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SURGICAL TECHNIQUE

Instruments and implants approved by the AO Foundation.This publication is not intended for distribution in the USA.

For Osteotomies and Fracture Fixation of the Proximal and Distal Femur

LCP PEDIATRIC PLATE SYSTEM

Image intensifier 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 MaintenanceFor general guidelines, function control and dismantling of multi-part instruments, as well as processing guidelines for implants, please contact your local sales representative or refer to:http://emea.depuysynthes.com/hcp/reprocessing-care-maintenanceFor 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: http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance

http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance

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LCP Pediatric Plate System Surgical Technique DePuy Synthes 1

TABLE OF CONTENTS

INTRODUCTION System Overview 3

AO Principles 6

Intended Use, Indications and Contraindications 7

SURGICAL TECHNIQUE LCP Pediatric Hip Plate 2.7 for proximal femoral osteotomies 9

– Clinical Cases 9 – Preoperative Planning 11 – Patient Positioning and Approach 14 – Positioning Wire Insertion 15 – Proximal Screws 20 – Osteotomy 22 – Proximal Fixation 23 – Reduction 29 – Distal Fixation 30 – Postoperative Treatment 31

LCP Pediatric Hip Plate 3.5/5.0 for varus osteotomies 32 – Clinical Cases 32 – Preoperative Planning 34 – Patient Positioning and Approach 39 – Guide Wire Insertion 40 – Osteotomy 45 – Considerations for external/ internal rotation osteotomy 47 – Proximal Fixation 48 – Reduction 53 – Distal Fixation 54 – Medialization 57

Alternative Surgical Technique – Preoperative Planning 61 – Patient Positioning and Approach 62 – Guide Wire Insertion 63

2 DePuy Synthes LCP Pediatric Plate System Surgical Technique

Table of Contents

Surgical Technique LCP Pediatric Hip Plates 3.5 and 5.0 for valgus osteotomies 67

– Clinical Cases 67 – Preoperative Planning 69 – Patient Positioning and Approach 74 – Guide Wire Insertion 75 – Osteotomy 81 – Proximal Fixation 82 – Distal Fixation 89

Alternative Surgical Technique – Preoperative Planning 91 – Patient Positioning and Approach 92 – Guide Wire Insertion 93

LCP Pediatric Condylar Plate 90°, 3.5 and 5.0 for distal femur osteotomies 96 – Clinical Cases 96 – Preoperative Planning 98 – Patient Positioning and Approach 100 – Guide Wire Insertion 101 – Osteotomy 107 – Distal Fixation 109 – Reduction 116 – Proximal Fixation 117 – Medialization 123

Implant Removal 127

PRODUCT INFORMATION Implants 128

Instruments 132

BIBLIOGRAPHY 143

MRI INFORMATION 144


SYSTEM OVERVIEW

PEDIATRIC LCP PLATESThe Pediatric LCP Plate System is designed for stable fi xation of varus, valgus or rotational osteotomies and trauma applications in pediatric orthopaedics and is designed to meet the specifi c requirements of pediatric orthopaedic surgery.

The Pediatric LCP Plate System offers a wide range of locking compression plates along with a surgical tech-nique specifi cally developed for the pediatric patient. The Pediatric LCP Plates have a universal design for the left and right femur. The head of the plate features threaded holes for locking screws that either angle into the femoral neck in the proximal femur or parallel to the growth plate in the distal femur in place of the tradi-tional angled blade.

In the proximal femur plates, an additional diverging calcar screw ensures increased fi xation in the bone. The 100˚ and 110˚ plates are designed with an offset for osteotomies. The 2.7 mm plates have a 6 mm offset; the 3.5 mm plates have an 8 mm offset and the 5.0 mm plates have a 10 mm offset.

Plate shafts feature limited-contact profi les and Combi holes. The Combi hole combines a dynamic compression unit (DCU) hole with a locking screw hole. Combi holes provide the choice of axial compression and locking capability throughout the length of the plate shaft.


Angular stabilityAngular stability reduces the risk of primary and second-ary loss of correction. Improved connections between screw and plate, as well as within the cortical bone, make casting unnecessary in the majority of cases.

Intraoperative correction and flexibilityInitial plate positioning with Kirschner wires allows for intraoperative fl exibility and correction. The range of plate sizes, angles and screw lengths allows optimal patient fi t.

MedializationAdditional medialization can be obtained using the 3.5 mm and 5.0 mm Pediatric LCP Plates, requiring one offset for each plate size.

Low-profile designPlate design and locking construct reduce muscle disrup-tion and soft tissue irritation.

System OverviewPediatric LCP Plates


Angle Recommended Use 2.7 mm Plates 3.5 mm and 5.0 mm Plates

90˚ (Condylar) Distal femur osteotomies and fractures

100˚ Varus osteotomies

110˚ Varus osteotomies

120˚** Fractures

130˚ Fractures

140˚ Valgus osteotomies

150˚** Valgus osteotomies

2 holes

2 holes

2 holes

3 holes

3 holes

3 holes

3 holes

3, 5, 7 or 9 holes

4 holes

Pediatric lCP plates are available in the following sizes and angles.*

* screws sold separately** additionally available

3, 5, or 7 holes

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4 DePuy Synthes Expert Lateral Femoral Nail Surgical Technique

AO PRINCIPLES

In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation1, 2.

1 Müller ME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal Fixation. 3rd ed. Berlin Heidelberg New York: Springer. 1991.

2 Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme. 2007.

Anatomic reductionFracture reduction and fixation to restore anatomical relationships.

Early, active mobilizationEarly and safe mobilization and rehabilitation of the injured part and the patient as a whole.

Stable fixationFracture fixation providing abso-lute or relative stability, as required by the patient, the injury, and the personality of the fracture.

Preservation of blood supplyPreservation of the blood supply to soft tissues and bone by gentle reduction techniques and careful handling.


Stable fixationFracture fixation providing absolute or relative stability, as required by the patient, the injury, and the per-sonality of the fracture.

Anatomic reductionFracture reduction and fixation to restore anatomical relation-ships.

Early, active mobilizationEarly and safe mobilization and rehabilitation of the injured part and the patient as a whole.

Preservation of blood supplyPreservation of the blood supply to soft tissues and bone by gentle reduction techniques and careful handling.

In 1958, the AO formulated four basic principles, which have become the guidelines for internal fixation1,2.

AO PRINCIPLES

1 Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal Fixation. 3rd ed. Berlin, Heidelberg, New York: Springer. 1991.

2 Rüedi TP, Buckley RE, Moran CG. AO Principles of Fracture Management. 2nd ed. Stuttgart, New York: Thieme. 2007.


Intended UsePediatric Plates are intended for temporary fixation, correction or stabilization of bones in various anatomical regions.

IndicationsThe LCP Pediatric Plate System consists of different plates for different indications.

The LCP Pediatric Hip Plate 2.7 is intended for use in infants up to three years, depending on body weight and bone quality.

• Neglected dislocation of the hip in combination with open reduction

• Developmental coxa valga • Severe hip dysplasia

The LCP Pediatric Hip Plate for varus osteotomies is intended for use in pediatric patients up to adolescence and for small-stature adult patients.

Specific indications include: • Idiopathic valgus hip • Idiopathic and acquired subluxation of the femoral

head • Femoral head subluxation in neuromuscular

diseases/problems • High retroversion and anteversion in combination

with a high CCD-angle

The LCP Pediatric Hip Plate for valgus osteotomies is intended for use in pediatric patients up to adolescence and for small stature adult patients.

Specific indications include: • High riding of greater trochanter and low shortening

of the leg • Perthes’ disease • Congenital pseudarthrosis of the femoral neck

Deformity of SCFE (Slipped Capital Femoral Epiphysis) • PFFD (Proximal Femoral Focal Deficiency) • Idiopathic coxa vara • Posttraumatic pseudarthrosis of the femoral neck

INTENDED USE, INDICATIONS AND CONTRAINDICATIONS


LCP Pediatric Hip Plate (3.5 & 5.0) 120° & 130° for fracture treatment and rotation correction is indi-cated for trans-trochanteric fractures with sufficient medial support, and femoral neck fractures Type I to III (see AO fracture classification).

The LCP Pediatric Condylar Plate is intended for use in pediatric patients up to adolescence and for small-stature adult patients.

Specific indications include: • Fixed flexion contracture of knee in neurological

conditions • Deformity correction in the distal femur • Rotational malalignment of the femur (if distal

correction preferred) • Supracondylar fractures of the femur

ContraindicationsNo specific contraindications.

Precautions:• Make sure to choose the appropriate plate

corresponding to age, size and bone quality of the patient.

• Ensure that the plate selected has a neck/screw angle which corresponds to preoperative planning.

Intended Use, Indications and Contraindications


Surgical Technique

LCP PEDIATRIC HIP PLATE 2.7 FOR PROXIMAL FEMORAL OSTEOTOMIES

CLINICAL CASESCase 1*18 month old girl, with severe dysplasia and subluxation of the right hip. Intraoperative arthrogram in AP view and abduction with 35° internal rotation shows good head positioning.

An intertrochanteric osteotomy was performed with a LCP Pediatric Hip Plate 2.7, 110°. Postoperative x-rays show good containment after correction of varisation and 30° external rotation. External splintage, such as a spica, was applied as the plate is small and the infant non-compliant.

* Images courtesy of: Theddy F. Slongo, MD Children‘s University Hospital Bern, Switzerland.

Preoperative, AP view

Preoperative, AP view in abduction

Postoperative, Lateral view

Postoperative, AP view


Case 2*18 month old girl with neglected dislocation of the left hip. The left hip had a 150° preoperative CCD angle. An open reduction was performed in combination with an intertrochanteric osteotomy, which reduced the CCD angle to 115° (34° correction angle) in combination with 30° external rotation correction. The osteotomy was fixed using a LCP Pediatric Hip Plate 2.7, 110°.

Postoperative x-rays show good correction and central-ization of the hip in AP and lateral views.

6 weeks postoperative follow-up shows no loss of reduction, no plate or screw loosening and good callus formation.

* Images courtesy of: Dr Geoff Donald, MD Royal Children’s Hospital, Brisbane, Queensland, Australia.

Follow up 6 weeks, AP view Follow up 6 weeks, Lateral view

Postoperative, AP view Postoperative, Lateral view

Preoperative, AP view Preoperative, AP view, in abduction

Surgical TechniqueLCP Pediatric Hip Plate 2.7

Clinical Cases

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PREOPERATIVE PLANNING

1Determine correction angle

Preoperative planning is vital for proximal femoral osteo-tomies. Although there are different ways of planning, they are all designed to achieve the same result.

The first step is to decide on the desired final position after osteotomy, in particular the neck/shaft angle that is to be achieved.

Options:1. Take an AP pelvis x-ray (1).2. Take an AP pelvis x-ray in abduction and with internal

rota tion to assess the cover (2).3. Create a blueprint to assess the correction that will

achieve cover. (3)4. Choose a target neck/shaft angle based on the pa-

tient’s pathology (4).

2Select plate

The angle of the plate should be close to that of the desired neck/shaft angle. The offset of the 100° and 110° LCP Pediatric Hip Plates for varus deformities makes them ideal for varus osteotomies.


3Determine point of reference

The femoral shaft or neck can be used as a reference while planning and later inserting the positioning Kirschner wire.

a) Shaft referencingTo calculate the correction angle, subtract the desired neck/shaft angle from the initial pathological neck/shaft angle.

For example:Current pathological neck/shaft angle: 150°Desired neck/shaft angle: 120°Correction angle: 30°

To calculate the insertion angle of the positioning Kirschner wire using the aiming block and the positioner for aiming block on the shaft, add together the newly calculated correc tion angle and the plate angle.

For example:110° Plate angle + 30° correction angle = 140°Insert positioning Kirschner wire at 140° to the shaft

b) Neck referencingThe positioning Kirschner wire is inserted at an angle to the femoral neck. To calculate the insertion angle of the posi tioning Kirschner wire using the aiming block and positioner for aiming block, subtract the plate angle from the desired neck/shaft angle.

For example:Desired neck/shaft angle: 130°Plate angle: 110°Insert positioning Kirschner wire at 20° to the femoral neck


Preoperative Planning

C

A

D

B

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4Plate Type

This surgical technique focuses on the LCP Pediatric Hip Plate 2.7 and describes a varus osteotomy of the proxi-mal femur using a LCP Pediatric Hip Plate 2.7, 110° (cor-responds to implant Art. No. 02.108.301).

The surgical technique refers to screw holes using the designation as marked in this picture.

A: Neck screwB: Calcar screwC and D: Positioning Kirschner wires1 and 2: LCP or cortex shaft screws


PATIENT POSITIONING AND APPROACH

1Position patient

Position the patient in a supine or lateral position. A ra-diolucent table is recommended for the supine position.

2Approach

Use a standard lateral approach for the proximal femur.



POSITIONING WIRE INSERTION

1Localize trochanteric epiphysis and determine anteversion

Instrument

292.790.01 Kirschner Wire B 2.0 mm with threaded tip, length 150/15 mm, Stainless Steel

Place the Kirschner wire on the ventral aspect of the femoral neck to determine the anteversion. Align the Kirschner wire with the central line of the femoral neck.

Note: Carefully position the Kirschner wire to avoid interference with the positioner for aiming block.

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2Insert positioning Kirschner wires in holes C and D

Instruments

292.650 Guide Wire B 2.0 mm with threaded tip with trocar, length 230 mm, Stainless Steel

03.108.033 Aiming Block for Screws B 2.7 mm, for LCP Pediatric Hip Plates 2.7

03.108.034 Positioner for Aiming Block, for LCP Pediatric Hip Plates 2.7

313.302 Screwdriver Stardrive, SD8, cylindrical, with Groove, shaft B 3.5 mm

Set the calculated positioning Kirschner wire angle (see “Preoperative Planning“ section) on the positioner for aiming block and tighten the Stardrive screw (1).

Slide the aiming block over the positioner for aiming block (2).


Positioning Wire Insertion

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The wing of the positioner for aiming block must be placed parallel to the proximal femoral shaft in AP and lateral view. The positioner for aiming block and the two front spikes of the aiming block must be in contact with the femur (3).

The entry points for the positioning Kirschner wires are 10–15 mm distal to the trochanteric epiphysis in AP view.

Precaution: If there is extreme coxa valga, the posi-tioner for aiming block must be placed more distally to prevent the neck screw from perforating the piri-formis fossa.

Insert the positioning Kirschner wires in holes C and D parallel to the anteversion Kirschner wire in the lateral/axial view, such that they define the middle third of the femoral neck (4).

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Begin with the posterior positioning Kirschner wire to avoid interference with the anteversion wire (5). Once this wire is in place the anteversion wire can be removed. Then insert the positioning Kirschner wire in the anterior hole (6).

Note: To avoid slippage of the positioner for aiming block, do not remove the positioning Kirschner wires until the top neck screw is in place.

Precaution: All subsequent steps refer to the posi-tioning Kirschner wires, therefore their exact posi-tion is crucial.

Precaution: Use the 230 mm wire to reduce the risk of interference with the power tool.

Note: To facilitate insertion, center-punch the sur-face of the bone at the entry point before inserting positioner and wire.

Precaution: Do not bend the Kirschner wires during insertion as this may result in correction errors. This can occur when flexing the hip in lateral/axial view.

Precaution: If extension or flexion is required at the osteotomy, the aiming block for screws with the po-sitioner for aiming block has to be rotated accord-ingly before insertion of the second positioning Kirschner wire.


Positioning Wire Insertion


Precaution: Verify optimal placement of the posi-tioning Kirschner wires with the image intensifier in AP and lateral view.

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PROXIMAL SCREWSInsert Kirschner wires for proximal screws

Instruments





03.108.037 Direct Measuring Device for Kirschner Wires B 2.0 mm, length 150 mm, for LCP Pediatric Hip Plates 2.7

Use the aiming block to insert the Kirschner guide wire in hole A (1).To ensure optimal screw length, the Kirschner wire should not be placed closer than 5 mm from the femoral head growth plate (2). Use image in-tensifier control to check the correct distance from the growth plate.

Note: The direct measuring device can only be used for 150 mm Kirschner wires.

Precaution: Do not penetrate the epiphysis. Verify the position of the Kirschner wire with the image intensifier in the AP (2) and axial views (3 on next page).


3


Once the Kirschner guide wire has been correctly in-serted in hole A, remove the positioner for aiming block and the aiming block. The Kirschner guide wire defines the position and length of the screw and predrills the hole for the 2.7 mm screws.

Precaution: Avoid bending the positioning Kirschner wire with the aiming block while insert-ing the guide wire as this may result in failed cor-rection.

Note: To remove the positioner for aiming block and the aiming block, loosen the Stardrive screw on the positioner for aiming block.

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OSTEOTOMYInstrument

03.108.039 Positioner for Osteotomy, for LCP Pediatric Hip Plates 2.7

The optimal position of the osteotomy for the 2.7 mm plate is 9 mm distal to the positioning Kirschner wires in holes C and D. Determine the distance with the corre-sponding end of the positioner for osteotomy (1). Hold the positioner for osteotomy against the positioning Kirschner wires and mark the distance with the oscillat-ing saw or another sharp instrument on the bone (2).

Precaution: Prior to cutting the osteotomy insert Kirschner wires into the greater trochanter and the distal fragment (either the shaft or the knee) to con-trol the rotation. Even if no rota tion is planned, it is recommended to insert the two Kirschner wires or to make a mark on the bone. This ensures that rota-tional alignment is maintained.

Perform the osteotomy in one cut perpendicular to the femoral shaft with an oscillating saw (3). Use constant irrigation and cooling.

Note: If there is extreme coxa valga, the osteotomy cut has to be 3–4 mm further distal, otherwise the distance for the calcar screw is too short.


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PROXIMAL FIXATION

1Position Plate

Instruments

03.108.036 LCP Drill Sleeve 2.7, for Drill Bits B 2.0 mm, for LCP Pediatric Hip Plates 2.7



Fixation in the proximal neck/head fragment must always be performed with locking screws. Ensure that the lock-ing screws are at least 5 mm away from the growth plate of the femoral head.

Insert the drill sleeve into hole A. Tighten the drill sleeve with the wrench for the positioner for osteotomy (2). Slide the plate over the two Kirschner wires (1).

Notes: • If the plate stands too far off the proximal frag-

ment, it is acceptable to remove a small bone wedge from the lateral cortex near the osteotomy.

• Hold the proximal femoral neck/head fragment with forceps taking care not to disturb the plate positioning or manipulate the Kirschner wires. This provides improved handling of the proximal fragment and greater rotational stability (3).


2Determine femoral neck screw length

Instrument


Use the direct measuring device over the Kirschner wire against the drill sleeve to determine the screw length by measuring the insertion depth of the Kirschner guide wire (1, 2).

Remove the drill sleeve and the Kirschner guide wire from hole A. If necessary, use the wrench at one end of the positioner for osteotomy.

Note: The correct screw length can only be deter-mined if the direct measuring device is used with the 150 mm Kirschner wire.


Proximal Fixation


3Insert femoral neck screw in hole A

Instruments

511.776 Torque Limiter, 0.8 Nm, with AO/ASIF Quick Coupling

313.304 Screwdriver Shaft Stardrive, SD8, cylindrical, with Groove, shaft B 3.5 mm, for AO/ASIF Quick Coupling


03.110.005 Handle for Torque Limiters 0.4/0.8/1.2 Nm

Insert the screw in hole A.

Option A – Manual insertionTo insert the locking screw manually, attach the handle for torque limiter to the torque limiter and insert the screwdriver shaft. Insert the locking screw, and lock it in the plate.

Note: The optimum torque is reached after one click.


Option B – Insertion with a power toolTo insert the locking screw using a power tool and the 0.8 Nm Torque Limiter, pick up the locking screw and in-sert it into the plate hole until the screw head is slightly above the plate.

Precaution: Do not fully tighten the screws with the power tool.

Note: Always perform final tightening by hand.

Uncouple the power tool, mount the handle, torque lim-iting attachment, screwdriver shaft and manually tighten the screw. The optimum torque is reached after one click.

The torque limiting attachment controls the tightening torque to:• Ensure that enough torque is used to minimize the risk

of the locking screw backing out of the plate; and • Avoid locking the screw to the plate at full speed, thus

minimizing the risk of cold-welding the screw to the plate.

Precaution: Do not remove the positioning wire until proximal fixation is achieved.


Proximal Fixation

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4Insert calcar screw in hole B

Instruments

323.062 Drill Bit B 2.0 mm, with double marking, length 140/115 mm, 3-flute, for Quick Coupling


03.503.036 Depth Gauge for MatrixMANDIBLE, measuring range from 6 to 40 mm



314.467 Screwdriver Shaft, Stardrive, SD8, self-holding


Mount the drill sleeve onto hole B and use the drill bit B 2.0 mm to drill a bicortical hole for the calcar screw (1). Remove the drill sleeve and determine the screw length with the depth gauge (2).

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Insert the screw in hole B (3).

Then remove the positioning Kirschner wires in holes C and D (4).

Hole D

Hole C


Proximal Fixation


REDUCTIONInstrument

399.098 Reduction Forceps, toothed, soft lock, length 194 mm

For optimal fixation, the plate must be aligned parallel with the femoral shaft axis in AP and lateral views. Once the plate is aligned, secure the plate with the reduction forceps.

Precautions:• If the plate is not aligned parallel to the femoral

shaft axis in AP view, it can lead to variations of the planned neck/shaft CCD angle.

• In case of a planned internal or external rotation osteotomy, the plate is fixed with the forceps and the distal part of the femur rotated (in this case laterally) until the two rotation wires are parallel in axial view. Obtain definitive fixation with the forceps and final fixation of the plate by inserting screws in holes 1 and 2. Afterwards, the rotation wires can be removed (2).

Notes: • The alignment can be facilitated with forceps fixed

on the proximal part. This serves as a handle dur-ing the repositioning of the osteotomy.

• Alignment can be facilitated with LCP drill sleeves in the distal part of the plate and/or with a forceps fixed on the proximal part. These instruments serve as handles during the repositioning of the osteotomy.

• If the achieved rotation correction is too little or too much, the wires should be left in the bone for another rotation correction.

• Check whether medialization is required under the image intensifier. If so, follow the steps de-scribed on page 57–60.

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DISTAL FIXATIONInstruments




311.430 Handle with Quick Coupling, length 110 mm




323.260 Universal Drill Guide 2.7

The LCP Pediatric Hip Plate 2.7 is a combi-hole plate, therefore either locking or cortex screws can be used in the shaft. To achieve compression, always insert a corti-cal screw prior to any locking screws.

Screw the LCP drill sleeve into the LCP portion of hole 1 until it is completely gripped by the thread. Drill the screw hole using the drill bit B 2.0 mm (1). Remove the drill sleeve. Determine the screw length with the depth gauge and insert the screw.

Repeat this step for screw insertion in hole 2 (2).

Note: When cortex screws B 2.7 mm are inserted, the universal drill guide 2.7 can be used. Drill threaded holes with the drill bit B 2.0 mm and measure the screw length with the depth gauge.

Precaution: Cortical screws cannot safely be in-serted after a locking screw has been used in the distal fragment.



POSTOPERATIVE TREATMENTExternal splintage, such as a spica, is recommended as the plate is small and the infant non-compliant. Fre-quently this plate will be used in combination with other procedures that require immobilization, such as open fracture reduction.

Notes: • A hip spica in abduction allows a release of stress

on the muscles.• In osteoporotic bone, external splintage must be

used.


Surgical Technique

LCP PEDIATRIC HIP PLATE 3.5/5.0 FOR VARUS OSTEOTOMIES

CLINICAL CASESCase 1 11 year old girl, severe in-toeing which was the reason for clarification. The diagnosis shows poor coverage of both hip joints and strong valgus deformation of the femoral necks. Since the strong valgus deformation was the main component and the parents refused a pelvic osteotomy, the indication was set for a varisation and derotation intertrochanteric osteotomy. Internal fixation was achieved with a 5.0 LCP Pediatric Hip Plate 110°.

Case 23 year old, slightly retarded girl, unstable hip. Radiologic clarification shows subluxation with dysplastic hip cup and extremely high valgus. A bilateral varisation osteot-omy was planned and performed with a 3.5 LCP Pediat-ric Hip Plate 110°, combined with a triple osteotomy of the right pelvis. A bilateral pelvic osteotomy is not indi-cated due to high pelvis instability.

Preoperative, AP view Postoperative, good containment after bilateral correction of varisation by 30°

Preoperative, AP view and abduction Postoperative, good containment


Case 3 16 year old, tall boy with severe out-toeing. Internal and external rotation of the hip 0–10–100. With a good cov-erage of the hip, the patient and his parents requested a correction of the rotation. Internal fixation was achieved with a 5.0 LCP Pediatric Hip Plate 120°.

Case 4 10 year old, girl with hiperlaxity dislocated right hip. Ge-netic disease. Femoral osteotomy: derotation and Dega acetabular osteotomy.

Preoperative Postoperative

Preoperative, reduced anteversion, respectively retroversion

Postoperative, rotation by 20°




The surgical procedure described on the following pages uses guide wires to help plate placement. These guide wires are inserted with the help of an aiming block. In order to set the correct angle of the aiming block, the correction angle has to be determined first.

The angle of the aiming block can be calculated on the basis of the selected plate/screw angle and the desired correction angle. The correction angle can be estab-lished with two different planning methods described below.

A. Functional aspect: The functional abduction view on the x-ray shows the amount of correction.This technique is based on the optimal anatomical posi-tion of the femoral head in the acetabulum (contain-ment) and is not focused on an anatomical calculated correction angle. The pathological neck/shaft (CCD) an-gle is not relevant to determine the correction angle.

B. Anatomical aspect: The planning is based on the actual pathological neck/shaft angle (CCD).This technique is used when the desired final neck shaft angle is not one of the plate/screw angles. The tech-nique is derived from the original osteotomy technique described by Müller (1971).

Surgical TechniqueLCP Pediatric Hip Plate 3.5/5.0

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A. Functional aspect

The functional planning is based on a clear ap pelvis x-ray. For the calculation of the correction angle there are two options:1. Functional, abduction x-ray until we have an optimal

containment of the femoral head.– AP pelvis x-ray (1)– AP pelvis x-ray in abduction and with internal

rotation to assess the coverage (2)2. Create a blueprint of the proximal femur on the AP

pelvic x-ray, rotate this blueprint around the center of the femoral head until you have a satisfactory contain-ment.– Assess the correction that will achieve coverage (3)– Choose a target neck/shaft angle based on patient

pathology

Calculation of the correction: The angle between the anatomical axis of the femur in the AP x-ray and the ab-duction x-ray or the AP x-ray and the blueprint, respec-tively determine the correction angle.

Note: The use of the blueprint technique template reduces the x-ray exposure!


B. Anatomical aspect

The anatomical planning is based on a clear AP pelvis x-ray with at least 30° of internal rotation of both legs. This guarantees the correct projection of the real femo-ral neck/shaft (CCD) angle.1. Measure the pathological neck/shaft angle2. Determine the desired neck/shaft angle

Note: To control the planned correction a blueprint of the proximal femur on the AP pelvic x-ray can be performed. Rotate this blueprint around the planned osteotomy up your planned CCD angle and control the position of the femoral head.

Calculation of the correction: The angle between the initial axis of the femoral neck in the AP x-ray and the planned neck/shaft angle determine the correction angle.



+

+

=

=


or

Formula

Example: Current CCD: 165°Rotation: 65°Desired CCD: 130°Plate/screw angle: 110°

Positioning Kirschner wire angle = 35° (correction angle)plus 110° (plate/screw angle) = 145°

Positioning Kirschner wire angle correction angle (results from the functional or anatomical aspects)

plate/screw angle

A

C

1

2

3

D

B


2Plate Type

This technique guide focuses on the LCP Pediatric Hip Plates 3.5/5.0 and describes a varus osteotomy of the proximal femur with a 110° varus plate 3.5 (corresponds to implant Art. No. 02.108.311).

The surgical technique refers to screw holes where applicable. Please see the designation of each hole as marked.

A, B: Neck screwsC: Calcar screwD: Positioning Kirschner wire1, 2 and 3: LCP or cortex shaft screws



1

2



1Position patient

Position the patient either in the supine (1) or lateral (2) position. For the supine position a radiolucent table is recommended.

2Approach

Use a standard lateral approach to the proximal femur.


GUIDE WIRE INSERTION


Instrument


Place the Kirschner wire on the ventral aspect of the femoral neck to determine the anteversion. Control the parallel alignment of the Kirschner wire with the center-line of the femoral neck under the image intensifier.

Note: Position the Kirschner wire at a downward angle to avoid interference with the instruments.

Axial AP view


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2


2Insert positioning Kirschner wire in hole D

Instruments for 3.5 mm plate


03.108.001 Aiming Block for Screws B 3.5 mm, for LCP Pediatric Hip Plates

03.108.006 Positioner for Aiming Block

314.070 Screwdriver, hexagonal, small, B 2.5 mm, with Groove






Set the calculated positioning wire angle (see “Preopera-tive Planning” section) on the positioner for aiming block and tighten the hex screw. (1)

Assemble the positioner and the aiming block. (2)

3

4


The wing of the aiming block must be placed parallel to the proximal femur shaft in the AP and lateral views. The posi-tioner and the two front spikes of the aiming block must be in contact with the femur. (3)

The entry point for the positioning Kirschner wire is 5 to 6 mm distal to the trochanteric epiphysis in the AP view. Insert the positioning Kirschner wire parallel to the ini-tially positioned anteversion Kirschner wire and, in the axial view, in the center of the femoral neck. Remove the anteversion Kirschner wire.

Note: To facilitate insertion, first center-punch the surface of the bone at the entry point before insert-ing positioner and wire.

Precaution: All following steps refer to the position-ing Kirschner wire, therefore its exact position is crucial for a successful surgery.

Verify optimal placement of the positioning Kirschner wire with the image intensifier. (4)

To avoid slippage of the positioner do not remove the positioning Kirschner wire until the two neck screws are in place.

Precautions:• Do not bend the Kirschner wire while drilling as

this may result in failed correction.• If extension or flexion is required at the osteotomy,

the guiding block with the positioning device has to be rotated accordingly before insertion of the Kirschner wires.

Axial AP view


Guide Wire Insertion

1

2


3Insert Kirschner wires for proximal screws



03.108.005 Kirschner Wire B 2.8 mm with spade point tip


03.108.040 Kirschner Wire Adaptor

314.070 Screwdriver, hexagonal small, B 2.5 mm, with Groove







Insert the Kirschner guide wires for holes A and B with the help of the aiming block (1). To prevent any interfer-ence with other wires adjust the Kirschner wire adaptor before inserting Kirschner guide wire for hole B (2).

To ensure optimal screw lengths, place the Kirschner wires to within 5 mm of the femoral head growth plate.

If extension or flexion is required the aiming block has to be rotated accordingly around the positioning Kirscher wire (hole D) before insertion of the guiding Kirschner wire for proximal screws.

3

4


With the Kirschner guide wires for holes A and B, the position and length of the screws are defi ned while, at the same time, the holes are predrilled for the 3.5 mm screws.

After inserting the Kirschner wires for holes A and B, remove the aiming block and positioner for aiming block.

Precaution: Avoid bending the positioning Kirschner wire with the aiming block while insert-ing the guide wires as this may result in correction mistakes.

Notes: • Once a guiding Kirschner wire is inserted, fl exion

or extension correction can no longer be achieved.• To remove the positioner and aiming block loosen

the hex screw on the positioner.

Precaution: Verify the optimal position of the Kirschner wires with the image intensifi er in the AP and axial views. (3, 4) Do not penetrate the epiphy-sis.

AP view

Axial AP view



1

2


OSTEOTOMYInstruments

03.108.008 Positioner for Osteotomy

333.060 Positioning Plate, triangular, length 45 mm, 90°/50°/40°




The optimal position of the osteotomy for the 3.5 mm plate is 10 mm distal to the Kirschner guide wires. Determine the distance with the corresponding end of the positioner for osteotomy (1). Hold the positioner for osteotomy against the two Kirschner guide wires and mark the distance with the oscillating saw or another sharp instrument on the bone.

Perform the osteotomy in one cut – with an oscillating saw and constant irrigation and cooling – perpendicular to the femoral shaft. (2)

Note: If there is extreme coxa valga the osteotomy cut has to be 3–4 mm further distal otherwise the distance for the calcar screw is too short.

Note for 5.0 mm plate: The optimal position of the osteotomy is 13 mm distal to the Kirschner guide wires.

3

4


Note: In case of a planned internal or external rota-tion osteotomy, insert Kirschner wires bicortically into the greater trochanter and the distal fragment (either the shaft or the knee) to control the internal or external rotation.

Precaution: The positioning plates are used to adjust the correction angle of internal or external rotation. Even if no internal or external rotation is planned it is recommended to insert the two Kirschner wires or to make a mark onto the bone. This ensures that rotational alignment is maintained. (3, 4)

The proximal wire should be inserted slightly anteriorly, slighly below the proximal screw wires in order to avoid interference later with the calcar screw. The distal wire should be positioned preferably medial to avoid collision with the plate later.

The picture 4 represents the case with Kirschner wires with divergent angle of 35°, wherein the angle is defined by the distal wire, because the distal fragment will be rotated (30° angle + 5°). This has the advantage that without future measuring the wires can be aligned in axial view.


Osteotomy

3

4


CONSIDERATIONS FOR EXTERNAL/ INTERNAL ROTATION OSTEOTOMYIn the case of planned external or internal rotation oste-otomy, insert Kirschner wires bicortically proximal into the greater trochanter and distal, either in the shaft or the knee, to control the internal or external rotation.

For example, Kirschner wires with divergent angle of 35°, wherein the angle is defined by the distal wire as the distal fragment will be rotated (30° angle plus 5°) (3).

Further, during reduction, the plate is fixed with the forceps and the distal femur is rotated until the two rotation wires are parallel in axial view (4).


PROXIMAL FIXATIONFixation in the proximal fragment must always be done with locking screws. Ensure that the locking screws are at least 5 mm away from the growth plate of the femo-ral head.

1Position plate


03.108.009 LCP Drill Sleeve 3.5, for Drill Bits B 2.8 mm, for LCP Pediatric Hip Plate




03.108.004 Reduction Sleeve 4.3/2.8


Fixation in the proximal neck/head fragment must always be performed with locking screws. Ensure the locking screws are at least 5 mm away from the growth plate of the femoral head.

Insert drill sleeves into plate holes A and B. Tighten the sleeves with the wrench of the positioner for osteotomy. Slide the plate over the Kirschner guide wires and the positioning Kirschner wire.

Notes: • In case of a slight misfit (too far) of the proximal

fragment, remove a small bone wedge from the lateral cortex near the osteotomy.

• Fix the proximal fragment (femoral neck/head fragment) with forceps taking care not to disturb the positioning of the plate or manipulate the wires. This improves handling of the proximal fragment and provides rotational stability.

Note for 5.0 mm plate: An additional reduction sleeve must be inserted in each LCP drill sleeve before sliding the plate over the wires.



2Determine screw length and insert femoral neck screws A and B

Instrument

03.108.003 Direct Measuring Device for Kirschner Wires B 2.8 mm, length 200 mm

Determine the screw length by measuring the insertion depth of the Kirschner guide wire with the direct mea-suring device for Kirschner guide wires. Slide the appro-priate end of the measuring device over the Kirschner guide wire against the LCP drill sleeve and determine the proper screw length, which will typically be the next size smaller than what was measured. Remove the LCP drill sleeve and the Kirschner guide wire in hole A.

If necessary use the wrench at one end of the positioner for osteotomy.


Note: If the positioning Kirschner wire has already been removed, for screw insertion it has to be rein-serted in hole D since it protects against rotation during screw insertion.

Note for 5.0 mm plate: Remove the reduction sleeve and enlarge the hole from 2.8 mm to 4.3 mm with the LCP drill bit. Then follow the instructions as de-scribed in step 2.



511.770 Torque Limiter, 1.5 Nm, for Compact Air Drive and for Power Drive

314.030 Screwdriver Shaft, hexagonal, small, B 2.5 mm

314.116 Screwdriver Shaft Stardrive 3.5, SD15, self-holding, for AO/ASIF Quick Coupling

397.705 Handle for Torque Limiter Nos. 511.770 and 511.771


310.430 LCP Drill Bit B 4.3 mm with Stop, length 221 mm, 2-flute, for Quick Coupling

511.771 Torque Limiter, 4 Nm, for Compact Air Drive and Power Drive

314.152 Screwdriver Shaft 3.5, hexagonal, self-holding

314.164 Screwdriver Stardrive 4.5/5.0, SD25, with Groove, length 240 mm


Option A – Manual insertionTo insert the locking screw manually, attach the handle for torque limiter to the torque limiter and insert a screwdriver shaft. Insert the locking screw, and lock it in the plate. The optimum torque is reached after one click.

Option B – Insertion with a power toolTo insert the locking screw using a power tool, pick up the locking screw and insert it into the plate hole until the screw head is slightly above the plate. Do not fully tighten the screw with the power tool. Uncouple the power tool, mount the handle and manually tighten the screw. The optimum torque is reached after one click.Insert the screw in hole B in the same way as in hole A. Then remove the positioning Kirschner wire in hole D.


Proximal Fixation


3Insert calcar screw in hole C




319.010 Depth Gauge for Screws B 2.7 to 4.0 mm, measuring range up to 60 mm











4

3

1

2

1


Mount the LCP Drill sleeve onto hole C (1) and drill the hole for the calcar screw (2) with the LCP drill bit through both cortices. Remove the LCP drill sleeve and determine the screw length with the depth gauge.

Insert the screw in hole C. (3, 4)


Proximal Fixation

1

2


REDUCTIONInstrument

399.121 Bone Holding Forceps, self-centering, soft lock, length 239 mm

For an optimal fixation the plate must be aligned with the axis of the femoral shaft. When the plate is aligned, fix it with the reduction forceps. (1)

Precautions: • If the plate is not aligned parallel to the femoral

shaft in the AP view it can lead to variations of the planned neck/shaft (CCD) angle.

• In case of a planned internal or external rotation osteotomy, the plate is fixed with the forceps and the distal part of the femur rotated (in this case laterally) until the two rotation wires are parallel in axial view. Obtain definitive fixation with the forceps and final fixation of the plate by screw in-sertion in hole 1 and 3. Afterwards, the rotation wires can be removed. (2)

Note: If the achieved rotation correction is too little or too much, the wires should be left in the bone for another rotation correction.

If additional extension or flexion is required, the plate will no longer be aligned with the femoral shaft, making fixation more difficult due to the skewed position of the plate.

Notes: • The alignment can be facilitated with LCP drill

sleeves in the distal part of the plate and /or with a forceps fixed on the proximal part. These instru-ments serve as handles during the repositioning of the osteotomy.

• Check whether medialization is required under the image intensifier. If so, follow the steps described on page 57–60.


DISTAL FIXATIONSince this plate is an LCP plate, either locking or cortex screws can be used in the shaft. To achieve compression, always insert a cortical screw prior to any locking screws.

Option A: Distal fixation with locking screwsInsert screws in holes 1, 2 and 3.



314.119 Screwdriver Shaft Stardrive 4.5/5.0, SD25, self-holding, for AO/ASIF Quick Coupling















1

2


Screw the LCP drill sleeve into the locking portion of LCP combi hole 1 until it is completely gripped by the thread.Drill the screw hole through both cortices using an ap-propriate drill bit.Remove the drill sleeve and determine screw length with the depth gauge.

Insert the screw. (1)

Repeat steps for screw insertion in holes 2 and 3. (2)

Note: DO NOT fully insert the locking screws by power. Always perform final tightening by hand using the screwdriver handle, torque limiting attachment and screwdriver shaft. The screw is securely locked to the plate when a click is heard.

1

2


Option B: Distal fixation with cortex screwsInsert screws in holes 1, 2 and 3.




314.041 Screwdriver Stardrive 3.5, SD15, with Groove, length 200 mm



312.280 Double Drill Guide 3.5/2.5


314.270 Screwdriver, hexagonal, large, B 3.5 mm, with Groove, length 240 mm



314.119 Screwdriver Shaft Stardrive 4.5 /5.0, SD25, self-holding, for AO/ASIF Quick Coupling



Pre-drill with the appropriate drill bit and drill guide in plate hole 1.Measure screw length with the depth gauge and insert a self-tapping cortex screw in hole 1.

Repeat steps for screw insertion in holes 2 and 3.


Distal Fixation


MEDIALIZATIONNote: Medialization is only possible if the distal part is fixed with locking screws.






03.108.007 Instrument for Medialization






314.119 Screwdriver Shaft Stardrive 4.5/5.0, SD25, self-holding, for AO/ASIF Quick Coupling







1

2


Planned medialization

1Adjust the desired medialization with the instrument for medialization. Screw the corresponding end of the in-strument into the locking portion of LCP combi holes 1 and 3 until they are firmly gripped. Then screw an LCP drill sleeve into the locking portion of combi hole 2 (1).

The plate must be adjusted and aligned distally to the axis of the femoral shaft. When the plate is aligned, fix it with the reduction forceps.

Drill the screw hole and remove the drill sleeve. Deter-mine the screw length with the depth gauge and insert a locking screw (2).

Control the mechanical axis and check under the image intensifier. If mechanical axis is correctly aligned, follow step 2, if not, follow either the steps for additional medi-alization or varus/valgus correction.


Medialization

3

4


2Remove the instrument for medialization in hole 1 and insert a drill sleeve. Pre-drill the screw hole and remove the drill sleeve. Determine the screw length with the depth gauge and insert a locking screw (3). Repeat step two for hole 3 (4).

Note: Tighten the screws manually with the torque limiter.


Additional medialization (following planned medial-ization) If the mechanical axis is not in line, additional medialization is required.

1. Loosen screw in hole 2 if already inserted.2. Adjust the desired medialization with both instru-

ments for medialization to the same correction level.3. Tighten screw in hole 2.

If the mechanical situation is satisfactory, follow step 2 on page 59. If not, repeat additional medialization.


Medialization

1

2


Alternative Surgical TechniqueLCP Pediatric Hip Plate 3.5/5.0

PREOPERATIVE PLANNINGSurgical technique based on the plate/screw angleIn this technique the plate/screw angle defines the final neck shaft angle as the screws are inserted along the axis of the femoral neck in the AP view (1). It is suitable when the final desired angle conforms to one of the plate angles. The plate angle defines the final correction angle (2).

Determine the final neck/shaft anglePrior to surgery the surgeon determines which neck/shaft angle given by the plates (100° and 110°) has to be achieved after surgery. Further calculations are not nec-essary.

1

2



1Position patient

Position the patient in the supine (1) or lateral (2) posi-tion on the radiolucent table. Then position the image intensifier so that the visualization of the hip is possible in AP and axial views.

2Approach






Instrument




Axial AP view

1

2








03.108.002 Aiming Block for screws B 5.0 mm, for LCP Pediatric Hip Plates



Assemble the positioner and the aiming block. Do not tighten the hex screw. (1)

Insert the positioning Kirschner wire parallel to the initial positioned anteversion guide wire and absolutely parallel to the femoral neck axis so that the Kirschner wire corre-sponds exactly with the femoral anti-torsion (AT) angle in line with the intermediary femoral neck. (2)

The entry point is 4–5 mm distal to the trochanteric phy-sis in AP view and centered in the femoral neck in the lateral view (2).



3

4


Precaution: All following steps refer to the position-ing Kirschner wire, therefore the exact position is crucial for a successful surgery.

Verify the optimal placement of the positioning Kirschner wire with the image intensifi er. (3, 4)

Notes:• If additional extension or fl exion is required the

aiming block has to be positioned accordingly.• The two front spikes of the aiming block must be

in contact with the femur.• The positioning Kirschner wire stays inserted un-

til the two neck shaft screws are fi xed.

Precaution: Do not bend the Kirschner wire while drilling as this may result in correction mistakes.

If the insertion of the positioning Kirschner wire is satis-factory, follow step 3 on page 43.

Axial AP view

AP view

2

1


Considerations for fracture treatment • An open approach, including open fracture reduction,

is necessary (1).• Before inserting the positioning Kirschner wire in plate

hole D, use temporary Kirschner wire fi xation to reduce the fracture (1).

Insert the positioning Kirschner wire using the assembled positioner for aiming block/aiming block at fi xed angle: 130° for the 130° plate; 120° for the 120° plate (2).

Achieving compression:First insert a cortex screw as a lag screw in plate hole C. Then insert locking screws in plate holes A and B and re-place the lag screw in plate hole C with a locking screw.

X-ray images courtesy of: Theddy F. Slongo, MD Children’s University Hospital Bern, Switzerland.




Surgical Technique

LCP PEDIATRIC HIP PLATES 3.5 AND 5.0 FOR VALGUS OSTEOTOMIES

CLINICAL CASESCase 1*9-year-old girl; destroyed femoral neck after a plasma-cellular osteomyelitis; healed in a 90° varus position and 40° retroversion of the rest of the femoral head.

preoperative

postoperative


Surgical TechniqueLCP Pediatric Hip Plates 3.5 and 5.0

Clinical Cases

Case 2*9-year-old boy, situation 8 and a half years after bilateral osteoarthritis in both hips; right hip fully destroyed; left 90° varus hip with pseudarthrosis of the femoral neck.

preoperative

3 months postoperativepostoperative

* Acknowledgement: Theddy F. Slongo, MD Chirurgische Universitäts-Kinderklinik, Kinderspital Bern




The surgical procedure described on the following pages uses guide wires to help plate placement. These guide wires are inserted with the help of an aiming block. In order to set the correct angle of the aiming block, the correction angle has to be determined first.

The angle of the aiming block can be calculated on the basis of the plate/screw angle and the desired correction angle. The correction angle can be established with two different planning methods described below.

A. Functional aspect: The functional abduction view on the x-ray shows the amount of correctionThis technique is based on the optimal anatomical posi-tion of the femoral head in the acetabulum (contain-ment) and is not focused on an anatomical calculated correction angle. The pathological neck/shaft (CCD) angle is not relevant to determine the correction angle.

B. Anatomical aspect: The planning is based on the actual pathological neck/shaft angle (CCD)This technique is used when the desired final neck shaft angle is not one of the plate/screw angles. The tech-nique is derived from the original osteotomy technique described by Müller (1971).




A. Functional aspect

The functional planning is based on a clear ap pelvis x-ray. For the calculation of the correction angle there are two options;1. Functional, adduction x-ray until we have an optimal

containment of the femoral head.2. Create a blueprint of the proximal femur on the ap

pelvic x-ray, rotate this blueprint around the center of the femoral head until you have a satisfactory contain-ment.

Calculation of the correction: The angle between the anatomical axis of the femur in the ap x-ray and the adduction x-ray or the ap x-ray and the blueprint, re-spectively determine the correction angle.

Note: The use of the blueprint technique may reduce the x-ray exposure!


B. Anatomical aspect

The anatomical planning is based on a clear ap pelvis x-ray with at least 30° of internal rotation of both legs. This guarantees the correct projection of the real femo-ral neck/shaft (CCD) angle.1. Measure the pathological neck/shaft angle.2. Determine the desired neck/shaft angle.

Note: To control the planned correction a blueprint of the proximal femur on the ap pelvic x-ray can be performed. Rotate this blueprint around the planned Osteotomy of your planned CCD angle and control the position of the femoral head.

Calculation of the correction: The angle between the initial axis of the femoral neck in the ap x-ray and the planned neck/shaft angle determine the correction angle.

–

–

=

=

=

–




or

Current CCD: 95°Rotation: 35°Desired CCD: 130°Plate/screw angle: 140°

Formula

Positioning wire angle

105° (Positioning wire angle)

plate/screw angle

140° (plate/screw angle)

correction angle (results from the functional or anatomical aspects)

35° (correction angle)

A

C

1

2

3

DB


2Plate Type

This technique guide focuses on the LCP Pediatric Hip Plates and describes a valgus osteotomy of the proximal femur with 140° straight valgus plate (corresponds to implant Art. No. 02.108.316).

The surgical technique refers to screw holes where applicable. Please see the designation of each hole as marked.

A, B: Neck screwsC: Calcar screwD: Positioning Kirschner wire

1, 2 and 3: LCP or cortex shaft screws

1

2




1Position patient

Position the patient either in the supine (1) or lateral (2) position. For the supine position a radiolucent table is recommended.

2Approach





Instrument




Axial AP view

1

2















Set the calculated positioning wire angle (see “Preopera-tive Planning” section) on the positioner for aiming block and tighten the hex screw. (1)

Slide the aiming block over the positioner (2).

3

4


The wing of the aiming block must be placed parallel to the proximal femur shaft in the AP and lateral views. The positioner and the two front spikes of the aiming block must be in contact with the femur. (3)

The entry point for the positioning Kirschner wire is 5 to 6 mm distal to the trochanteric epiphysis in the AP view. Insert the positioning Kirschner wire parallel to the initially positioned anteversion Kirschner wire and, in the lateral/axial view, in the center of the femoral neck. Remove the anteversion Kirschner wire.

Note: To facilitate insertion, center-punch the sur-face of the bone at the entry point before inserting positioner and wire.

Precaution: All following steps refer to the position-ing Kirschner wire, therefore its exact position is crucial for a successful surgery.

Verify optimal placement of the positioning Kirschner wire with the image intensifier. (4)

To avoid slippage of the positioner, do not remove the positioning Kirschner wire until the two neck screws are in place.

Precautions: • Do not bend the Kirschner wire while drilling as

this may result in failed correction.• If there is extreme coxa valga, the positioner must

be placed more distally to prevent the neck screw from perforating the piriformis fossa.

• If extension or flexion is required at the osteotomy, the aiming block with the positioner has to be ro-tated accordingly before insertion of the Kirshner wires.

Axial AP view

1

2




3Insert Kirschner guide wires for proximal screws













Insert the Kirschner guide wires for holes A and B with the help of the aiming block (1). To prevent any interfer-ence with other wires adjust the Kirschner wire adaptor before inserting Kirschner guide wire for hole B (2).

In order to assure an optimal screw length place the Kirschner guide wires as close as possible to the growth plate (maximum distance to the growth plate of the femoral head 5 mm).


Precaution: If extension or flexion is required the aiming block has to be rotated accordingly around the positioning Kirscher wire (hole D) before inser-tion of the guiding Kirschner wire for proximal screws.

3

4




With the Kirschner guide wires for holes A and B, the position and length of the screws are defined while, at the same time, the holes are predrilled for the 3.5 mm screws.

When the Kirschner guide wires are inserted correctly, remove the aiming block and positioner for aiming block.

Precautions:• Do not bend the positioning Kirschner wire with

the aiming block while inserting the guide wires as this may result in failed correction.

• Once a guiding Kirschner wire is inserted, flexion or extension correction will not be able any more.

Note: To remove the positioner and aiming block loosen the hex screw on the positioner.

Precaution: Verify the optimal position of the Kirschner wires with the image intensifier in the AP and axial views. (3, 4) Do not penetrate the epiphy-sis.

AP view

Axial AP view

3

1

2


Instruments





The optimal position of the osteotomy for the 3.5 mm plate is 18 mm distal to the Kirschner guide wires. Determine the distance with the corresponding end of the positioner for osteotomy (1). Hold the positioner for osteotomy against the two Kirschner guide wires and mark the distance with the oscillating saw or another sharp instrument on the bone.

Perform the osteotomy in one cut – with an oscillating saw and constant irrigation and cooling – perpendicular to the femoral shaft. (3)

Note: If there is extreme coxa vara the osteotomy cut has to be 3–4 mm further distal, otherwise the distance for the calcar screw is too short.

Note for 5.0 mm plate: The optimal position of the osteotomy is 23 mm distal to the Kirschner guide wires.

Precaution: In case of a planned derotation or rota-tion osteotomy, insert Kirschner wires bicortically into the greater trochanter and the distal fragment (either the shaft or the knee) to control the derota-tion or rotation. The positioning plates are used to adjust the correction angle of rotation/derotation. Even if no derotation or rotation is planned it is rec-ommended to insert the two Kirschner wires or to make a mark onto the bone. This ensures that the two bone fragments are fixed in the right position. (2)

OSTEOTOMY

2

1



PROXIMAL FIXATIONFixation in the proximal fragment must always be done with locking screws. Ensure that the locking screws are at least 5 mm away from the growth plate of the femo-ral head.

1Position plate








Insert drill sleeves into plate holes A and B. Tighten the sleeves with the wrench of the positioner for osteotomy. Slide the plate over the Kirschner guide wires and the positioning Kirschner wire. (1)

Notes: • In case of a slight misfit of the proximal fragment,

it is acceptable to remove a small bone wedge.• Fix the proximal fragment (femoral neck/head

fragment) with forceps taking care not to disturb the positioning of the plate. This provides better handling of the proximal fragment in terms of ro-tation. (2)

Note for 5.0 mm plate: An additional reduction sleeve must be inserted in each LCP drill sleeve be-fore sliding the plate over the wires.


2Determine screw length and insert femoral neck screws A and B

Instrument


Determine the screw length by measuring the insertion depth of the Kirschner guide wire with the direct mea-suring device for Kirschner guide wires. Slide the appro-priate end of the measuring device over the Kirschner guide wire against the LCP drill sleeve and determine the proper screw length, which will typically be the next size smaller than what was measured. Remove the LCP drill sleeve and the Kirschner guide wire in hole A. If neces-sary use the wrench at one end of the positioner for os-teotomy.


Note: If the positioning Kirschner wire has already been removed, for screw insertion it has to be rein-serted in hole D since it protects against rotation during screw insertion.

Note for 5.0 mm plate: Remove the reduction sleeve and enlarge the hole from 2.8 mm to 4.3 mm with the LCP drill bit. Then follow the instructions as de-scribed in step 2.



Proximal Fixation




314.116 Screwdriver Shaft Stardrive 3.5, T15, self-holding, for AO/ASIF Quick Coupling






314.164 Screwdriver Stardrive 4.5/5.0, T25, with Groove, length 240 mm


Option A – Manual insertionTo insert the locking screw manually, attach the handle for torque limiter to the torque limiter and insert a screwdriver shaft. Insert the locking screw, and lock it in the plate.

Note: The optimum torque is reached after one click.


Option B – Insertion with a power toolTo insert the locking screw using a power tool, pick up the locking screw and insert it into the plate hole until the screw head is slightly above the plate.

Precaution: Do not fully tighten the screw with the power tool.

Note: Always perform final tightening by hand. Uncouple the power tool, mount the handle, torque limiting attachment, screwdriver shaft and manu-ally tighten the screw. The optimum torque is reached after one click.

Insert the screw in hole B in the same way as in hole A. Then remove the positioning Kirschner wire in hole D.


3Insert calcar screw in hole C
















Proximal Fixation

4

3

1

2


Mount the LCP Drill sleeve onto hole C (1) and drill the hole for the calcar screw (2) with the LCP drill bit through both cortices. Remove the LCP drill sleeve and determine the screw length with the depth gauge.

Note: Do not fully tighten the screw with the power tool. Always perform final tightening by hand. Uncouple the power tool, mount the handle and manually tighten the screw. The optimum torque is reached after one click.

Insert the screw in hole C. (3, 4)

1


Instrument


For an optimal fixation, the plate must be aligned with the axis of the femoral shaft. When the plate is aligned, fix it with the reduction forceps. (1)

Precaution: If the plate is not aligned parallel to the femoral shaft in the AP view it can lead to varia-tions of the planned neck/shaft (CCD) angle.

If additional extension or flexion is required, the plate will no longer be aligned with the femoral shaft, making fixation more difficult due to the skewed position of the plate.

Note: The alignment can be facilitated with LCP drill sleeves in the distal part of the plate and /or with a forceps fixed on the proximal part. These in-struments serve as handles during the repositioning of the osteotomy.


Proximal Fixation


DISTAL FIXATIONSince this plate is an LCP plate, either locking or cortex screws can be used in the shaft. To achieve compression, always insert a cortical screw prior to any locking screws.

Option A: Distal fixation with locking screwsInsert screws in holes 1, 2 and 3.



314.119 Screwdriver Shaft Stardrive 4.5/5.0, T25, self-holding, for AO/ASIF Quick Coupling














1

2



Distal Fixation

Screw the LCP drill sleeves into the locking portion of combi holes 1, 2 and 3 until they are completely gripped by the thread (1).

Drill the screw hole using an appropriate drill bit. Remove the drill sleeve. Determine the screw length with the depth gauge. Insert the screws in holes 1, 2 and 3 (2).

Note: Do not fully tighten the screw with the power tool. Always perform final tightening by hand. Uncouple the power tool, mount the handle and manually tighten the screw. The optimum torque is reached after one click.

1

2


Alternative Surgical TechniqueLCP Pediatric Hip Plates 3.5 and 5.0

PREOPERATIVE PLANNINGSurgical technique based on the plate/screw angleIn this technique the plate/screw angle defines the final neck shaft angle as the screws are inserted along the axis of the femoral neck in the AP view (1). It is suitable when the final desired angle conforms to one of the plate angles. The plate angle defines the final correction angle (2).

1

2




1Position patient

Position the patient in the supine (1) or lateral (2) posi-tion on the radiolucent table. Then position the image intensifier so that the visualization of the hip is possible in AP and axial views.

2Approach





Instrument

292.790 Kirschner Wire B 2.0 mm with threaded tip, length 150/15 mm, Stainless Steel

Place the Kirschner wire on the ventral aspect of the femoral neck to determine the anteversion. Control the parallel alignment of the Kirschner wire with the center-line of the femoral neck under the image intensifier

Note: Position the Kirschner wire at a downward angle to avoid interference with the aiming block.

Axial AP view

2

1










03.108.002 Aiming Block for screws B 5.0 mm, for LCP Pediatric Hip Plates



Assemble the positioner and the aiming block. Do not tighten the hex screw. (1)

Insert the positioning Kirschner wire parallel to the initial positioned anteversion guide wire in axial view so that the Kirschner wire corresponds exactly with the anti- torsion (AT) angle in line with the intermediary femoral neck. (2)

3

4


Precaution: All following steps refer to the position-ing Kirschner wire, therefore the exact position is crucial for a successful surgery.

Verify the optimal placement of the positioning Kirschner wire with the image intensifier. (3, 4)

Notes:• If additional extension or flexion is required the

aiming block has to be positioned accordingly.• The two front spikes of the aiming block must be

in contact with the femur.• The positioning Kirschner wire stays inserted un-

til the two neck shaft screws are fixed.

Precaution: Do not bend the Kirschner wire while drilling as this may result in failed correction.

If the insertion of the positioning Kirschner wire is satis-factory, follow step 3 on page 78.

Axial AP view

AP view


Surgical Technique

LCP PEDIATRIC CONDYLAR PLATE 90°, 3.5 AND 5.0 FOR DISTAL FEMUR OSTEOTOMIES

CLINICAL CASESCase 1*

Preoperative, AP10 years old male with spastic diplegia.

Preoperative, lateralFrac§ture of the inferior pole of the patella as a sign of high stress caused by fixed flexion contrac-ture of 30°.

Postoperative, AP and lateralAnatomical position of the plate in AP view following supracondylar extending osteotomy with 30° of exten-sion and 15° of external rotation shown in lateral view. This procedure was combined with patellar tendon shortening.

Preoperative, AP and lateral8 year old girl with arthrogryposis multiplex congenita and bilateral severe, fixed knee flexion deformity.

Postoperative, AP and lateralEight weeks after bilateral supracondylar 25° extension osteotomy with complete consolidation.

Case 2*


* Images provide with permission from Prof. Dr Reinald Brunner and Dr Erich Rutz, MD Children’s University Hospital of Basel, UKBB, Switzerland

Case 3*

Preoperative, AP and lateral17 years old male with spastic diplegia and fixed flexion contracture of 25°.

Postoperative, AP and lateralComplete consolidation after one year.

Postoperative, AP and lateralSix weeks after bilateral supracondylar extension osteot-omy of 25° and 20° of external rotation stable correction is shown.


Surgical TechniqueLCP Pediatric Condylar Plate 90°, 3.5 and 5.0

PREOPERATIVE PLANNINGPreoperative planning of osteotomies of the distal femur is different from that for hip osteotomies.

The principles, however, are identical:

1. Decide what corrections in what planes are required. This may be achieved by a combination of clinical exami nation, x-rays (for example long leg views for alignment), CT scans (to assess femoral torsion) or frequently through examination under anesthesia

2. Decide how the implant should be placed to achieve the correction e.g. bone wedges to be excised, open-ing wedges to be created (unusual in the distal femur due to the neurovascular structures), shortening of the femur required to relax for soft tissues (common in neurological disease with contracture)

Note: The condylar plate is contoured such that dis-tal screws will be at 90° to the midline of the shaft if the plate is fitted on the surface of the bone. Gen-erally, the distal screws should be parallel to the growth plate in the coronal plane, although care must be taken to establish that there is no deformity of the distal fragment that would negate this as-sumption.

A

C

1

2

3

DB


Plate type

This technique guide focuses on the LCP Pediatric Con-dylar Plates 3.5 and 5.0 and describes the options of axial corrections in the distal femur.

The pictures represent the LCP Pediatric Condylar Plate 3.5 (corresponding to implant Art. No. 02.108.410). The surgical technique involves the use of screw holes where applicable. Please see the designation of each hole as indicated.

The surgical technique described is based on a 30° ex-tension and 30° external rotation osteotomy.

A, B, C: Distal locking screwsD: Positioning Kirschner wire1, 2 and 3: Locking or cortical screws




1Positioning and preparation of the patient

The operation is performed with the patient supine on a radiolucent table. The whole leg is prepared up to the inguinal region.

Note: In difficult cases it may be advisable to pre-pare both legs to allow a visual check of both legs.

2Approach

A standard lateral approach to the distal femur reflecting the vastus lateralis anteriorly should be used. The level of the incision should be determined under image intensi-fier control.

Note: The use of a sterile tourniquet may facilitate the approach.



1Localize the frontal plane of the distal femur

Instrument

292.200 Kirschner Wire B 2.0 mm with trocar tip, length 150 mm, Stainless Steel

After subperiosteal preparation of the distal femur, place a Kirschner wire extra-periosteally over the front of the femur 1 cm above the physis or by rotating the leg under image intensifier control until the patella is perfectly an-terior and in the midline. Check the alignment of the Kirschner wire in the frontal plane.

2

1













Assemble the positioner and the aiming block accord-ingly (1).

Localize distal femoral growth plate under image intensi-fier control.

The insertion point for the positioning Kirschner wire depends on the age and size of the patient. For the 3.5 mm plate insertion is 1.0–2.0 cm and the 5.0 mm plate 1.5–2.5 cm above the distal physis.

Note: In extension osteotomy the insertion point will need to be more proximal and more posterior as the plane of the two distal screws will not be parallel to the physis in the sagittal view (2).

30°

3

4


Using the positioner/aiming block assembly to determine the angle for correction in the coronal (frontal) plane may prove difficult. This is because the cortex of the distal femur is at an angle to the line of the shaft due to the supracondylar flare. In the coronal (frontal) plane, the positioning wire is therefore inserted parallel to the physis and the positioner/aiming block assembly is used to determine the angle of correction in the sagittal plane.

Insert the positioning Kirschner wire in the appropriate hole in the aiming block (hole D) so that it is parallel to the anterior surface orientation Kirschner wire and such that when the block is rotated for the correction in the sagittal plane there will be space for the main Kirschner wires that correspond to the screws (3; 4).

When the positioning Kirschner wire is correctly posi-tioned, remove the anterior orientation Kirschner wire.




3Insert Kirschner guide wires for distal screws





03.108.040 Adapter for Kirschner Wires B 2.8 mm, for LCP Pediatric Hip Plates 3.5/5.0









03.108.040 Adapter for Kirschner Wires B 2.8 mm, for LCP Pediatric Hip Plates 3.5/5.0





1


Rotate the aiming block and positioner into the correct position for the sagittal plane correction. This can be done by calculation but is more commonly achieved by placing the positioner in line with the tibia in the posi-tion of maximum achievable extension.

Insert the 2.8 mm Kirschner guide wires for plate holes A and B through the aiming block (1).

2




To prevent any interference with other wires, adjust the Kirschner wire adapter before inserting the Kirschner guide wire for hole B. (Insertion of wire for hole B shown in red in picture 2).

1

2


OSTEOTOMYInstrument


Level of the osteotomyThe osteotomy needs to be at least 15 mm proximal to the aiming block for the 3.5 mm plate and 20 mm for the 5.0 mm plate. Make a mark with an oscillating saw (1).

Precaution: Prior to cutting, the reference wires should be inserted to allow assessment and control of rotation. In the distal fragment the initial posi-tioning wire is adequate. In the proximal fragment, a bicortical wire should be inserted such that it does not interfere with the osteotomy. It is helpful to cal-culate the rotational correction before inserting this wire so that after the osteotomy is fixed the wire lies parallel to the positioning wire in the distal frag-ment (2). If no rotational correction is planned, then clearly marking the femur with the saw may adequately control rotation.

3 4

65



Osteotomy

The first cut of the osteotomy should be parallel to the Kirschner wires and sufficiently proximal to allow the third screw in hole C to gain adequate purchase (3). If considerable sagittal plane correction is planned then that must be taken into account. If the positioner for os-teotomy is laid against the wires, this gives the minimum distance that will allow insertion of the screw in hole C.

Note: The cut is best made freehand under image in-tensifier control, keeping the blade parallel to the Kirschner wires in both planes.

Opening wedge osteotomy can be used in deformity correction. It is generally not recommended when treat-ing contracture in neurological conditions. A second cut to the osteotomy is therefore recommended in this situation and this should be made in the proximal fragment at a right angle to the line of the shaft in all planes (5). The size of the wedge is determined by preoperative planning and depending on the clinical situation.

The resulting wedge is removed (6).

Notes: • Before completing the distal cut, it is recommend

to make the proximal cut to half the diameter of the bone (4). This guarantees optimal fit of both fragments after reduction.

• When shortening is required, the fragment of bone excised will be trapezoidal rather than wedge shaped.

2

1


DISTAL FIXATION

1Position plate








Insert the drill sleeves into plate holes A and B until they are completely gripped by the thread. Slide the plate over the Kirschner guide wires and the positioning Kirschner wire (1; 2).

Note for 5.0 mm plate: An additional reduction sleeve must be inserted in each LCP drill sleeve before sliding the plate over the wires.

Note: Fixation in the distal fragment must always be done with locking screws.

2

1



Distal Fixation

2Determine screw length and insert distal femoral locking screws A and B









Determine the screw length by measuring the insertion depth of the Kirschner guide wire with the direct mea-suring device for Kirschner guide wires. Slide the appro-priate end of the measuring device over the Kirschner wire against the LCP drill sleeve and determine the proper screw length (1). Remove the Kirschner wire and the LCP drill sleeve in hole A. If necessary, use the wrench at one end of the positioner for osteotomy (2).

Insert the screw in hole A (see step 3 for insertion options).

Note for 5.0 mm plate: Remove the reduction sleeve and then measure the Kirschner wire length over the drill sleeve. Enlarge the hole from 2.8 to 4.3 mm with the LCP drill bit. Then remove the drill sleeve and insert the screw as above.

Note: It is recommended to use a power tool to insert the self-tapping screw.


3Distal fixation


511.770 Torque Limiter, 1.5 Nm, for Compact Air Drive and Power Drive









2

1



Distal Fixation

Two options are available:

Option A – Manual insertionTo insert the locking screw manually, attach the torque limiter handle corresponding to the plate size to the torque limiter and insert a screwdriver shaft. Insert the locking screw, and lock it in the plate. The optimum torque is reached after one click.

Option B – Insertion with a power toolTo insert the locking screw using a power tool, pick up the locking screw and insert it into the plate hole until the screw head is slightly above the plate.

Note: Do not fully tighten the screw with the power tool.

Always perform final tightening by hand. Uncouple the power tool, fit the handle and tighten the screw manually. The optimum torque is reached after one click using the corresponding torque limiter.

Insert the screw in hole B in the same way as in hole A (1; 2).

Note: Do not remove the positioning wire until the end of the proximal fixation.


4Insert locking screw in hole C

















1



Distal Fixation

Mount the LCP drill sleeve onto hole C and drill the hole with the LCP drill bit through both cortices. Either read off the screw length from the calibrated drill or deter-mine the screw length with the depth gauge (1).

2

3


Insert the screw in hole C (2; 3).

Notes: • Do not fully tighten the screw with the power tool.

Always perform final tightening by hand. Un-couple the power tool, mount the handle and man-ually tighten the screw. The optimum torque is reached after one click.

• Do not remove the positioning wire until distal fix-ation is achieved.

3

2

1



REDUCTIONInstruments



Reduce the plate onto the femoral shaft and check the alignment on the image intensifier (1; 2). Decide whether medialization will be required. Check visually that the plate is parallel to the shaft in the sagittal plane.

Note: After reduction, the initial positioning wire in the distal fragment lies parallel to the bicortical wire in the proximal part to achieve correct axial alignment (3).

Note: If medialization is required, follow the steps as described on pages 123–126.


PROXIMAL FIXATIONSince this is an LCP plate, either locking or cortical screws can be used. After a locking screw has been in-serted into in the proximal fragment it is not permissible to insert a cortical screw; locking screws can however be inserted after cortical screws.

Note: To achieve compression always insert a corti-cal screw prior to any locking screws.

Option A: Proximal fixation with locking screwsInsert screws in holes 1, 2 and 3.







511.771 Torque Limiter, 4 mm, for Compact Air Drive and Power Drive




314.116 Screwdriver Shaft Stardrive, 3.5, T15, self-holding, for AO/ASIF Quick Coupling






3

2

1



Proximal Fixation

Insert screw in hole 3 (3).

Notes: • Do not fully tighten the screw with the power tool.

Always perform final tightening by hand. Un-couple the power tool, mount the handle and manually tighten the screw. The optimum torque is reached after one click.

• Do not remove the positioning wire until proximal fixation is achieved.

Drill the screw hole 3 over the LCP drill sleeve using an appropriate drill bit. Either read off the screw length from the calibrated drill or determine the screw length with the depth gauge (1; 2).

4


Repeat this step for screw insertion in holes 1 and 2 (4).

Then remove the initial positioning wire in the distal fragment and the bicortical positioning wire in the proxi-mal part.



Proximal Fixation

Option B: Proximal fixation with cortical screwsInsert screws in holes 1, 2 and 3.


310.310 Drill Bit B 3.2 mm, length 145/120 mm, 2-flute, for Quick Coupling




314.119 Screwdriver Shaft Stardrive 4.5 /5.0, T25, self-holding, for AO/ASIF Quick Coupling



323.460 Universal Drill Guide 4.5 /3.2, for neutral and load position





314.041 Screwdriver Stardrive 3.5, T15, with Groove, length 200 mm





1


If cortical screw fixation is selected, this is generally because compression at the osteotomy site is desired. Using the spring-loaded drill guide without pressing the guide down on the plate, place the drill hole as proxi-mally as possible in the combi-hole to achieve compres-sion when the screw is tightened (1).

2



Proximal Fixation

Choose the appropriate size drill bit. Measure the screw length with the depth gauge and place a self-tapping cortex screw in hole 1.

Repeat this step for screw insertion in holes 2 and 3.Then remove the initial positioning wire in the distal frag-ment and the bicortical positioning wire in the proximal part. (2)


MEDIALIZATIONNote: In order to facilitate medialization, locking screws must be used throughout.






03.108.007 Instrument for medialization











03.108.007 Instrument for medialization






2

1



Medialization

Drill the screw hole and remove the drill sleeve. Deter-mine the screw length with the depth gauge and insert a locking screw (2).

Check the position throughout under image intensifier guid ance to ensure satisfactory reduction and medializa-tion.

Attach the medialization instruments to holes 1 and 3. Turn the knob on the bars until the required amount is pro truding. Then screw an LCP drill sleeve into LCP hole 2. Reduce the plate to the shaft of the femur until com-plete contact of the bars of the medialization device with the bone is achieved and hold it with the reduction forceps (1).

3


After the screw in hole 2 is securely fixed, remove the instrument for medialization in hole 1 and insert a drill sleeve. Pre-drill the screw hole and remove the drill sleeve. Determine the screw length with the depth gauge and insert a locking screw. Repeat step two for hole 3 (3).

Note: Tighten the screws manually with the torque limiter.



Medialization

Additional medialization (if required)

If the mechanical axis is not in line, additional medializa-tion is required.

1. Remove screws in holes 1 and 32. Loosen screw in hole 2 if already inserted.

It may be necessary to use a longer screw3. Place positioning plates (triangles) over holes 1 and 3

to prevent protrusion of the bar into the pre-existing holes.

4. Further adjust the knob on both medialization instru-ments in holes 1 and 3 to the new correction level.

5. Tighten screw in hole 2.6. Add screws 1 and 3.

Note: Should the correction not turn out as planned, further correction may be achieved by re-position-ing locking screws in the proximal fragment to cor-rect unintended deviation.


Unlock all screws from the plate, then remove the screws completely from the bone. This prevents simulta-neous rotation of the plate when unlocking the last locking screw.

For details regarding implant removal refer to the Surgical Technique “Screw Extraction Set” DSEM/TRM/0614/0104.

Surgical Technique

IMPLANT REMOVAL


IMPLANTS

Product range of LCP Pediatric PlatesThe product range consists of different plate sizes:• LCP Pediatric Hip Plates 2.7• LCP Pediatric Hip Plates 3.5 and 5.0• LCP Pediatric Condylar Plates 3.5 and 5.0• Available sterile or unsterile packed

For proximal femur

Plates for varus osteotomies (2.7, 3.5 and 5.0)The plates are available with screw angles of 100° or 110° and 2 (2.7) or 3 (3.5 / 5.0) distal fixation screws.

Plates for valgization osteotomies (3.5 and 5.0)The plates are available with a screw angle of 140° or 150° and 3 distal fixation screws.

Plates for fractures and rotation osteotomies (2.7, 3.5 and 5.0)The plates are available with screw angles of 120° or 130° and 2 (2.7) or 3, 4, 5, 7 or 9 (3.5 / 5.0) distal fixa-tion screws.

For distal femur

Plates for fractures and deformities (3.5 and 5.0)The plates are available with a screw angle of 90° and 3, 5 or 7 distal fixation screws.


2.7 mm Pediatric LCP Hip Plates*

Shaft Length Proximal/Distal Angle Holes (mm) Width (mm)

02.108.300 100° 2 46 12/8

02.108.301 110° 2 46 12/8

02.108.303 130° 2 46 12/8



02.108.310 100° 3 73 19/12

02.108.311 110° 3 73 19/12

02.108.313 120° 4 75 19/12

02.108.330 130° 3 62 19/12

02.108.331 130° 5 88 19/12

02.108.332 130° 7 114 19/12

02.108.333 130° 9 140 19/12

02.108.316 140° 3 70 19/12

02.108.315 150° 3 58 19/12

These implants are available or sterile-packed. * Add “S” to product number to order sterile product.




02.108.320 100° 3 90 23/15

02.108.321 110° 3 90 23/15

02.108.323 120° 4 95 23/15

02.108.340 130° 3 79 23/15

02.108.341 130° 5 111 23/15

02.108.342 130° 7 143 23/15

02.108.343 130° 9 175 23/15

02.108.326 140° 3 90 23/15

02.108.325 150° 3 74 23/15

3.5 mm Pediatric LCP Condylar Plates*


02.108.410 90° 3 75 19/12

02.108.411 90° 5 101 19/12

02.108.412 90° 7 127 19/12

5.0 mm Pediatric LCP Condylar Plates*


02.108.420 90° 3 95 23/15

02.108.421 90° 5 127 23/15

02.108.422 90° 7 159 23/15

These implants are available or sterile-packed. * Add “S” to product number to order sterile product.

Implants


Screw overviewCortex screws, self-tapping, stainless steel

202.866 – Cortex Screws Stardrive B 2.7 mm,202.969 lengths 6–60 mm

204.816 – Cortex Screws B 3.5 mm,204.860 lengths 16–60 mm

02.200.016 – Cortex Screws Stardrive B 3.5 mm,02.200.070 self-tapping, lengths 16–70 mm

214.818 – Cortex Screws B 4.5 mm, self-tapping,214.870 lengths 18–70 mm

Locking screws, self-tapping, stainless steel

202.206 – Locking Screws Stardrive B 2.7 mm 202.260 (head LCP 2.4), lengths 6–60 mm

213.016 – Locking Screws B 3.5 mm,213.060 lengths 16–60 mm

212.104 – Locking Screws Stardrive B 3.5 mm,212.124 lengths 16–60 mm

213.318 – Locking Screws B 5.0 mm,213.375 lengths 18–75 mm

212.203 – Locking Screws Stardrive B 5.0 mm,212.224 lengths 18–75 mm

All implants are also available sterile packed.Add Suffix “S” to part number.


INSTRUMENTS

Positioners for Aiming Blocks




Aiming Blocks





Positioners for Osteotomy


Drill Sleeves and Reduction Sleeve





03.108.037 Direct Measuring Device for Kirschner Wires B 2.0 mm, for LCP Pediatric Hip Plates 2.7



03.108.040* Kirschner Wire Adaptor

292.650 Guide Wire B 2.0 mm with threaded tip with trocar, length 230 mm, Stainless Steel

292.790S Kirschner Wire B 2.0 mm with threadedtip, length 150/15 mm, Stainless Steel – Sterile


292.200S Kirschner Wire B2.0 mm with trocartip, length 150 mm, Stainless Steel – Sterile

Positioning Wires, Guide Wires and Adapter

292.200.01 Kirschner Wire B 2.0 mm with trocar tip, length 150 mm, Stainless Steel

03.108.005* Kirschner Wire B 2.8 mm with spade point tip

292.160.01 Kirschner Wire B 1.6 mm w/trocar tip, L 150 mm

292.160S Kirschner Wire B 1.6 mm w/trocar tip, L 150 mm, sterile

292.120S Kirschner Wire B 1.25 mm w/trocar tip, L 150 mm, sterile

292.120.01 Kirschner Wire B 1.25 mm w/trocar tip, L 150 mm

* All Kirschner wires are available sterile. For sterile wires with * add suffix “S” to article numbers .

Instruments




Drill Bits










Drill Guides


Instruments




Depth Gauges



314.041 Screwdriver Stardrive 3.5, T15, with Groove, length 200 mm

313.302 Screwdriver Stardrive, T8, cylindrical, with Groove, shaft B 3.5 mm


Screwdrivers and Screwdriver shafts



Instruments






313.304 Screwdriver Shaft Stardrive, T8, cylindri-cal, with Groove, shaft B 3.5 mm, for AO/ASIF Quick Coupling

314.467 Screwdriver Shaft, Stardrive, SD8, self-holding


Bone Holding Forceps and Reduction Forceps





Instruments





Torque Limiters

03.110.005 Handle for Torque Limiters 0.4/0.8/1.2 Nm




Positioning Plates



Others


313.300 Combined Holding Sleeve for Cortex Screws Stardrive B 2.4/2.7 mm, T8, for Screwdriver Shafts B 3.5 mm

313.301 Holding Sleeve for LCP Screws Stardrive B 2.4/2.7 mm (head LCP 2.4), SD8, for Screwdriver Shafts B 3.5 mm

Instruments


Kay M.R., Rethlefsen P.T., Hale J.M, Skaggs D., Tolo V. (2003) J of Pediatric Orthopaedics 23: 150-154. Compar-ison of Proximal and Distal Rotational Femoral Osteot-omy in Children with Cerebral Palsy.

Mortazavi S.M.J., Heidari P., Esfandiari H., Motamedi M. (2008). J of Haemophilia 4, 85-90. Trapezoid supracon-dylar femoral extension osteotomy for knee flexion con-tractures in patients with haemophilia.

Oppenheim W.L., Fischer S.R., Salusky I. (1997). J of Pediatric Orthopaedics 17: 41-49. Surgical Correction of Angular Deformity of the Knee in Children with Renal Osteodystrophy.

Piripiris M., Trivett A., Baker R., Rodda J., Nattrass G.R., Graham H.K. (2003). J of Bone and Joint Surgery Vol 85-B. No. 2. Femoral derotation osteotomy in spastic diple-gia. Proximal or Distal?

Hefti F et al. (1998) Kinderorthopädie in der Praxis. Berlin Heidelberg New York: Springer

Morrissy R.T., Weinstein SL (2001) Atlas of Pediatric Or-thopedic Surgery. Philadelphia: Williams & Wilkins-Verlag

Müller M.E., Schneider R. et al., AO manual of internal fixation. 3rd Edition ed. 1991, Berlin-Heidelberg-New York: Springer.

Müller M.E. (1971) Die hüftnahen Femurosteotomien. 2. Auflage. Stuttgart: Thieme

Müller M.E., Allgöwer M, Schneider R, Willenegger H (1995) Manual of Internal Fixation. 3rd, expanded and completely revised ed. 1991. Berlin, Heidelberg, New York: Springer

Rüedi T.P., Buckley RE, Moran CG (2007) AO Principles of Fracture Management. 2nd expanded ed. 2002. Stutt-gart, New York: Thieme

BIBLIOGRAPHY


Torque, Displacement and Image Artifacts according to ASTM F 2213-06, ASTM F 2052-06e1 and ASTM F 2119-07Non-clinical testing of worst case scenario in a 3 T MRI system did not reveal any relevant torque or displace-ment of the construct for an experimentally measured local spatial gradient of the magnetic field of 3.69 T/m. The largest image artifact extended approximately 169 mm from the construct when scanned using the Gradient Echo (GE). Testing was conducted on a 3 T MRI system.

Radio-Frequency-(RF-)induced heating according to ASTM F 2182-11aNon-clinical electromagnetic and thermal testing of worst case scenario lead to peak temperature rise of 9.5 °C with an average temperature rise of 6.6 °C (1.5 T) and a peak temperature rise of 5.9 °C (3 T) under MRI Conditions using RF Coils (whole body averaged specific absorption rate [SAR] of 2 W/kg for 6 minutes [1.5 T] and for 15 minutes [3 T]).

Precautions: The above mentioned test relies on non-clinical testing. The actual temperature rise in the patient will depend on a variety of factors beyond the SAR and time of RF application. Thus, it is recommended to pay particular attention to the following points: • It is recommended to thoroughly monitor patients

undergoing MR scanning for perceived tempera-ture and/or pain sensations.

• Patients with impaired thermoregulation or temperature sensation should be excluded from MR scanning procedures.

• Generally, it is recommended to use a MR system with low field strength in the presence of conduc-tive implants. The employed specific absorption rate (SAR) should be reduced as far as possible.

• Using the ventilation system may further contrib-ute to reduce temperature increase in the body.

MRI INFORMATION

Synthes GmbHEimattstrasse 34436 OberdorfSwitzerlandTel: +41 61 965 61 11Fax: +41 61 965 66 00www.depuysynthes.com 0123

Not all products are currently available in all markets.

This publication is not intended for distribution in the USA.

All surgical techniques are available as PDF files at www.depuysynthes.com/ifu ©

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