DVR Anatomic Surgical Technique

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Surgical Technique

DVR® Anatomic

Volar Plating System

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DVR® Anatomic Volar Plating System

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• F.A.S.T. Guide® Technology to

simplify and speed up surgery

• Cobalt chrome multi-directional

pegs to provide the surgeon

the flexibility to adjust peg

trajectories while still creating

a strong, stable construct

Clinical Indications

The DVR® Anatomic Plate is intended for

the fixation of fractures and osteotomies

involving the distal radius.

Surgical Approaches

Simple and acute fractures can be treated

through the standard Flexor Carpi Radialis

(FCR) approach.

Intra-articular fractures, nascent malunions

and established malunions are best man-

aged through the extended form of the

FCR approach.

Introduction

Ten years ago the DVR helped change the treatment of

distal radius fractures. Through the past decade the DVR

has been continually improved and adapted to provide a

broad range of surgical options to help surgeons address

the needs of their patients. With 10 years of positive clini-

cal experience and over 300,0001 plates sold worldwide,

Biomet, Inc. is proud and honored to have participated

with Dr. Orbay and the surgeon community to advance the

art and science of fracture fixation. Biomet, Inc. is commit-

ted to providing our surgeons with the best combination of

technology and service possible in order to treat their pa-

tients. We look forward to another 10 years of innovation

and clinical success for the DVR® Anatomic Distal Radius

Plating System.

The list of DVR innovations include:

• The first implant system with divergent pegs to

capture dorsally displaced fractures from a volar

approach

• A low profile implant designed

to mimic the volar aspect of

the bone and be used as a reduction template

• Fixed angle K-wires to confirm implant placement

prior to final implantation

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The distal end of the plate is contoured to match

the watershed line and the topographic surface

of the distal volar radius

Multi-directional threaded pegs allow for angula-

tion within a cone of 20 degrees for maximum in-

teroperative flexibility of locking screw placement

F.A.S.T. Guide

®

technology allows for easy

drilling of fixed angle locking screws as well as

indicates side specific implants by color coding

Screws/Pegs Available Lengths

Smooth Pegs (Locking) 10, 12, 14, 16, 18, 20, 22, 24, 26, 28 and 30 mm

Partially Threaded Pegs (Locking) 10, 12, 14, 16, 18, 20, 22, 24, 26, 28 and 30 mm

Multi Directional Threaded Pegs (Locking) 10, 12, 14, 16, 18, 20, 22, 24, 26, 28 and 30 mm

Cortical Bone Screws 10, 12, 13, 14, 15, 16, 18 and 20 mm

Screws (Non-locking) 10, 12,14, 16, 18, 20, 22, 24, 26, 28 and 30 mm

Screws and Pegs

Oblong screw hole allows for fine tuning

of the plate position.

Proprietary divergent and converging

rows of pegs provide 3 dimensional scaf-

fold for maximum subchondral support

Ulnar most proximal fixed angle k-wire is used to reference

proper plate position as well as predict peg distribution when

using the standard technique

Locking pegs and screws provide a strong peg

to plate interface

Threaded pegs available to secure fragments in

the coronal plane

Distal fixed angle k-wire hole used to reference proper plate

position when using the distal first technique

Anatomic design of the plate matches the to-

pography of the distal radius and thus follows

the “watershed” line to provide maximum but-

tress for volar marginal fragments

Available plate sizes and lengths listed on page 18.

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DVR® Anatomic Volar Plating System

DVR® Anatomic Volar Plating System

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FCR Approach

Incision

Make an incision over the course of the flexor carpi radialis

(FCR) tendon.

A zigzag incision is made across the wrist flexion creases

to allow better access and visualization. (Figure 1)

Flexor Carpi Radialis (FCR)

Incision

Figure 2

Figure 3 Figure 1

Release the Flexor Carpi Radialis (FCR)

Tendon Sheath

Expose and open the sheath of the FCR tendon. (Figure 2)

Dissect the FCR tendon distally to the level of the superfi-

cial radial artery.

Crossing the Deep Fascia

Retract the FCR tendon towards the ulna while protecting

the median nerve. (Figure 3)

Incise through the floor of the FCR sheath to gain access

to the deeper levels.

Split the sheath of the FCR tendon distally up to the tuber-

osity of the scaphoid.

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Figure 4 Figure 5

Watershed Line

Pronator Quadratus (PQ) Incision

Mid-Level Dissection

Develop the plane between the flexor pollicis longus (FPL)

and the radial septum to reach the surface of the radius.

Develop widely the subtendinous space of parona and

expose the pronator quadratus muscle (PQ). (Figure 4)

Identifying the Watershed Line

Palpate the radius distally to identify the volar rim of the lu-

nate fossa. This establishes the location of the watershed

line. (Figure 5)

The transitional fibrous zone (TFZ) is a 1 cm wide band of

fibrous tissue located between the watershed line and the

PQ that must be elevated to properly visualise the fracture.

Release the PQ by sharply incising over the watershed line

and proximally on the lateral edge of the radius. (Figure 5)

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Figure 6 Figure 7

Brachioradialis

Elevating the Pronator Quadratus (PQ)

Use a periosteal elevator to elevate the PQ to expose the

volar surface of the radius. (Figure 6)

The fracture line on the volar cortex is usually simple,

facilitating reduction.

The origin of the FPL muscle can be partially released for

added exposure.

Note: The pronator quadratus is frequently ruptured.

Caution: Please refer to Warning and Precautions Section

on Page 21.

Release of the Distal Fragment

Release the insertion of the brachioradialis which is found

on the floor of the first compartment in a step cut fashion.

(Figure 7)

Note: The brachioradialis is the prime deforming force of

the distal fragment.

Identify and retract the APL and EPB tendons.

Note: Care should be taken to protect the radial artery.

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Figure 8 Figure 9

The Extended FCR Approach

Pronation of the proximal fragment out of the way provides

exposure to the dorsal aspect of the fracture allowing frac-

ture debridement and reduction.

Intra-Focal Exposure

Intra-focal exposure is obtained by pronating the proximal

fragment out of the way. A bone clamp facilitates this ma-

neuver. (Figure 8)

Preserve the soft tissue attachments to the medial aspect

of the proximal fragment.

Note: This is where the anterior interosseous vessels that

feed the radial shaft are located.

Provisional Fracture Reduction

After fracture debridement, supinate the proximal radius

back into place and restore radial length by reducing the

volar cortex. (Figure 9)

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Figure 10

Figure 11

Figure 12

Proximal Plate Positioning

Determine the correct position for the plate by judging how

the plate conforms to the watershed line and the volar

surface of the radius.

Using the 2.5 mm bit, drill through the proximal oblong

hole of the plate, which will allow for plate adjustments.

(Figure 10)

Measure the required screw depth using the flat side of the

Depth Gauge. (Figure 11)

Insert the appropriate length cortical screw. (Figure 12)

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Distal Plate Fixation

Final Fracture Reduction

Final reduction is obtained by indirect means using the

DVR® Anatomic Plate as a template, then applying trac-

tion, ligamentotaxis and direct pressure over the dorsal

aspect. (Figure 13)

Note: A properly applied bolster helps to maintain the

reduction.

Distal Plate Fixation

First, secure the distal fragment to the plate by inserting a

k-wire through the most ulnar k-wire hole on the proximal

row. (Figure 14) Proper plate positioning can be confirmed

by obtaining a 20-30 degree lateral. The k-wire should be

2–3 mm subchondral to the joint line on this view.

Figure 13

Figure 14 Figure 15

Drilling the Proximal Rows

Using a 2.0 mm bit, drill through the proximal single-use

F.A.S.T. Guide® starting on the ulnar side in order to stabi-

lize the lunate fossa. (Figure 15)

Note: Bend the K-wire out of the way to facilitate drilling.

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Figure 17

Figure 18 Figure 16

Gauging Through the F.A.S.T. Guide®

Assess carefully the length of the proximal row pegs with

the appropriate side of the depth gauge. (Figure 16)

Caution: Avoid excessive peg length as this can poten-

tially cause extensor tendon irritation.

Note: if the F.A.S.T. Guide® is removed before gauging the

screw depth, use the scale on the flat side of the depth

gauge.

Proximal Peg Placement

Remove each F.A.S.T. Guide® with the peg driver after

checking the drilled depth. (Figure 17)

Using the same peg driver, fill the peg holes with the ap-

propriate length peg. (Figure 18)

Note: The use of threaded pegs will help to capture dorsal

comminuted fragments.

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Final Proximal Plate Fixation

Final Plate Fixation

Fill all the holes of the distal peg row.

As the distal row converges on the proximal row between

16 mm and 18 mm, an 18 mm length peg is all that is

needed in the distal row.

Apply the remaining proximal cortical screws. (Figure 19)

SP screws are not intended to provide subchondral sup-

port and use should be limited to capture of remote bone

fragments where partially threaded pegs can not be used.

Note: The proximal row of pegs provides support to the

dorsal aspect of the articular surface. The distal row of

pegs provides support to the central and volar aspects of

the subchondral plate.

Remove all F.A.S.T. Guide® even if the peg hole is not

used.

Figure 19 Figure 20

Final Radiographs

A 20° – 30° elevated lateral fluoroscopic view allows visu-

alization of the articular surface, evaluation of volar tilt, and

confirmation for proper peg placement 2 – 3 mm proximal

to the subchondral plate. (Figure 20)

To confirm that the length of each individual peg is correct,

pronate and supinate the wrist under fluoroscopy.

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Final Appearance

A properly applied plate should be just proximal to the

watershed line and not project above or beyond it in order

to avoid contact with the flexor tendons. (Figure 21)

Wound Closure

Repair the TFZ in order to cover the distal edge of the

DVR® Anatomic Plate.

Repair the brachioradialis.

Suture the PQ to the TFZ and the repaired brachioradialis.

Figure 21

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Distal Fragment First Technique

For Established Malunions

Complete exposure and place a K-wire 2 – 3 mm proximal

to the articulating surface and parallel to the joint line.

Note: Use the K-wire hole on the distal row of the DVR®

Anatomic Plate as a guide for proper K-wire placement.

(Figure 22)

Create the osteotomy plane parallel to the K-wire. (Figure 23)

Figure 22

Figure 23

Osteotomy Plane

K-wire

Figure 24

Release the brachioradialis, then pronate the radius and

release the dorsal periosteum. (Figure 24)

Note: The location of the distal peg rows can be identified

and drilled prior to the osteotomy.

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Supinate the proximal fragment and slide the DVR®

Anatomic Plate over the K-wire. (Figure 25) The K-Wire will

assure proper restoration of volar tilt.

Fix the DVR® Anatomic Plate to the distal fragment. (Figure

26) The watershed line provides guidance for proper radio-

lunate deviation.

Figure 25

Figure 26

Figure 27

Figure 28

Once distal fixation is complete, the tail of the implant is

secured to the shaft of the radius to re-create the 12 de-

grees of normal volar tilt.

After fixation, autograft is applied and the wound closed.

(Figure 28)

Confirm postoperative results with radiographs.

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Installation of Multi Directional

Threaded Peg

Ensure that the fixed-angle pegs have been installed prior

to installing the MDTP.

Remove the F.A.S.T. Guide® using the peg driver.

Place the 2.0 mm end of the Soft Tissue Guide (STG) into

the radial styloid and/or the most ulnar hole in the proximal

row of the DVR Anatomic plate.

Note: The MDTPs are not recommended for the distal row.

Figure 29 Figure 30

Place the 2.0 mm drill bit through the STG until it comes

in contact with the bone. Determine the trajectory of the

drill bit by varying the angle of the STG and drill (Figure 29).

The MDTP’s can be successfully installed within a cone of

20 degrees off of the fixed angle trajectory.

Assemble the Multi Direct 2.0 mm insert (231211002) into

the modular handle (MQC), verifying that it is firmly at-

tached. (Figure 30)

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Figure 31

Figure 33 Figure 32

Measure the depth of the hole using the flat side of the

F.A.S.T. Bone Depth Gauge (FBDG). (Figure 31)

Load the appropriately sized MDTP into the driver. The

peg should grip the driver. (Figure 32)

Install the MDTP into the pre-drilled hole. Be careful to

keep the driver fully engaged with the peg. Install the peg

firmly until increased torque yields in no further rotation.

(Figure 33)

Note: If necessary, after installation the MDTP can be re-

moved and reinstalled to further improve positioning.

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Ordering Information

Smooth Peg, Locking

Provides subchondral support

PXX000

Diameter: 2.0 mm

10 mm – 30 mm lengths (2 mm steps)

Threaded Peg, Locking

Distal threads to capture and lag fragments

TPXX000

Diameter 2.5 mm

10 mm – 30 mm lengths (2 mm steps)

Multi Directional Threaded Peg

Provides interoperative freedom to vary the tra-

jectory of a fixed angle locking trajectory within

a cone of 20 degrees.

1312111XX

Diameter: 2.5 mm

10 mm – 30 mm lengths (2 mm steps)

Screws, Non-Locking

Fully threaded to anchor fragments for

added fixation

SPXX000

Diameter: 2.5 mm

10 mm – 30 mm lengths (2 mm steps)

Cortical Screws

Provide bicortical fixation for proximal fragments

CSXX000

Diameter: 3.5 mm

10,12,13,14,15,16, 18 and 20 mm

Pegs and Screws

DVR® Anatomic Plates

Narrow Short:

21.6 mm x 48.9 mm

DVRANSL

DVRANSR

Narrow Standard:

21.6 mm x 57.2 mm

DVRANL

DVRANR

Wide:

28.2 mm x 62.6 mm

DVRAWL

DVRAWR

Standard Short:

24.4 mm x 51.3 mm

DVRASL

DVRASR

Standard:

24.4 mm x 59.5 mm

DVRAL

DVRAR

Standard Extended:

24.4 mm x 89.5 mm

DVRAXL

DVRAXR

Standard Extra Extended:

24.4 mm x 175.3 mm

DVRAXXL

DVRAXXR

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DVR® Anatomic Plate Modular Tray

Fully modular tray system addresses multiple applications with the use of a single tray

• Reduced OR Instruments

• Improved Workflow

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DVRA Tray System Instrumentation

DG20 Drill Guide 2.0

FPD20 Peg Driver F.A.S.T.

FBDG Bone Depth Gauge F.A.S.T.

SDG Depth Gauge Sleeveless

MQC Handle Peg Driver/Handle Mini Quick Connect

BC Bone Clamp DR

MHR Retractor Mini Hohmann

STG Soft Tissue Guide DR

231211000 Modular QK Connect Handle

231211001 Captive Insert

231211002 MDTP Driver Mini Quick Connect

DVRA Plate System Cortical Screws

CS10000 Screw Cortical 3.5mm, 10mm

CS12000 Screw Cortical 3.5mm, 12mm

CS13000 Screw Cortical 3.5mm, 13mm

CS14000 Screw Cortical 3.5mm, 14mm

CS15000 Screw Cortical 3.5mm, 15mm

CS16000 Screw Cortical 3.5mm, 16mm

CS18000 Screw Cortical 3.5mm, 18mm

CS20000 Screw Cortical 3.5mm, 20mm

DVRA Plate System

DVRAR DVR Anatomic Standard Right

DVRAL DVR Anatomic Standard Left

DVRAXR DVR Anatomic Ext Right

DVRAXL DVR Anatomic Ext Left

DVRASR DVR™ Anatomic Short Right with F.A.S.T. Guides

DVRASL DVR™ Anatomic Short Left with F.A.S.T. Guides

DVRANR DVR™ Anatomic Narrow Right with F.A.S.T. Guides

DVRANL DVR™ Anatomic Narrow Left with F.A.S.T. Guides

DVRANSR DVR™ Anatomic Narrow Short Right with F.A.S.T. Guides

DVRANSL DVR™ Anatomic Narrow Short Left with F.A.S.T. Guides

DVRAWR DVR™ Anatomic Wide Head Right with F.A.S.T. Guides

DVRAWL DVR™ Anatomic Wide Head Left with F.A.S.T. Guides

DVRAXXR DVR™ Anatomic Extra Ext Right with F.A.S.T. Guides

DVRAXXL DVR™ Anatomic Extra Ext Left with F.A.S.T. Guides

Disposables:

FDB20 Drill Bit F.A.S.T. 2.0mm

DB25 Drill Bit 2.5mm

KW062SS KWIRE 1.6MM SS

DVRA Steel Tray

DRT Sterilization Tray DVR Anatomic

DRTSC Screw Caddy DRT

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DVR® Anatomic Volar Plating System

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Multidiectional threaded Pegs (MDTP)

131211110 Peg Thread Multidir 2.5X10Mm

131211112 Peg Thread Multidir 2.5X12Mm

131211114 Peg Thread Multidir 2.5X14Mm

131211116 Peg Thread Multidir 2.5X16Mm

131211118 Peg Thread Multidir 2.5X18Mm

131211120 Peg Thread Multidir 2.5X20Mm

131211122 Peg Thread Multidir 2.5X22Mm

131211124 Peg Thread Multidir 2.5X24Mm

131211126 Peg Thread Multidir 2.5X26Mm

131211128 Peg Thread Multidir 2.5X28Mm

131211130 Peg Thread Multidir 2.5X30Mm

Screw Pegs (Non-Locking)

SP10000 Peg Screw 2.5mm, 10mm

SP12000 Peg Screw 2.5mm, 12mm

SP14000 Peg Screw 2.5mm, 14mm

SP16000 Peg Screw 2.5mm, 16mm

SP18000 Peg Screw 2.5mm, 18mm

SP20000 Peg Screw 2.5mm, 20mm

SP22000 Peg Screw 2.5mm, 22mm

SP24000 Peg Screw 2.5mm, 24mm

SP26000 Peg Screw 2.5mm, 26mm

SP28000 Peg Screw 2.5mm, 28mm

SP30000 Peg Screw 2.5mm, 30mm

Threaded Pegs

TP10000 Peg Thread 2.5mm, 10mm

TP12000 Peg Thread 2.5mm, 12mm

TP14000 Peg Thread 2.5mm, 14mm

TP16000 Peg Thread 2.5mm, 16mm

TP18000 Peg Thread 2.5mm, 18mm

TP20000 Peg Thread 2.5mm, 20mm

TP22000 Peg Thread 2.5mm, 22mm

TP24000 Peg Thread 2.5mm, 24mm

TP26000 Peg Thread 2.5mm, 26mm

TP28000 Peg Thread 2.5mm, 28mm

TP30000 Peg Thread 2.5mm, 30mm

Smooth Pegs

P10000 Peg Smooth 2.0mm, 10mm

P12000 Peg Smooth 2.0mm, 12mm

P14000 Peg Smooth 2.0mm, 14mm

P16000 Peg Smooth 2.0mm, 16mm

P18000 Peg Smooth 2.0mm, 18mm

P20000 Peg Smooth 2.0mm, 20mm

P22000 Peg Smooth 2.0mm, 22mm

P24000 Peg Smooth 2.0mm, 24mm

P26000 Peg Smooth 2.0mm, 26mm

P28000 Peg Smooth 2.0mm, 28mm

P30000 Peg Smooth 2.0mm, 30mm

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Notes

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DVR® Anatomic Volar Plating System

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DVR® Anatomic Plate

Important

This Essential Product Information sheet does not include all of the

information necessary for selection and use of a device. Please

see full labelling for all necessary information.

Indications (DVR

®

Anatomic and DNP

®

Anatomic Systems)

The Distal Radius Fracture Repair System is intended for the

fixation of fractures and osteotomies involving the distal radius.

Indications (Fragment Plate System)

The Fragment Plate System is intended for essentially non-load

bearing stabilization and fixation of small bone fragments in fresh

fractures, revision procedures, joint fusion and reconstruction of

small bones of the hand, foot, wrist, ankle, humerus, scapula,

finger, toe, pelvis and craniomaxillofacial skeleton.

Contraindications

If any of the following are suspected, tests are to be performed

prior to implantation. Active or latent infection. Sepsis. Insufficient

quantity or quality of bone and/or soft tissue. Material sensitivity.

Patients who are unwilling or incapable of following post operative

care instructions.

Warning and Precautions

Although the surgeon is the learned intermediary between the

company and the patient, the important information conveyed

in this document should be conveyed to the patient. The patient

must be cautioned about the use, limitations and possible adverse

effects of these implants. The patient must be warned that failure

to follow postoperative care instructions may cause the implant or

treatment to fail.

An implant must never be reused. Previous stresses may have

created imperfections that can potentially lead to device failure.

Protect implant appliances against scratching or nicking. Such

stress concentration can lead to failure.

Orthopaedic instrumentation does not have an indefinite functional

life. All re-usable instruments are subjected to repeated stresses

related to bone contact, impaction, routine cleaning and sterilization

processes. Instruments should be carefully inspected before each

use to ensure that they are fully functional. Scratches or dents can

result in breakage. Dullness of cutting edges can result in poor

functionality. Damaged instruments should be replaced to prevent

potential patient injury such as metal fragments into the surgical

site. Care should be taken to remove any debris, tissue or bone

fragments that may collect on the instrument. Most instrument

systems include inserts/trays and a container(s). Many instruments

are intended for use with a specific implant system. It is essential

that the surgeon and operating theatre staff are fully familiar

with the appropriate surgical technique for the instruments and

associated implant, if any.

• Do NOT open the volar wrist capsule. Doing so may cause

devascularisation of the fracture fragments and destabilisation

of the volar wrist ligaments.

• If necessary, contour the DVR

®

Anatomic plate in small incre-

ments. Excessive contouring may weaken or fracture the plate.

• Exercise care when bending the fragment plates to avoid

weakening or fracture of the plates.

• Ensure removal of all F.A.S.T. Guide

®

inserts after use.

• Do NOT use fully threaded pegs (FP) with the DVR

®

Anatomic

and DNP

®

Anatomic plates. The fully threaded pegs (FP) are

designed for use with the fragment plates.

• Do NOT use peg/screw lengths that will excessively protrude

through the far cortex. Protrusion through the far cortex may

result in soft tissue irritation.

• SP series screws are NOT intended to provide subchondral

support and use should be limited to capture of remote bone

fragments where partially or fully threaded pegs cannot be

used.

• Do NOT permanently implant K-wires through the holes of the

plate as they may back out and cause tissue damage. Use of

the K-wires allows you to provisionally secure the plates to the

anatomy.

• Do NOT use the MDTPs in the distal row of the DVR

®

Anatomic Plate. The MDTPs are intended to be used

only with the DVR

®

Anatomic plates. Ensure the MDTPs

are installed after insertion of the fixed angle pegs.

Adverse Effects

The following are possible adverse effects of these implants:

potential for these devices failing as a result of loose fixation and/or

loosening, stress, excessive activity, load bearing particularly when

the implants experience increased loads due to a delayed union,

nonunion, or incomplete healing.

Note: It is NOT required to remove F.A.S.T. Guide

®

inserts to

sterilize the plate.

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References

1. Biomet Internal Sales Data

All trademarks herein are the property of Biomet, Inc. or its subsidiaries unless

otherwise indicated.

This material is intended for the sole use and benefit of the Biomet sales force and

physicians. It is not to be redistributed, duplicated or disclosed without the express

written consent of Biomet.

For product information, including indications, contraindications, warnings, precautions

and potential adverse effects, see the product labeling.

P.O.Box587,Warsaw,IN46581-0587•800.348.9500x1501

©2012BiometOrthopedics•biomet.com

FormNo.BMET0011.0•REV053112

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