入普通

(φ3*900) , ,

The plastic Guide Wire Exchange Tube is inserted over the Guide Wire with Olive, so

that it is well across the fracture site. Holding the tube in place, the Guide Wire with Olive

is now removed, and the Guide Wire (φ3*900) is inserted. After confirming that the tip of

the Guide Wire is in the correct position, the plastic tube is removed for insertion of the

cannulated nail.


18


10Fig.10

11Fig.11

12Fig.12

NAIL INSERTION

, 手柄上( 10),并用SW5

手

Select the appropriate size Nail. The nail must be rotated until

it seats into the correct position of the Nail Support Handle

and the Locking Rod is then firmly tightened into the

nail(Fig.10), completing this with the SW5 Wrench.

,

度( 11)。理想的状况下, ,

The nail is now manually inserted over the Guide Wire into the medullary canal until the

nail is seated at the desired depth, under image intensification (Fig.11). This indicates

that the nail has been inserted to the correct depth. Ideally, the nail should be inserted

by hand. If insertion can not be achieved by hand, gentle tapping may be necessary.

将打入(拔出)器 ,

( 12)

The Sliding Hammer maybe attached to the end of the nail Locking Rod, and it must be

tightened fully to avoid damage to the thread. The nail can then be inserted into the

correct position by gentle hammering (Fig.12). Don’t persist if the nail is not advancing,

remove it and ream some more.

注意:

Note:Remove the Guide wire

prior to drilling holes and insert

the Locking Screws.


19


13Fig.13

PROXIMAL LOCKING

, ,

, ,

Before locking with the Lag screws, attention should be paid that the femoral head has

been properly reduced.If the anatomical reduction cannot be achieved with the closed

technique, especially concerning malrotation of the femoral head and neck fragment. The

incision for the Lag screws should be enlarged, such that a forceps can be used for

reduction.

C-臂X ,并使用和

(φ2.5*300)

The projected path of the Lag Screw into the Femoral Head should be assessed using the

C-arm. This may be verified using the Targeting Device and the Threaded Guide

wire(φ2.5*300).

,并用 (φ9)的 (φ11/φ9)

, , ,

套推向骨面( 13) (φ9/φ2.8)。

The Targeting Device is mounted on the Nail Support

Handle. The Targeting Device Locking Screw is inserted

into the appropriate holes. It is then locked in this position.

The Screw Guide(φ11/φ9) with inserted Obturator (φ9) is

introduced into the distal Lag Screw targeting hole of the

Proximal Guide Bar. The skin is incised at the appropriate

site, and the Lateral cortex exposed by blunt dissection

using the Obturator. And then pushed the Screw Guide

forward up to the bone (Fig.13). Remove the Obturator and

insert the Guide wire sleeve (φ9/φ2.8) through the Screw

Guide.


20


15Fig.15

14Fig.14

( )PROXIMAL LOCKING (CONTINUED)

(φ2.5*300) (φ9/φ2.8), 2mm( 14)。需

, 要

,可以使用打入(拔出器) ,再用C-臂X

也

The Treaded Guide wire(φ2.5*300), is inserted through

the Guide wire sleeve. The guide wire should be

inserted up to about 2mm before the cortex of the

femoral head(Fig.14). The correct position of the guide

wire needs to be checked in the axial view using the

image intensifier. The wire needs to be parallel to the

femoral neck axis and should pass through the center

of the femoral head. If the nail anteversion requires

adjustment, move the nail up or down the canal by

gently impacting using the Sliding Hammer until the

correct depth is achieved. Check the position of the nail

with the C-arm. Adjusting nail depth may be useful in

accommodating various femoral neck anatomies.

用 ( 15)

,

下, 10mm。

Next, the length of the inserted guide wire is

measured with the Lag Screw Depth Gauge for Lag

screws (Fig.15). The Depth Gauge for Lag screws

measures the actual length of the guide wire in the

bone. If the tip of the guide wire was inserted into the

subcortical bone, a Lag screw approximately 10mm

shorter must be chosen.


21


16Fig.16

( )PROXIMAL LOCKING (CONTINUED)

(φ9) (φ11/φ9) , ,取出

(φ9/φ2.8), ( 16)。

For the proximal Lag screw, the skin is opened at the entry point. The Screw Guide

(φ11/φ9) with inserted Obturator(φ9) is intro-duced into the proximal targeting hole of the

Proximal Guide Bar and pushed forward until reaching the bone. The trocar is replaced by

the Guide wire sleeve (φ9/φ2.8). Next, the second Guide Wire (φ2.5*300) is inserted. The

penetration depth of the guide wire is again read on the Lag Screw Depth Gauge (Fig.16).


22



17Fig.17

19-1Fig.19-1

19-2Fig.19-2

20-1Fig.20-1

20-2Fig.20-2

Drilling of the proximal Lag screw hole

,(φ7.5/φ4.9) , ( 17)。

。

Remove the proximal Threaded Guide Wire. Be certain that the Screw Guides are firmly seated on the bone. Drilling is done cautiously over through the Tissue Protection Sleeve with the Step drill (φ7.5./φ4.9) into the femoral neck until the predetermined length (Fig. 17) of the Lag screw is reached. Do not drill any deeper than previously measured.

/ (φ7.5) ( 18),注, ,

( 19-1)。如有必要, ,当C臂X, / ( 19-2)。

Remove the Step drill and Drill Guide. Using the Lag Screwdriver, the selected Lag screw is screwed in through the Screw Guide. The Lag screw should be inserted carefully(Fig.18). In the case of weak cancellous bone, the danger of overrotation exists, even with very low insertion torques. After inserting the Lag Screw to the appropriate depth, the correct position of the Lag Screw is checked in both planes with the image intensifier(Fig.19-1). If necessary,begin advancing the Lag screwdriver clockwise against the Screw Guide. The surgeon continues to advance the Compressor while monitoring femoral neck compression using the C-arm, until the desired fracture reduction is achieved (Fig.19-2).

( 20-1, 20-2),

The distal Lag screw is inserted in the same way after drilling with step drill as described previously (Fig.20-1, Fig.20-2)And the two Screw Guides are removed.

,插入 (φ8/φ4),(φ4)的 (φ4) ( 22)

, ,10mm( )并固定好,

,

The Obturator is withdrawn, and the Drill Guide (φ8/φ4) inserted. Advance the appropriate size Drill bit (φ4),with the Drill Stop (φ4) attached to it at its proximal end, through the Guide(Fig.22). The surgeon now drills steadily through the lateral cortex. The drill should be stopped when the second cortex is reached. The Drill Stop is moved down until it is about 10 mm above the top of the Drill Guide, and fixed into place. This represents the thickness of the second cortex. Drilling is now continued through the second cortex. The Drill Stop prevents damage to the tissues beyond the bone, and also provides a method of estimating the correct length of the locking screw.

23



DISTAL LOCKING

如有必要, ,将 (φ8 )插入(φ10/φ8), ( 21)。作小切口,

, ,

With the Proximal Targeting still in place, retighten the Locking Screw if necessary. Assemble the appropriate Obturator (φ8) into the Screw Guide (φ10/φ8), and place both the Guide through one of the distal targeting holes for Lag Screw in the Proximal Targeting Guide (Fig21). Make a small incision through the skin and fascia lata. Spread the soft tissue down to the bone. Advance the Guide until it contacts the lateral femoral cortex.

21Fig.21

22Fig.22

24



23Fig.23

( )DISTAL LOCKING (CONTINUED)

, ,

( 23) ,

The appropriate length locking screw, measured from the base of the screw head to its tip,

is determined by measuring the amount of drill bit protruding from the drill guide,

ignoring the tapered end (Fig.23). A locking screw of this length is reserved, but not yet

inserted.

,将 ( 24),

,

,并按

The Drill Bit is removed with the Drill Guide. The

Graduated Angled Trocar is now inserted into the

Screw Guide (Fig.24), so that it passes through the nail,

and engages the far cortex. This trocar has now

stabilized the position of the Guide Bar. Do not drill

the second hole before inserting the angled trocar.

The second locking hole is now drilled, using an

identical technique. The length of the second locking

screw is determined as described above. 24Fig.24

25



25Fig.25


,需要使用

If the bone quality is good, it may be necessary to tap the proximal cortex using the Tap.

,用 ( 25),推入, ,部8〜20mm ,

T型手柄, ,

Remove the Drill Bit and Drill Guide from the second Screw Guide. A locking screw of correct length is now inserted into screw guide (Fig.25), and pushed through the bone with the Hex Screwdriver first, until its thread engages the lateral cortex. Note that there is a circular mark on the T-wrench. This mark will be 8〜20 mm above the top of the screw guide when the locking screw has been pushed in sufficiently. There is no point in turning the T-wrench until this position has been reached, because there will be no thread in contact with the bone. The T-wrench is now turned steadily clockwise, exerting gentle pressure, until the mark on the shaft of the T-wrench reaches the top of the screw guide. One more full turn should be made to tighten the screw fully. It is important not to continue turning after this position has been reached, or the thread in the bone will be stripped.

, ,

The trocar is removed from the first Screw Guide, and the same technique followed for insertion of the second locking screw. Both Screw Guides are now removed. Before proceeding with distal locking, a final check must be made to ensure that any rotational deformity has been corrected, and that there is no distraction of the bone ends at the fracture site.

26



ALTERNATIVE METHOD OF ESTIMATING LOCKINGSCREW LENGTH USING THE DEPTH GAUGE

, ,

, , ,

If there is any doubt about the correct length of locking screw, either in respect of the

measurement recorded following drilling, or because the surgeon omitted this step, the

Depth Gauge may be used as follows: the surgeon should first check that the screw guide

is positioned correctly. The depth gauge cover is then unscrewed and removed.

, , ORTHMED®的

,

Remove the Drill bit and Drill Guide, and insert the Depth Gauge through the Guide until

the gauge captures the far cortex of bone. Read the measurement for the screw from at

the top of the Screw Guide. This depth gauge is only suitable for use with ORTHMED®

Tibial and Femoral nails, since its accuracy depends on a fixed length of screw guide.

注意: 2.5mm

Note:Choose a screw length that is at least 2.5mm longer than the depth measured, to

ensure that bicortical screw fixation is attained.

27



前言INTRODUCTION

ORTHMED® ,:1) ;2)

折部位;3) ;4) ,

The ORTHMED® Long Gamma Locking Nail system has extended the indications of intramedullary nailing to include comminuted fractures, fractures with bone loss, and proximal and distal fractures of the femur. The interlocking technique offers the advantages of: 1) a closed intramedullary nailing technique; 2) small incisions away from the fracture site; 3) reduced risk of infection; and 4) decreased risk of shortening or rotation. Exposure to radiation during proximal and distal targeting screw placement has been reduced with the instrumentation and methods described in these surgical techniques.

ORTHMED® ,直径从9mm到11mm, 340mm到420mm 20mm

The ORTHMED® Long Gamma Locking Nails is available in the most commonly used sizes. These nails range in diameters from 9.0mm to 11.0mm and lengths from 340mm to 420mm in 20mm increment.

ORTHMED® :The ORTHMED Long Gamma Locking Nail is indicated for use in a variety of femoral fractures (Fig. 1), such as: A. A. Comminuted fractures B. 多段骨折 B. Segmental fractures C. 骨折伴骨缺失 C. Fractures with bone loss D. D. Proximal and distal fractures E. E. Nonunions F. 粗隆下骨折 F. Subtrochanteric fractures G. G. Intertrochanteric fractures

28



:Contraindications include: Femoral fractures involving the knee joint A medullary canal obliterated by a previous fracture or tumor (如畸形) Femoral shaft having grossly abnormal, excessive bow (i.e., curvature deformity)

Overt systemic infection is an absolute contraindication.

, /

The implant is contraindicated for use in medial neck fractures. This implant may not provide the required/desired stability when used to treat some medial neck fractures.

注意: ,Note:The surgeon should be aware that the use of the system in osteoporotic bone, or improper placement of the nail could increase the risk of failure or cut out of the implant.

29



SURGICAL TECHNIQUE FOR ORTHMED® LONG GAMMA LOCKING NAIL

PRE-OPERATIVE TECHNIQUE

X

Proper preoperative planning is essential to successful interlocking or recon nailing of the femur. To determine the appropriate nail size, and an x-ray film of the unaffected extremity are necessary for determining canal size at the isthmus and for measuring the length of the femur to aid in determining nail length. The proper length of nail should extend from the tip of the greater trochanter to the epiphyseal scar. The diameter of the femoral nail should match the isthmus in the lateral x-ray projection.

注意:从36 X 10%〜15 X

NOTE:X-rays taken at a 36-inch distance from the x-ray source result in 10-15 percent magnification of bone. The surgeon should review the x-ray to assure that there are no unusual anatomic variations.

30



REDUCTION

It is important to reduce the fracture before beginning the surgical procedure.

INCISION AND EXPOSURE

从大粗隆上方1cm 5cm, ,, ,

Begin the skin incision 1cm proximal to the greater trochanter and carry it proximally about 5cm in line with the gluteus maximus muscle. A larger incision may be desired for obese patients. Split the fascia of the gluteus maximus in line with its fibers. Identify the subfascial plane of the gluteus medius, and palpate the posterior tip of the greater trochanter. Retract the muscles to facilitate visualization of the piriformis fossa.

, ,点。

This may be difficult in the obese patient, especially if flexion causes the tip of the trochanter to lie against the ilium. Positioning techniques used to expose the tip of the trochanter include adduction of the leg and positioning of the patient’s torso away from the affected extremity.

31



INSERTION SITE

( 26) ,( 27) ,并且靠近大粗隆;

, , (φ2.5*300)。

Locating the correct entry portal in the piriformis fossa is extremely important(Fig. 26). For the interlocking procedure, place the Pointed Awl at the piriformis fossa (Fig. 27) and check its position with A/P and lateral views before creating the portal. On the A/P image, the awl should lie at the base of the femoral neck adjacent to the greater trochanter. On the lateral view, it should be oriented just posterior to the center of the femoral neck. When the correct position is achieved, rotate the awl to create the entry portal for the Threaded Guide Wire (φ2.5*300).

, ,底

部,靠近大粗隆,好入口位置后, ,近端股骨使用8mm口。

An alternative method is to insert the Threaded Guide Wire(φ2.5*300)into the piriformis fossa while checking the position with A/P and lateral image intensification. The Guide Wire must lie at the base of the femoral neck just medial to the greater trochanter on the A/P view, and oriented just posterior to the center of the femoral neck on the lateral view. Remove the Guide Wire and use the optional 8mm Rigid Reamer to create the entry

portal.

GUIDE WIRE PLACEMENT

15See the chapter of "UIDE WIRE PLACEMENT" on page 15.

REAMING PROCEDURE

16See the chapter of "EAMING" on page 16.

26Fig.26

27Fig.27

32

29Fig.29

NAIL INSERTION

, ( 28),并用SW5

Select the appropriate size Nail. The nail must be rotated until it seats into the correct

position of the Nail Support Handle (Fig. 28) and the Locking Rod is then firmly tightened into

the nail, completing this with the SW 5 Wrench .

,

, ,

况下, ,

The nail is now manually inserted over the Guide Wire into the medullary

canal as far as possible, under image intensification. The nail is advanced

into the distal fragment until the step on the nail support is flush with the

surface of the bone. This indicates that the nail has been inserted to the

correct depth. Ideally, the nail should be inserted by hand, but gentle

tapping may be necessary.

注意:

Note: Remove the Guide wire prior to drilling holes and insert the Locking

Screws.

( 29),

The Sliding Hammer maybe attached to the end of the nail Locking Rod

(Fig. 29), and it must be tightened fully to avoid damage to the thread. The

nail can then be inserted into the correct position by gentle hammering.



28Fig.28

33

PROXIMAL LOCKING

19

See the chapter of "ROXIMAL LOCKING"on page 19.

DISTAL LOCKING

,

, ;

, 提供定位杆安装的位置,定位杆可以穿

, ,并用

There may be some bending of the nail, due to the pressure and weight of the soft tissues

and the bone. Medio-lateral bending of the nail will not affect the targeting significantly,

since this is the plane of screw insertion, but any bending antero-posteriorly will result in

failure of the locking. The stabilizing system is therefore designed to correct antero-

posterior alignment between the guide bar and the nail. The Distal Outrigger provides the

mounting point for a Stabilizing Rod which is inserted down to the nail through the

anterior femoral cortex, and the U-shaped Stabilizing Spacer correct the distance and

lock the Stabilizing Rod to the outrigger.

:

1. ,

2. , ,

The stages of distal locking therefore are as follows:

1. Stabilize the guide bar in the appropriate position to correct for any bending of the nail.

2. Make the incision(s) for distal locking, insert the screw guides down to the bone, and

complete the procedure.



34




, SW5

;将 , , , ,

( 30)。

Remove the Proximal Guide Bar, tightened the Locking Rod using Sw5 Wrench. The

Connector Bar is attached to the Nail Support Handle and the Target device Locking Screw

tighten firmly by hand. The Guide Bar is mounted on the Connect Bar and the Bar Locking

Screw tighten firmly by hand. There have tow holes for Bar Locking Screw to fit in the

Connector Bar. Make sure to use the correct one that will promise the curvature of the

guide bar structure match the curvature of the femur or the nail (Fig.30).

, 。

The Distal Outrigger is now attached on the anterior side of the guide bar, at the middle of

the two distal locking holes. The Distal Outrigger Locking Screw is tightened firmly by

hand.

30Fig.30

35



32Fig.32

32Fig.32


将 , , 15mm切

口至深筋膜, ( 31),推向骨面, ,

A Stabilizing Rod Guide is inserted through the hole in the outrigger down to the skin

anteriorly, and by palpation is centred over the middle of the femur. The point of contact

with the skin is noted. A 15 mm incision is made at this point, down to the deep fascia.

The Obturator is inserted into the Screw Guide (Fig.31), and the two pushed together down

to the bone. The muscle is then split longitudinally down to the bone. The Screw Guide is

centered over the middle of the femoral shaft, by palpation, using gentle pressure on the

guide bar in the frontal plane.

,插入 (φ8/φ6),并将 (φ6) , ,然后

( 32)。

The Obturator is withdrawn, and the Drill Guide (φ8/φ6) inserted. The Drill Bit (φ6) is

inserted down to the bone, using gentle pressure to keep the point in contact with the

cortex. The anterior cortex only is then drilled (Fig.32).

36




,插入 (φ6), , ,

,

The drill bit is removed and the T-handled Reamer (φ6) inserted. The hole in the bone is

cleared by turning the hand reamer, until its tip can be heard and felt touching the nail.

Tapping the nail to confirm contact may be helpful. The hand reamer is then removed.

, ,

The Stabilizing Rod is inserted through the Screw Guide, and the hole in the anterior

femoral cortex, down to the nail, contact being confirmed by tapping its tip on to the nail.

: ,

端支架( 33)。

The U-shaped Stabilizing Spacer is now attached so that: the upper, narrowest fork fits into

the groove in the shaft of the stabilizing rod. The two other forks grip the screw guide and

the outrigger (Fig.33).

33Fig.33

37




把持住定位杆的手柄,, , ,

,

The handle of the stabilizing rod is now held so that its tip is in contact with the nail. The surgeon maintains this contact throughout. If the handle is pushed too hard, it is sometimes possible to push the tip of the stabilizing rod past the nail. This must be avoided, since it will result in the drill bit passing posterior to the nail. Gentle contact is all that is required.

(φ10/φ8), 4〜5cm的皮, , ,

致。

Screw Guides (φ10/φ8) are now inserted through each of the holes in the guide bar. A single 4〜5 cm incision is made over the points of contact with the skin, down through the deep fascia. The incision is deepened by blunt dissection, splitting the ilio-tibial tract longitudinally, down to the bone, taking care to keep the incision in line with the fibres of the ilio-tibial band.

(φ8)

The more proximal Screw Guide is now inserted down to the bone, with the aid of the Obturator (φ8).

(φ8/φ4) , , (φ4) ,( 34)。

A Drill Guide (φ8/φ4) is inserted into this screw guide, and tapped gently to engage its teeth in the bone. The Drill Bit (φ4) is attached to the drill guide, and the Drill Stop locked

34Fig.34

38




, ,

, (φ4) ,

定性。

The surgeon now grips the T-handle of the Stabilizing Rod, to keep its tip against the nail,

and MAINTAINS THIS　POSITION THROUGHOUT THE DRILLING PROCEDURE. The first

locking hole is now drilled as for proximal locking, and the drill guide removed. A Pin(φ4)

can also be used to drill a recess on the cortex before using Drill Bit to increase its

stability.

, ,

The Graduated Angled Trocar is now inserted into the Screw Guide, so that it passes

through the nail, and engages the far cortex. This trocar has now stabilized the position of

the guide bar. Do not drill the second hole until the Graduated angled trocar is in position.

, ,

,

Now that Screw Guide alignment is maintained by this trocar, the surgeon may release the

handle of the stabilizing rod. The appropriate length locking screw, measured from the

base of the screw head to its tip, is determined as before, and a locking screw of this

length reserved, but not yet inserted.

, ,

,

The distal Screw Guide is now advanced down to the bone using the straight trocar and

locked in position. The Drill Stop is returned to the proximal end of the drill bit and the

second locking hole drilled, using an identical technique. The length of the second locking

screw is determined as described above.

39



35Fig.35


, , ,再按

( 35)。

A locking screw of correct length is now inserted into the second Screw Guide, pushed

through the bone with the Hex Screwdriver until its thread engages the lateral cortex, and

screwed into place as described for distal locking of Standard Gamma Locking Nail

(Fig.35).

, ,

, X

失后,

The graduated trocar is removed from the first screw guide, and the surgeon again

maintains the position of the stabilizing rod by gripping its handle. The same technique is

followed for insertion of the remaining locking screw, after which both screw guides are

removed. A check is now carried out with the Image Intensifier or by X-ray to confirm that

both screws have passed through the nail and that reduction has been maintained. The

Stabilizing rod, and Distal Outrigger are removed.

40



LOCKING SCREW REPLACEMENT

, ,需要使用 , ,

If a locking screw should need replacing for any reason during the course of the operation,

the Locking Screw Extractor should be used, inserting it through the appropriate hole in

the guide bar, as described in the section on Nail Removal below.

FINAL CHECK

在拆除手柄之前, X ( 36),

, , , X

Before removing the handle from the nail, it is important to check all of the screws for

correct insertion (Fig. 36), both in the AP and lateral planes, either by image intensification

or X-ray films, ensuring that fracture reduction is satisfactory. All Lag Screws in the correct

position, both distal locking screws pass through the nail and penetrate the distal cortex.

These X-rays can also be used to confirm that the base of each screw head is firmly

positioned against the surface of the cortex.

36Fig.36

41



REMOVAL OF THE HANDLE AND CLOSURE

用SW5 , ,

,

,

The handle is removed after loosening the Locking Rod a few turns with the SW5 Wrench.

Once the Locking Rod and the Handle have been removed, a nail End Cap is placed over

the end of the nail. Note that the end cap has an unthreaded portion at its end. This

enables the surgeon to push the end into the nail to establish the correct alignment, and

thereby avoid damaging the thread. The nail end cap locked into place with the

Screwdriver.

骨屑,

It is recommended that the insertion area is washed liberally with saline to remove any

debris of reaming from the wound. This will reduce the likelihood of heterotopic bone

formation.

,

, , 24~48

In general, suction drainage should be used in the proximal wound only. The deep fascia

should be repaired in all incisions, and all wounds should be closed in layers in the usual

manner. Dressings should include a compression dressing and an elastic bandage wrapped

around the hip, in order to avoid wound seroma. The drain is removed after 24~48 hours.

42



POST-OPERATIVE MANAGEMENT

, , X

, 8周以后。

Early range of motion exercises of the knee and ankle are encouraged. Allow toe-touch

weight bearing to progress to full weight bearing as fracture callus increases on the X-ray

films, usually at six to eight weeks.

NAIL REMOVAL

, , ,

再将拔出手柄 ,

The proximal end of the nail is exposed through a small incision. It may be necessary to

clear some new bone from the end of the nail. The nail end cap is removed with the

Screwdriver. The Screw Adapter is screwed fully on to the nail. It is important to avoid

crossing the thread in the nail.

,清除新生骨, / ,

Make a small incision in the area of the existing proximal incision to expose the ends of

the Lag Screw. Clear any bony ingrowth away from the Lag Screw hex, and thread the Lag

Screwdriver into the Lag Screw. Threaded the Lag Screw Inserter into the Lag Screw and

tighten. Remove the lag screw, turning counter clockwise.

( ,

), : ,

,

, ,

,

上旋下, 的。

43



( )NAIL REMOVAL (CONTINUED)

The locking screws are now all removed. When locking screws require to be removed for

any reason, (e.g. nail extraction, or in the occasional case where the length of the chosen

locking screw is incorrect), this maybe accomplished using the Locking Screw Extractor as

follows: the Extractor is inserted down to the head of the screw, and is turned

counterclockwise. The thread on the outside of the locking screw head is a verse thread,

so it is necessary to turn the Extractor counterclockwise throughout this procedure. The

first turns lock the extractor to the screw head, and further turns will release the screw

thread from the bone. Once the thread has been disengaged from the cortex, the screw

should be pulled out directly. Further turns at this point will achieve nothing, as no thread

remains in the bone. Note that the locking screw is then disengaged from the extractor by

turning the latter clockwise, which is the opposite direction to normal. It may be necessary

to grip the smooth shaft of the screw with forceps during this procedure.

将打入(拔出) ( 37),

Attach the Screw Adapter into the nail (Fig.37). Screw the Sliding Hammer on to the Screw

Adapter and remove the nail.

,

In the normal course of events there is no restriction of physical activity once the wounds

have healed.

37Fig.37

Documents

PRE-OPERATIVE PLANNINGSurgical Technique REDUCTION, ,, It is critical to reduce the fracture before beginning the surgical procedure. An anatomic reduction or a slight valgus reduction