Cable Ready Greater Trochanteric Reattachment Surgical Technique 97 2232 107 00 Rev 3 07 2010
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Cable-Ready® Greater Trochanteric Reattachment Surgical Technique 1 Cable-Ready Greater Trochanteric Reattachment Surgical Technique Cable-Ready Greater Trochanteric Reattachment Surgical Technique Table of Contents Surgical Technique for Cable-Ready Short GTR Plate Cable Insertion Impaction Tensioning and Locking the Cable 2 2 2 Surgical Technique for Cable-Ready Long GTR Plate Cable Insertion Impaction Tensioning and Locking the Cable 3 3 4 Surgical Technique for Cable-Ready Extended GTR Plate Cable Insertion Impaction Fracture Reduction Tensioning and Locking the Cable Instruments and Implants 5 5 5 6 7 2 Cable-Ready Greater Trochanteric Reattachment Surgical Technique Short Integral Crimp GTR Surgical Technique Cable Insertion Individual cables may be inserted into the GTR before or after the GTR is attached to the bone. However, the cables must be inserted into the GTR prior to passing the cable around the femur. Two cables are included with the GTR device. Should the most distal cable be necessary, it is not packaged with the device but is available separately (item #00-2232-004-18). Note: Cables can be passed from medial to lateral or lateral to medial depending on surgeon preference. Place the first cable just distal to the lesser trochanter, and the second cable distal to the first cable. Do not place the cable directly around the prosthesis. Impaction Screw the Impact Driver into the GTR. Impact the GTR onto the greater trochanter. The upper hooks should engage and wrap around the superior portion of the trochanter (Fig. 2). In the usual lateral approach to the femur, insert the cable into the posterior side of the GTR (transverse hole without the set screw), and pull until the plug countersinks into the plate. Pass the large Cable Passer around the proximal femur from posterior to anterior. Insert the free end of the cable into the tip of the Cable Passer until the cable is seen exiting from the shaft of the Cable Passer (Fig. 1). Withdraw the Cable Passer, leaving the cable around the bone. Insert the cable through the transverse hole with the Cable Passer. Tensioning and Locking the Cable It is recommended to use a cable at each transverse pair of holes. Whether or not a cable is utilized at a particular location in the GTR, all set screws must be seated at completion of the procedure. To tension the cable, insert the Cable Plate Tensioner Bit (#00-2232-009-00) into the tensioner. Thread the cable completely through the tensioner and pull the slack out of the cable. Depress the lever at the back end of the tensioner to lock the cable. To remove any remaining slack in the cable, depress the button on the tensioner and pull out the excess slack. Rotate the handle of the tensioner clockwise until the desired tension is achieved (Fig. 3). Tensioner Cable Plate Tensioner Bit Impact Driver Fig. 3 Fig. 2 Cable Passer Fig. 1 If an osteotomy was performed, use the Impact Driver as a guide and advance the greater trochanter onto a good bed of bleeding bone. Note: The most common reason for nonunion of the greater trochanter is poor or inadequate bone contact between the greater trochanter and proximal femur. The following tensioning sequence is recommended. Tension the cables in proximal to distal direction, using the tensioner bits to hold the tension. Note: If a third cable is desired when using the Short GTR, an externally crimped cerclage cable (#00-2232-00418) can be passed through the distal hole, and tensioned using the Cerclage Attachment Bit (#00-2232-008-00). Start proximally and work distally, tensioning each cable and locking by screwing in the appropriate set screw in the GTR. 3 Cable-Ready Greater Trochanteric Reattachment Surgical Technique Note: Whether or not all cable locations are utilized, all set screws should be locked down at the completion of the procedure. Long Integral Crimp GTR Surgical Technique After each set screw is firmly seated (Fig. 4), the tensioner and bits are removed and the excess cable is cut off flush with the GTR (Fig. 5). Cable Insertion Individual cables may be inserted into the GTR before or after the GTR is attached to the bone (Fig. 6). However, the cables must be inserted into the GTR prior to passing the cable around the femur. Pass the large Cable Passer around the proximal femur from posterior to anterior. Insert the free end of the cable into the tip of the Cable Passer until the cable is seen exiting from the shaft of the Cable Passer. Withdraw the Cable Passer, leaving the cable around the bone. Insert the cable through the transverse hole with the set screw. Note: Cables can be passed from medial to lateral or lateral to medial depending on surgeon preference. Place the first cable just distal to the lesser trochanter, and the second cable distal to the first cable. Do not place the cable directly around the prosthesis. Impaction Cable Passer Hex Screwdriver Screw the Impact Driver into the GTR. Impact the GTR onto the greater trochanter. The upper hooks should engage and wrap around the superior portion of the trochanter (Fig. 8). Fig. 6 Fig. 4 In the usual lateral approach to the femur, insert the cable into the posterior side of the GTR (transverse hole without the set screw), and pull until the plug countersinks into the plate (Fig. 7). Fig. 5 Plug Countersinks into plate Fig. 7 Fig. 8 4 Cable-Ready Greater Trochanteric Reattachment Surgical Technique If an osteotomy was performed, use the Impact Driver as a guide and advance the greater trochanter onto a good bed of bleeding bone. Note: The most common reason for nonunion of the greater trochanter is poor or inadequate bone contact between the greater trochanter and proximal femur. The following tensioning sequence is recommended. Tension the two proximal cables first, using the tensioner bits to hold the tension. The distal cables in the plate section of the Long GTR can then be tensioned, again using the Bone Plate Tensioner Bits to hold the tension (Fig. 10). The set screws are not locked down at this time. Tensioning and Locking the Cable It is recommended to use a cable at each transverse pair of holes. Whether or not a cable is utilized at a particular location in the GTR, all set screws must be seated at completion of the procedure. To tension the cable, insert the Cable Plate Tensioner Bit (#00-2232-009-00) into the tensioner. Thread the cable completely through the tensioner and pull the slack out of the cable. Depress the lever at the back end of the tensioner to lock the cable. To remove any remaining slack in the cable, depress the button on the tensioner and pull out the excess slack. Rotate the handle of the tensioner clockwise until the desired tension is achieved (Fig. 9). Fig. 10 Start proximally and work distally, tensioning each cable and locking by screwing in the appropriate set screw in the GTR. Note: Whether or not all cable locations are utilized, all set screws should be locked down at the completion of the procedure. After each set screw is firmly seated, the tensioner and bits are removed and the excess cable is cut off flush with the GTR (Fig. 11). Hex Screwdriver Fig. 9 Fig. 11 Cable Cutters 5 Cable-Ready Greater Trochanteric Reattachment Surgical Technique Extended Integral Crimp GTR Surgical Technique Cable Insertion Individual cables may be inserted into the GTR before or after the GTR is attached to the bone (Fig. 12). However, the cables must be inserted into the GTR prior to passing the cable around the femur. Cable Passer Pass the large Cable Passer around the proximal femur from posterior to anterior. Insert the free end of the cable into the tip of the Cable Passer until the cable is seen exiting from the shaft of the Cable Passer. Withdraw the Cable Passer, leaving the cable around the bone. Insert the cable through the transverse hole with the set screw. Note: Cables can be passed from medial to lateral or lateral to medial depending on surgeon preference. Place the first cable just distal to the lesser trochanter, and the second cable distal to the first cable. Do not place the cable directly around the prosthesis. Fracture Reduction The order of cable insertion depends upon the fracture pattern, particular use or situation. The cables can be loosely tensioned by hand and held with retensioning bits. The bone fragments are then manipulated and final reduction accomplished. Extended GTR Tech Tip #2 - If cables are inserted and pre-tensioned proximally and on each end of the plate section of the Extended GTR, the GTR and bone can be grossly stabilized (Fig. 14). The cables are very useful in holding the reduction while cortical bone screws are inserted. Extended GTR Tech Tip #1 - the cables may be harder to insert at the distal end of the GTR if access is limited due to the muscles, so it may be easier to insert the distal cables into the GTR prior to inserting the GTR. Impaction Fig. 12 In the usual lateral approach to the femur, insert the cable into the posterior side of the GTR (transverse hole without the set screw), and pull until the plug countersinks into the plate (Fig. 13). Plug Countersinks into plate Fig. 13 Screw the Impact Driver into the GTR. Impact the GTR onto the greater trochanter. The upper hooks should engage and wrap around the superior portion of the trochanter. If an osteotomy was performed, use the Impact Driver as a guide and advance the greater trochanter onto a good bed of bleeding bone. Note: The most common reason for nonunion of the greater trochanter is poor or inadequate bone contact between the greater trochanter and proximal femur. Fig. 14 6 Cable-Ready Greater Trochanteric Reattachment Surgical Technique Tensioning and Locking the Cable It is recommended to use a cable at each transverse pair of holes. Whether or not a cable is utilized at a particular location in the GTR, all set screws must be seated at completion of the procedure. To tension the cable, insert the Cable Plate Tensioner Bit (#00-2232-009-00) into the tensioner. Thread the cable completely through the tensioner and pull the slack out of the cable (Fig. 15). Extended GTR Tech Tip #3 - Once the cables are pre-tensioned and the fracture is reduced, cortical screws can be inserted through the applicable slots in the GTR (Fig. 16). Screws add rotational stability, while cables add bending strength to the construct. Because cables do not provide rotational stability, cortical screws should always be used on both sides (proximal and distal) of the fracture, even if only unicortical screws are used (4.5mm Trilogy® Acetabular System Cortical Bone Screw Fixation or NexGen® Complete Knee Solution Osteotomy Screws are recommended). Cables should not be locked down until after screws are added, because the addition of screws will fixate the GTR to the bone and may loosen the tension in the cables. After screws have been added to the GTR, the cables can be brought to final tension. Start proximally and work distally, tensioning each cable and locking by screwing in the appropriate set screw in the GTR (Fig. 17). Note: Whether or not all cable locations are utilized, all set screws should be locked down at the completion of the procedure. Fig. 17 After each set screw is firmly seated, the tensioner and bits are removed and the excess cable is cut off flush with the GTR (Fig. 18). Fig. 15 Depress the lever at the back end of the tensioner to lock the cable. To remove any remaining slack in the cable, depress the button on the tensioner and pull out the excess slack. Rotate the handle of the tensioner clockwise until the desired tension is achieved. The following tensioning sequence is recommended. Tension the two proximal cables first, using the tensioner bits to hold the tension. The distal cables in the plate section of the 4-hole and 5-hole Extended GTRs can then be tensioned, again using the Cable Plate Tensioner Bits to hold the tension. The set screws are not locked down at this time. Fig. 16 Fig. 18 Cable-Ready Greater Trochanteric Reattachment Surgical Technique Instruments and Implants Greater Trochanter Reattachment Device Prod. No. Description Size 00-2232-002-04 Integral Short GTR w/2 Cables* 23 x 53mm 00-2232-002-05 Integral Long GTR w/4 Cables* 23 x 121mm 00-2232-002-06 Extended 4-hole GTR w/4 Cables* 23 x 232mm 00-2232-002-07 Extended 5-hole GTR w/4 Cables* 23 x 261mm *Cable included is 00-2232-005-18 00-2232-004-18 Cable Assembly w/Cerclage Crimp, Cobalt-Chrome 1.8 x 635mm 00-2232-005-18 Cable for GTR Device, Cobalt-Chrome 1.8 x 635mm Bone Screws Prod. No. Description 00-6250-045-XX Trilogy Acetabular 4.5mm Cortical Bone Screws 00-5250-045-XX NexGen Osteotomy 4.5mm Cortical Bone Screws Cable Instrumentation Prod. No. Description 00-2232-000-01 Cable Instrumentation Set w/Case includes: 00-2232-005-00 Cable Tensioner for 1.8mm Cable 00-2232-006-00 Hex Head Screwdriver, 3.0mm 00-2232-007-20 Cable Passer, Medium 00-2232-007-30 Cable Passer, Large 00-2232-008-01 Cable Tensioner Bit 00-2232-009-00 Cable Plate Tensioner Bit 00-2232-011-00 GTR Impact Driver 00-3925-011-00 Cable Cutter 00-2232-095-00 Cable Instrument Case 7 Please refer to package insert for complete product information, including conrtaindications, warnings, precautions and adverse effects Contact your Zimmer representative or visit us at www.zimmer.com The CE mark is valid only if it is also printed on the product label. +H124972232011001/$100629R3G10M 97-2232-107-00 Rev. 3 1004-T33 1ML ©2001, 2008, 2010 Zimmer, Inc.
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