M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation Surgical Technique Mdn And 3

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M/DN® Femoral

Interlocking

& Recon Nail

Intramedullary

Fixation Surgical

Technique

1

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Surgical Techniques

for Fixation of

Femoral Fractures

with an M/DN Nail

Table of Contents

Introduction 2

Indications 3

Preoperative Planning 4

Patient Positioning and Radiographic Control 4

Reduction 5

Incision and Exposure 5

Creating the Entry Portal 5

Guide Wire Placement and Reaming 6

Nail Insertion 8

Interlocking Application 10

Recon Application 10

Proximal Locking 11

Interlocking Application 11

Recon Application 13

End Cap Placement 14

Distal Locking 14

Technique for Using the Freehand Targeting Device 14

Closure and Postoperative Care 17

Extraction 17

Instrument Case Options 18

2M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Fig A

Introduction

Closed intramedullary nailing has long

been a common method of treating

noncomminuted fractures of the femur

and tibia. The interlocking nail has

extended the indications of closed

intramedullary nailing to include

comminuted fractures, fractures with

bone loss, and proximal and distal

fractures of the femur.

Fig B Fig C

The multi-point fixation provided by the

cross-section of the M/DN® Nail makes

it appropriate for use unlocked (Fig. A)

as well as locked in either the dynamic

(Fig. B) or static mode (Fig. C). It also

makes it appropriate for reamed or

unreamed applications.

The successful use of any

intramedullary nail is technically

demanding. Close attention to

positioning, reduction, rod placement,

and insertion of the proximal and distal

locking screws is mandatory.

3

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Indications

The M/DN femoral nail is indicated for

use in a variety of femoral fractures

(Fig. 1), such as:

A. Comminuted fractures

B. Segmental fractures

C. Fractures with bone loss

D. Proximal and distal fractures

E. Nonunions

F. Subtrochanteric fractures

G. Intertrochanteric fractures

A Comminuted

Fracture

B Segmental

Fracture

C Fracture with

Bone Loss

D Proximal and

Distal Fractures

E Nonunions

Fig 1

F1 Subtrochanteric Fracture G1 Intertrochanteric

Fracture

4M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Surgical Technique

for M/DN Femoral

Nail Fixation

(Interlocking and Recon

Applications)

The M/DN Femoral Nail is designed for

varied use. A single nail can be used for

both right and left standard interlocking

or recon procedures. The femoral nail is

available in the most commonly used

sizes. These nails range in diameters

from 8.0mm to 16.0mm and lengths

from 24cm to 50cm.

Preoperative Planning

Proper preoperative planning is

essential to successful interlocking or

recon nailing of the femur. To determine

the appropriate nail size, an ossimeter,

roentgenogram templates, and an

x-ray film of the unaffected extremity

are necessary for determining canal

size at the isthmus and for measuring

the length of the femur to aid in

determining nail length.

The IM Nail Length Gauge or

Harris/Galante Bulb-Tip Guide Wires

(Sounds), available in diameters

from 10mm-17mm, can be used as

alternate techniques to determine

nail diameter and length.

X-rays taken at a 36-inch distance

from the x-ray source result in 10-15

percent magnification of bone. The

ossimeter has both an actual size

scale and one that takes into account

this magnification. It should be used

routinely to determine nail diameter

and length.

The proper length of nail should extend

from the tip of the greater trochanter

to the epiphyseal scar. The diameter

of the femoral nail should match the

isthmus in the lateral x-ray projection.

The surgeon should review the x-ray

to assure that there are no unusual

anatomic variations.

Patient Positioning and

Radiographic Control

The patient may be placed in either

the supine or the lateral decubitus

position (Fig. 2). In multiple trauma

patients, the supine position may be

used for easier access to the airways

as well as to facilitate the treatment

of other injuries. The supine position

also facilitates fracture reduction and

rotational alignment of the femur. The

disadvantage to the supine position

is that it impairs access to the tip of

the greater trochanter for insertion

of the nail.

It is essential to obtain excellent

A/P and lateral images of the femoral

head and neck prior to beginning the

surgery regardless of which patient

position is used.

The use of image intensification or

other x-ray imaging is required. The

image intensifier should be sterile-

draped and may be positioned from

either the contralateral or ipsilateral

side of the operating table. Confirm

visualization of the hip as well as

the shaft of the femur using image

intensification before prepping and

draping. Bend the patient’s torso away

from the affected extremity to improve

access to the greater trochanter. If

access to the greater trochanter is still

inadequate, adduct the affected leg.

However, to achieve proper alignment

of the fracture, this adducted position

must be corrected prior to insertion of

the nail.

Fig 2. Supine and lateral decubitus positions.

Supine

Lateral

5

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Reduction

It is important to reduce the

fracture before beginning the

surgical procedure.

Incision and Exposure

Begin the skin incision 1cm proximal

to the greater trochanter and carry

it proximally about 5cm in line with

the gluteus maximus muscle (Fig. 3).

A larger incision may be desired for

obese patients. Split the fascia of

the gluteus maximus in line with its

fibers. Identify the subfascial plane of

the gluteus medius, and palpate the

posterior tip of the greater trochanter.

Retract the muscles to facilitate

visualization of the piriformis fossa.

This may be difficult in the obese

patient, especially if flexion causes the

tip of the trochanter to lie against the

ilium. Positioning techniques used to

expose the tip of the trochanter include

adduction of the leg and positioning

of the patient’s torso away from the

affected extremity.

Creating the Entry Portal

Locating the correct entry portal in the

piriformis fossa is extremely important.

For the interlocking procedure, place

the Femoral Awl at the piriformis fossa

(Fig. 4) and check its position with A/P

and lateral views.

For the recon procedure, place the

Femoral Awl in the anterior portion

of the piriformis fossa approximately

5mm anterior to the position you

would choose when doing a standard

femoral nailing (Fig. 5). This will

facilitate screw placement in the

center of the femoral neck.

Check the position of the awl with both

A/P and lateral images before creating

the portal. On the A/P image, the awl

should lie at the base of the femoral

neck adjacent to the greater trochanter.

On the lateral view, it should be

oriented just posterior to the center

of the femoral neck. When the correct

position is achieved, rotate the awl to

create the entry portal for the Ball-Tip

Guide Wire.

If using the Long Cannulated Awl,

the 3.0mm Ball-Tip Guide Wire can

be inserted through the Awl.

An alternative method is to insert

a 3.2mm Steinmann Pin into the

piriformis fossa while checking the

position with A/P and lateral image

intensification. The Steinmann Pin must

lie at the base of the femoral neck just

medial to the greater trochanter on the

A/P view, and oriented just posterior to

the center of the femoral neck on the

lateral view. Seat the Steinmann Pin

well into the proximal femur and use

the optional 9mm Trochanteric Reamer

to create the entry portal (Fig. 6).

Fig 3

Entry Portal for Recon

Entry Portal for Interlocking

Fig 4

Fig 5 Fig 6

6M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Guide Wire Placement and

Reaming

Conventional Guide Wire/Exchange Tube

Technique

Attach the 3.0mm Ball-Tip Guide Wire

to the Wire-Grip T-Handle (Fig. 7) and

tighten. The Ball-Tip Guide Wire may also

be described as a Bulb-Tip or Bullet-Tip

Guide Wire. To aid in manipulation,

bend the tip of the Guide Wire at about

a 10˚angle/5cm from the end. Insert the

Guide Wire through the entry hole and

manipulate it down the proximal femur.

At the fracture site, manipulate the Guide

Wire under C-arm control (Fig. 8). Once in

the distal canal, pass the wire to its final

position in the epiphyseal scar (Fig. 9). 3.

CAUTION: If the guide wire is bent

shorter than 5cm from the end of the

wire and/or more than 10 degrees it

may be difficult to remove from the nail.

If the wire becomes lodged inside the

nail, utilize the WIRE GRIP T-HANDLE and

mallet to remove the guide wire from the

nail.

If reduction of the abducted and flexed

hip is difficult, place pressure on the

anterior aspect of the proximal fragment

either with the hand or directly with an

instrument.

Fig 9 Fig 10

The Reduction Finger can be used to

assist in femoral fracture reduction.

To use the Reduction Finger, advance

the Guide Wire and ream the proximal

segment. Pass the Reduction Finger

over the Ball-Tip Guide Wire. Manipulate

the fracture externally

while using the Reduction Finger

internally to aid in fracture reduction.

Once the Ball-Tip Guide Wire has passed

through the fracture site, the Ball-Tip

Guide Wire is advanced to epiphyseal

scar. If the Ball-Tip Guide Wire can not

advance through the fracture site, the

ball tip of the Guide Wire should be bent

slightly and then reinserted to aid in

internal reduction.

Determine the proper nail length by

placing a second guide wire of equal

length at the greater trochanter. The

length of the wire that is not overlapping

is the correct nail length (Fig. 10).

Fig 7

The 50cm Ruler or ossimeter may be

used for an accurate measurement.

Another way to measure the length

is to use the C-arm to position the 0

mark on the metal ruler at the tip of the

trochanter. Then read the correct length

at the epiphyseal scar directly off the

metal ruler.

Alternatively, the IM Nail Length Gauge

can be used to measure the appropriate

IM Nail length through measurement of

one 100cm guide wire. To use, place a

100cm Guide Wire down the medullary

canal. Slide the IM Nail Length Gauge

over the Guide Wire, ensuring that the

distal portion of the gauge is resting

on the piriformis fossa in order to

determine correct nail length. Nail length

is determined by noting the location of

the remaining Guide Wire and reading

the Nail Length Gauge at that particular

location. If the length indicated is

between two available nail sizes, it is

recommended that the shorter nail be

chosen.

NOTE: Nail Length Gauge can only be

used with 100cm Guide Wire.

Fig 8

7

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Remove the Wire-Grip T-Handle, and

place an intramedullary reamer over

the guide wire. The Pressure Sentinel®

Intramedullary Reaming System is a

system of one-piece reamers ranging

in size from 5mm diameter to 27mm

diameter in half millimeter increments.

Each reamer is composed of a fluted

reamer head, a shaft and a quick-

connect drive end. The quick-connect

end can be connected to a manual

or powered driver. The width of the

isthmus of the medullary canal is

determined by preoperative x-ray

examination. The instrument with the

smallest possible diameter is used

for initial reaming into the medullary

canal. Reamers with a diameter of 5mm

to 7.5mm use a 2.4mm Ball-Tip Guide

Wire while reamers with a diameter of

8mm to 27mm use a 3.0mm Ball-Tip

Guide Wire. As reaming continues,

the reamer size should be increased

by 0.5mm or 1.0mm increments until

an opening of the desired size is

obtained (Fig. 11).

Fig 11

NOTE: To avoid reamer lodging during

use, reaming should be immediately

stopped and the reamer retracted

when there is too much resistance.

If the reamer becomes lodged, stop

reaming immediately. Reverse the

direction of rotation of the handpiece

and back the reamer out of the canal.

The reamer can also be extracted

by snapping the T-Handle Extractor

onto the reamer end and then gently

tapping the extractor with a small

mallet or hammer.

CAUTION: Excessive blows to the

T-Handle Extractor may damage the

reamer or the extractor.

NOTE: The proximal diameter of the

8mm and 9mm M/DN Femoral Nail

is 12mm. Therefore, over ream the

proximal femur to 13mm for these nail

diameters. The proximal diameter of

the 10mm, 11mm, and 12mm M/DN

Femoral Nail is 13mm. Therefore, over

ream the proximal femur to just below

the level of the lesser trochanter to

14mm for these nail diameters.

NOTE: If the GUIDE WIRE becomes

lodged within the reamer, use the

WIRE GRIP T-Handle to push the GUIDE

WIRE back into the IM canal.

New Guide Wire Technique

Option

If using a Ball-Tip Guide Wire that does

NOT have a gold coated end OR if using

a nail less than 10mm:

When the reaming is complete and

the final measurements are made,

insert the plastic Exchange Tube

over the Ball-Tip Guide Wire. Remove

the Ball-Tip Guide Wire, and insert a

Smooth Guide Wire (Fig. 12).

If using a Ball-Tip Guide Wire that DOES

have a gold coated end and if using a

nail equal to or greater than 10mm:

The Ball-Tip Guide Wire can remain in

place. It is NOT NECESSARY to exchange

the Ball-Tip Guide Wire for a Smooth

Guide Wire. WARNING: If you are using

a Ball-Tip Guide Wire without a gold-

coated end, use the exchange tube

technique as the regular Ball-Tip Guide

Wire will not pass through the nail.

Smooth

Guide Wire

Ball-Tip

Guide

Wire

Plastic

Exchange

Tube

Fig 12

8M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Locking Bolt

Ratchet Mechanism

Femoral Proximal Guide

Femoral Guide Barrel

Fig 13

Nail Insertion

Insert the appropriate Femoral Guide

Barrel into the Femoral Proximal Guide.

There are two different Femoral Guide

Barrels (Fig. 13); one is for a right

interlocking or left recon nail, while

the other is for left interlocking or right

recon nail. It is extremely important to

use the correct barrel for the intended

procedure. The Femoral Guide Barrel

will help ensure the proper anteversion

for nail insertion. The barrel will snap

into place when fully inserted.

9

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Attach the selected nail to the Femoral

Proximal Guide (Table 1). Lift and turn

the ratchet lever 90 degrees to open

the ratchet mechanism of the guide.

Insert the Locking Bolt through the

barrel of the guide (Fig. 14).

Lift and turn the ratchet lever

90 degrees to close the ratchet

mechanism, and use the Pin Wrench

to tighten the Locking Bolt into the

proximal end of the nail (Fig. 15). A

keyway in the proximal end of the nail

will help ensure proper alignment

(Fig. 16). The ratchet mechanism will

prevent the Locking Bolt from loosening

during insertion of the nail.

NOTE: If the ratchet mechanism of

the Femoral Proximal Guide does not

operate freely, it may be necessary to

disassemble, clean, and reassemble

the mechanism. If the ratchet

mechanism becomes inoperative, it

may be removed. The assembly will

still function; however, the Locking

Bolt may loosen during the procedure.

Locking Bolt

Femoral Guide

Barrel

Unlocked Locked

Fig 14

Table 1. M/DN Femoral Recon Nails Expanded Set

Nail Length

(cm)

Nail Diameter (mm)

8 9 10 11 12 13 14 15 16

24 ••••••

26 ••••••

28 •••••••

30 •••••••••

32 •••••••••

34 •••••••••

36 •••••••••

38 •••••••••

40 •••••••••

42 •••••••••

44 •••••••••

46 ••••••••

48 •••••••

50 ••••

Pin Wrench

Fig 15

Fig 16

10 M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Interlocking Application

Verify proper alignment by inserting the

5.0mm Femoral Drill Bushing into the

8.0mm Femoral Screw Bushing; then,

insert the two nested bushings through

the interlocking hole. Insert the 5.0mm

Drill Bit through the interlocking hole.

When the device is properly aligned,

the drill will pass through the proximal

hole of the nail and will not contact the

nail (Fig. 17).

Fig 17

Femoral Drill Bushing

Femoral Screw

Bushing

Interlocking

Place the selected nail over the Ball-Tip

Guide Wire and into the femur. Screw

the Threaded Driver or Slaphammer

onto the back end of the Locking

Bolt. Begin seating the nail using

gentle impaction (Fig. 18). The mallet

can be used with the threaded driver

to make slight adjustments in depth.

While impacting the nail, use the

Femoral Proximal Guide to maintain the

proper rotation during impaction. Be

careful when crossing the fracture site.

Recon Application

Verify proper alignment by inserting the

3.2mm Femoral Pin/Drill Bushing into

the 5.0mm Femoral Drill Bushing; then,

insert these two nested bushings into

the 8.0mm Femoral Screw Bushing.

Place the three nested guide bushings

through one of the recon holes in the

Femoral Proximal Guide. Insert the

3.2mm, 14-inch Steinmann Pin through

the inner bushing. When the device is

properly aligned, the Steinmann Pin

will pass through the proximal hole of

the nail and will not contact the nail.

Fig 18

11

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

When performing the recon procedure,

slide a 14-inch Steinmann Pin

percutaneously along the anterior

aspect of the trochanter parallel to the

femoral neck. Verify pin placement

with the C-arm (Fig. 19). This will help

to identify the anteversion of the neck.

During insertion, the Femoral Proximal

Guide must remain parallel to this pin

to ensure proper anteversion for the

locking screws.

Take great care when crossing the

fracture site. Visualize the fracture in

two planes with image intensification

to assure proper passage of the nail

into the distal fragment. Reduce the

force of impaction as the proximal

end of the nail approaches the

greater trochanter.

If excessive resistance is encountered

during nail driving, remove the nail

and check the size of both the reamer

and nail. Once proper sizing has been

confirmed, the surgeon may choose to

over ream the canal further or select a

smaller size nail.

Continue to seat the nail until it is flush

with the trochanter. When the nail is

fully seated, REMOVE THE GUIDE WIRE

so it does not get trapped in the bone.

Remember, it might be concealed

inside the driver or Slaphammer.

Proximal Locking

Interlocking Application

Insert the 8.0mm Femoral Screw

Bushing through the Femoral Proximal

Guide (Fig. 20). Then insert the 5.0mm

Femoral Drill Bushing (Color Code:

Green) (Table 2), which screws into

the Femoral Screw Bushing. Insert

the 5.0mm Femoral Drill (Color Code:

Green) and drill until the medial cortex

is penetrated (Fig. 21). Remove the drill

and Femoral Drill Bushing.

Fig 20

Fig 21

Fig 19

Table 2. Implant / Instrumentation Specifications for Femoral Nails

Nail Diameter (mm) 8 9 10 11 12 13 14 15 16

Head Diameter (mm) 12 12 13 13 13 13 14 15 16

Guide Wire, Smooth (mm) 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0

Proximal Screw Size (mm) 5.5 5.5 5.5 5.5 5.5 5.5 5.5 5.5 5.5

green green green green green green green green green

Drill Bushing Size (mm) 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0

Proximal Drill Size (mm) 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0

Distal Screw Size (mm) 3.7 4.2 4.2 4.2 5.5 5.5 5.5 5.5 5.5

yellow blue blue blue green green green green green

Trocar Diameter (mm) 3.2 3.7 3.7 3.7 5.0 5.0 5.0 5.0 5.0

Distall Drill Size (mm) 3.2 3.7 3.7 3.7 5.0 5.0 5.0 5.0 5.0

Note: 4.5mm cortical interlocking screws are NOT indicated for use with the MDN system.

12 M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Use the Proximal Screw Depth Gauge to

determine screw length (Fig. 22). Then

use the T-Handle Screwdriver to insert

the appropriate length 5.5mm screw

(Color Code: Green) to the correct hash

mark (Fig. 23). Then use the C-arm to

check the position of the screw and

tighten it appropriately.

Remove the screwdriver and Femoral

Screw Bushing. Take A/P and lateral

C-arm views to check for correct

positioning. Disengage the ratchet

mechanism, then loosen and remove

the Locking Bolt and the Femoral

Proximal Guide.

NOTE: 5.5mm screws (Color Code:

Green) are used proximally for all

Femoral Nails. 3.7mm screws (Color

Code: Yellow) are used distally for all

8mm Femoral Nails. 4.2mm screws

(Color Code: Blue) are used distally for

all 9mm-11mm Femoral Nails. 5.5mm

screws (Color Code: Green) are used

distally for all 12mm-16mm Femoral

Nails.

Fig 22 Fig 23

Note: 4.5mm cortical interlocking

screws are NOT indicated for use

with the MDN system.

13

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Recon Application

Correct rotation of the nail is imperative

for retrograde insertion of the two

screws through the nail and into the

femur for the recon procedure. Be sure

that the nail is inserted to the correct

depth to allow placement of both

screws with the correct anteversion.

Insert the three nested guide bushings

through the inferior recon hole of the

Femoral Proximal Guide to the level of

the skin. Make an incision in the skin

and fascia at this point and continue

to insert the bushings until contact is

made with the lateral femoral cortex.

Drill a 14-inch Steinmann Pin into the

femoral head to the required level to

achieve fracture fragment stability

without penetrating the femoral head

cortex. Verify the proper position and

anteversion of the pin with A/P and

lateral C-arm views. Avoid excessive

twisting or torquing of the Femoral

Guide to ensure proper targeting.

The Femoral Proximal Guide is

radiolucent so it will not block the

lateral view. If the position is not

correct, remove the pin and adjust

the nail rotation and/or nail depth.

Then verify the new pin placement

with the C-arm.

Now place the second set of three

nested guide bushings into the

superior hole of the Femoral Proximal

Guide. Drill the second 14-inch

Steinmann Pin in and verify its

position with the C-arm (Fig. 24). If the

position is unacceptable, remove both

Steinmann Pins and reposition the nail.

If correct position is obtained, remove

the Threaded Driver or Slaphammer.

Then remove the inferior Steinmann Pin

and 3.2mm Proximal Pin/Drill Bushing.

Insert the 5.0mm Femoral Drill (Color

Code: Green) into the 5.0mm Femoral

Drill Bushing (Color Code: Green). Drill

the inferior proximal screw hole while

monitoring image intensification to

prevent penetration of the femoral

head (Fig. 25). Read the proper screw

length directly from the calibrated

Femoral Drill (Fig. 26). Remove the

5.0mm drill and Femoral Drill Bushing.

Insert the Recon Screw Counterbore

through the outer 8.0mm Femoral

Screw Bushing and counterbore

(Fig. 27). The blunt end of the

counterbore serves as a stop.

Screw length may alternatively be

measured using the Proximal Screw

Depth Gauge. Select a screw equal

to the measured length to avoid

penetration of the joint.

Fig 24

Fig 25

Fig 26

Fig 27

14 M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Another gauge that can be used

to measure screw length is the

Cannulated Depth Gauge. Slide the

Cannulated Depth Gauge over the

Steinmann Pin, i.e., the inferior of the

two Steinmann Pins if two pins are

used, until the gauge contacts the

lateral aspect of the femur. Assess that

the gauge is seated against the bone

using the C-arm. Read and record the

length of the Steinmann Pin from the

calibrations on the depth gauge.

NOTE: This measurement designates

the correct length of the screw to

be implanted.

Remove the counterbore. Insert the

appropriate length 5.5mm partially

threaded Recon Screw through the

outer bushing to the correct hash

mark using the T-Handle Screwdriver

(Fig. 28). Use the C-arm to ensure

proper seating of the locking screw

well within the femoral head. Tighten

it appropriately.

The first screw should lie in the inferior

neck to allow room for the second

screw to be placed. This may be

difficult in small patients or patients

Fig 28

Fig 29

with varus hips. Be certain to get

the inferior screw tight against

the medial cortex to prevent varus

deformity and allow for insertion of

the proximal screw.

Remove the T-Handle Screwdriver

and Femoral Screw Bushing. Take A/P

and lateral C-arm views to check for

correct positioning. Repeat the same

procedures for insertion of the superior

locking screw (Fig. 29). Again, observe

A/P and lateral C-arm views to ensure

proper seating within the femoral

head and neck. Disengage the ratchet

mechanism, then loosen and remove

the Locking Bolt and Femoral

Proximal Guide.

NOTE: 5.5mm recon screws (Color

Code: Candy Stripe Green) are used

proximally for the recon procedure.

3.7mm screws (Color Code: Yellow)

are used distally for all 8mm Femoral

Nails. 4.2mm screw (Color Code: Blue)

are used distally for all 9mm-11mm

Femoral Nails. 5.5mm screws (Color

Code: Green) are used distally for all

12mm-16mm Femoral Nails.

End Cap Placement

If desired, insert an M/DN End Cap of

the appropriate length (0mm, 5mm,

10mm, 15mm) in the proximal end of

the nail. These caps help protect the

internal threads of the nail, facilitate

future extraction, and allow the

surgeon to adjust the length of the nail.

Distal Locking

Technique for Using the Freehand

Targeting Device

The distal locking screws may be

inserted with a freehand technique

using the Freehand Targeting Device.

Insert an appropriate size Trocar

[3.2mm (Color Code: Yellow) for 3.7mm

screw, 3.7mm (Color Code: Blue) for

4.2mm screw, 5.0mm (Color Code:

Green) for 5.5mm screw] (Fig. 30) into

the Freehand Targeting Device. Finger

tighten the set screw.

Fig 30

Note: 4.5mm cortical interlocking screws are NOT indicated for use with the MDN system.

15

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Fig 31

Incorrect

Correct

Choose the appropriate locking hole

based on the need for dynamization.

The superior locking hole on the M/DN

Nail is used for static locking, while the

distal locking hole is used for dynamic

locking. If static locking is preferred,

but there is a potential need for later

dynamization, insert screws in both

locking holes. The locking screw in the

static hole can then be removed to

achieve later dynamization.

For success with this technique,

proper placement of the lateral x-ray

beam is critical. Position the C-arm

so the locking hole of the nail

appears perfectly round on the

monitor (Fig. 31).

When this is achieved, bring the tip of

the Trocar to the skin and use the C-arm

to center it over the hole. Make a lateral

stab wound opposite the appropriate

locking hole, and dissect down to

bone. Bring the tip of the Trocar to the

bone and center it over the locking hole

using the C-arm (Fig. 32a).

Fig 32

Fig 33

Fig 34

a.

b.

c.

Trocar

Drill

Align the Trocar with the axis of the

x-ray beam (Fig. 32b and c). Drive the

Trocar into the bone and across the

hole in the nail in line with the lateral

x-ray beam, but do not penetrate the

medial cortex.

Remove the Targeting Device by

loosening the set screw. Verify Trocar

placement in both the A/P and lateral

planes (Fig. 33).

After it has been correctly placed,

remove the Trocar. The path of the

Trocar in the bone acts as a pilot hole

for the appropriate size drill (Fig. 34).

Attach the appropriate drill (same size

as the Trocar) to the Freehand Targeting

Device. Insert the drill into the pilot

hole made by the Trocar. Before drilling

through the medial cortex, check the

A/P and lateral C-arm image to assure

that the drill is in the hole in the nail.

Then drill through the medial cortex.

16 M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Remove the drill and insert the Distal

Screw Depth Gauge (Fig. 35). The

length of the screw is determined by

reading it directly off the Distal Screw

Depth Gauge. Select an appropriate

length screw to ensure adequate

engagement of the medial cortex. Insert

the appropriate size M/DN Screw using

the Distal Screwdriver (Fig. 36) (Table 2).

Fig 35

Fig 38

Fig 36 Fig 37

If desired, insert the second screw in

the second locking hole of the nail in

an identical manner (Fig. 37). Check the

position of both screws with the C-arm

in the A/P and lateral planes (Fig. 38).

Bushings are available that can be

used with the Freehand Targeting

Device. A separate radiolucent Bushing

Insert is available to aid in targeting.

Nail

Diameter

(mm)

Screw Diameter

Distal

3.7mm

Cortical

Distal

4.2mm

Cortical

Distal

5.5mm

Cortical

8 •

9 •

10 •

11 •

12 •

13 •

14 •

15 •

16 •

Table 2. Distal Screw Sizes for M/DN

Femoral Recon Nails

Note: 4.5mm cortical interlocking screws are NOT indicated for use with the MDN system.

17

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Closure and Postoperative Care

Close the proximal wound over

suction drains, and apply a soft

compression dressing.

Extraction

Should extraction of the nail become

necessary, attach the Threaded

Extractor to the end of the nail

and use the Slaphammer to extract

the nail (Fig. 39).

NOTE: The cannulated Locking

Bolt should not be used for nail

removal. Extraction of the nail

should be accomplished by using

the Threaded Extractor.

Fig 39

18 M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Instrument Case Options

M/DN Instruments

Set Number 00-2255-000-15

(includes plastic case/trays/lid & instruments)

Prod. No. Description

00-2241-001-00 M/DN R-F Targeting Guide 1

00-2241-001-01 M/DN Adjustable Target Arm 1

00-2241-005-00 M/DN Nut Counterbore 1

00-2241-006-00 M/DN Cortical Nut Screwdriver 1

00-2241-008-37 M/DN R-T Bushing 3.7mm 2

00-2241-008-50 M/DN R-T Bushing 5.0mm 2

00-2246-023-00 Guide Pin 3.2mm Dia X 304.8mm 2

00-2246-063-01 Offset Driver Adaptor 1

00-2246-063-05 Adaptor Converter 1

00-2255-001-00 M/DN Locking Bolt 3

00-2255-002-00 M/DN Prox Targeting Guide Femoral 1

00-2255-003-00 M/DN Prox Targeting Guide Tibial 1

00-2255-003-01 M/DN Tibial Oblique Hole Adapter 1

00-2255-004-00 M/DN Prox Targeting Guide Humeral 1

00-2255-004-01 M/DN Oblique Hole Adapter Humeral 1

00-2255-005-32 M/DN Fem Pin/Drill Bushing 3.2mm 2

00-2255-005-50 M/DN Femoral Drill Bushing 5.0mm 2

00-2255-005-80 M/DN Fem Screw Bushing 8.0mm 4

00-2255-006-37 M/DN Tib/Hum Drill Bushing 3.7mm 1

00-2255-006-80 M/DN Tib/Hum Screw Bushing 8.0mm 1

00-2255-007-37 M/DN Bushing Awl 3.7mm Dia 1

00-2255-007-50 M/DN Bushing Awl 5.0mm Dia 2

00-2255-011-00 M/DN Recon Screw Counter Bore 1

00-2255-028-00 M/DN 9/16 in. Pin Wrench 3

00-2255-031-37 Retrograde Femoral Drill, 3.7mm 1

00-2255-032-37 Tibial/Humeral Drill, 3.7mm 1

00-2255-035-50 M/DN Femoral Drill Large 5.0mm 2

00-2255-070-00 Fem/Tib/Hum/Retro Inst Case

(includes plastic case/trays & lid)

1

General Instruments

Set Number 00-2255-000-11

(includes plastic case/trays/lid & instruments)

Prod. No. Description

00-0187-004-59 Steinmann Pins, Style 5, 3.2mm Dia X 229mm 1

00-2228-097-00 Pressure Sentinel Diameter Gauge 1

00-2237-001-07 Femoral Awl, 7mm 1

00-2237-005-00 Mallet 3 lb. 1

00-2237-008-00 Skin Protector 1

00-2237-042-00 Threaded Driver 1

00-2237-044-00 Trochanteric Reamer, 9mm 1

00-2237-046-00 Reduction Rod 1

00-2237-048-00 Flared Exchange Tube 1

00-2237-053-00 Wire Grip T-Handle 1

00-2237-054-00 Screw Depth Gauge 1

00-2237-055-00 Ruler 1

00-2239-001-00 Tibial Awl 1

00-2241-002-37 M/DN Proximal Bushing 3.7mm 1

00-2241-002-50 M/DN Proximal Bushing 5.0mm 1

00-2241-002-80 M/DN Proximal Bushing 8.0mm 1

00-2241-012-37 Pilot Tip Prox Stop Drill 3.7mm 1

00-2241-012-50 Pilot Tip Prox Stop Drill 5.0mm 1

00-2246-062-00 Reversed Tibial Awl 1

00-2255-009-00 Slaphammer 1

00-2255-012-33 M/DN Distal Trocar 3.2mm 1

00-2255-012-37 M/DN Distal Trocar 3.7mm 1

00-2255-012-50 M/DN Distal Trocar 5.0mm 1

00-2255-013-00 M/DN T-Handle HXHD Screwdriver 3.5mm 1

00-2255-013-01 M/DN Distal Screwdriver 3.5mm Hex 1

00-2255-014-00 M/DN Threaded Extractor 2

00-2255-015-01 M/DN Distal Insert 1

00-2255-015-02 M/DN Set Screw 1

00-2255-015-03 M/DN Handle 1

00-2255-015-04 M/DN Bushing Insert 1

00-2255-016-00 M/DN Fem Awl 7mm Dia Angled Tip 1

00-2255-017-00 M/DN Flared Exchange Tube 8mm 1

00-2255-018-00 M/DN Distal Screw Depth Gauge 1

00-2255-020-00 M/DN T-Handle Ratchet Screwdriver 1

00-2255-027-00 M/DN Locking Bolt Wrench 1

00-2255-033-32 Pilot Tip Distal Drill, 3.2mm 1

00-2255-033-37 Pilot Tip Distal Drill, 3.7mm 1

00-2255-033-50 Pilot Tip Distal Drill, 5.0mm 1

00-2255-065-00 General Instrument Case

(includes plastic case/trays & lid)

1

* The 7mm Straight Awl (00-2237-001-07) OR the 7mm

Angled Femoral Awl (00-2255-016-00) will fit in the case.

However, when you order the set number (00-2255-000-16),

you will get the Angled Awl.

NOTE: See sales representative for optional instruments.

19

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Pressure Sentinel Intramedullary Reaming System

Order Information

Prod. No. Description

00-2218-000-00 Long Pressure Sentinel Reamers

Tray/Case/Lid

Includes the following instruments & case:

00-2218-008-00 8.0mm Long Flexible PS Reamer

00-2218-008-05 8.5mm Long Flexible PS Reamer

00-2218-009-00 9.0mm Long Flexible PS Reamer

00-2218-009-05 9.5mm Long Flexible PS Reamer

00-2218-010-00 10.0mm Long Flexible PS Reamer

00-2218-010-05 10.5mm Long Flexible PS Reamer

00-2218-011-00 11.0mm Long Flexible PS Reamer

00-2218-011-05 11.5mm Long Flexible PS Reamer

00-2218-012-00 12.0mm Long Flexible PS Reamer

00-2218-012-05 12.5mm Long Flexible PS Reamer

00-2218-013-00 13.0mm Long Flexible PS Reamer

00-2218-013-05 13.5mm Long Flexible PS Reamer

00-2218-014-00 14.0mm Long Flexible PS Reamer

00-2218-014-05 14.5mm Long Flexible PS Reamer

00-2218-015-00 15.0mm Long Flexible PS Reamer

00-2218-015-05 15.5mm Long Flexible PS Reamer

00-2218-016-00 16.0mm Long Flexible PS Reamer

00-2218-016-05 16.5mm Long Flexible PS Reamer

00-2218-017-00 17.0mm Long Flexible PS Reamer

00-2218-017-05 17.5mm Long Flexible PS Reamer

00-2218-018-00 18.0mm Long Flexible PS Reamer

00-2228-030-00 T-Handle Extractor

00-2228-097-00 Diameter Gauge

00-5044-012-00 Adapter 3 Jaw Chuck

00-2228-098-10 Soak Tray

00-2218-025-00 Long Cleaning Brush*

00-2218-030-00 Torque Limiter

00-2237-075-00 Long Reamer/Instrument

Case Assembly

00-2237-076-00 Long Reamer/Instrument Case Base

00-2237-077-00 Long Reamer/Instrument Case Lid

00-2237-078-00 Long Reamer/Instrument Top Tray

(8mm-13.5mm)

00-2237-079-00 Long Reamer/Instrument Middle Tray

*Non-sterile

00-2228-000-00 Pressure Sentinel Reamer Full Set

Includes the following instruments & case:

00-2228-005-00 5.0mm Flexible Reamer

00-2228-005-05 5.5mm Flexible Reamer

00-2228-006-00 6.0mm Flexible Reamer

00-2228-006-05 6.5mm Flexible Reamer

00-2228-007-00 7.0mm Flexible Reamer

00-2228-007-05 7.5mm Flexible Reamer

00-2228-008-00 8.0mm Flexible Reamer

00-2228-008-05 8.5mm Flexible Reamer

00-2228-009-00 9.0mm Flexible Reamer

00-2228-009-05 9.5mm Flexible Reamer

00-2228-010-00 10.0mm Flexible Reamer

00-2228-010-05 10.5mm Flexible Reamer

00-2228-011-00 11.0mm Flexible Reamer

00-2228-011-05 11.5mm Flexible Reamer

00-2228-012-00 12.0mm Flexible Reamer

00-2228-012-05 12.5mm Flexible Reamer

00-2228-013-00 13.0mm Flexible Reamer

00-2228-013-05 13.5mm Flexible Reamer

00-2228-014-00 14.0mm Flexible Reamer

00-2228-014-05 14.5mm Flexible Reamer

00-2228-015-00 15.0mm Flexible Reamer

00-2228-015-05 15.5mm Flexible Reamer

00-2228-016-00 16.0mm Flexible Reamer

00-2228-016-05 16.5mm Flexible Reamer

00-2228-017-00 17.0mm Flexible Reamer

00-2228-017-05 17.5mm Flexible Reamer

00-2228-018-00 18.0mm Flexible Reamer

00-2228-018-05 18.5mm Flexible Reamer

00-2228-019-00 19.0mm Flexible Reamer

00-2228-019-05 19.5mm Flexible Reamer

00-2228-020-00 20.0mm Flexible Reamer

00-2228-020-05 20.5mm Flexible Reamer

00-2228-021-00 21.0mm Flexible Reamer

00-2228-021-05 21.5mm Flexible Reamer

00-2228-022-00 22.0mm Flexible Reamer

00-2228-030-00 T-Handle Extractor

00-2228-097-00 Diameter Gauge

00-2228-098-00 Soak Tray

00-5044-012-00 1/4 in. Jacob’s Chuck to Zimmer

Adapter, Qty=2

00-2228-090-00 Sterilization Case

20 M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Optional Reamer Sizes

Prod. No. Description

00-2228-022-05 22.5mm Flexible Reamer

00-2228-023-00 23.0mm Flexible Reamer

00-2228-023-05 23.5mm Flexible Reamer

00-2228-024-01 24.0mm Flexible Reamer

00-2228-024-05 24.5mm Flexible Reamer

00-2228-025-01 25.0mm Flexible Reamer

00-2228-025-05 25.5mm Flexible Reamer

00-2228-026-01 26.0mm Flexible Reamer

00-2228-026-05 26.5mm Flexible Reamer

00-2228-027-01 27.0mm Flexible Reamer

Pressure Sentinel Sets

Prod. No. Description

00-2228-000-01 Pressure Sentinel Reamer Trauma Set

Includes the following instruments & case:

5.0mm, 6.0mm, 7.0mm & 8.00mm-17.5mm

Flexible Reamers in .5mm increments (1 ea.)

00-2228 -030-00 T-Handle Extractor

00-5044-012-00 1/4 in. Jacob’s Chuck to Zimmer

Adapter, Qty=2

00-2228-090-00 Sterilization Case

00-2228-000-02 Pressure Sentinel Reamer Hip Set

Includes the following instruments & case:

8.0mm-18.0mm Flexible reamers in 1mm increments (1 ea.)

00-2228-030-00 T-Handle Extractor

00-5044-012-00 1/4 in. Jacob’s Chuck to Zimmer

Adapter, Qty=1

00-2228-090-00 Sterilization Case

00-2228-000-03 Pressure Sentinel Reamer Expanded

Hip Set

Includes the following instruments & case:

8.0mm-18.0mm Flexible reamers in .5mm increments (1 ea.)

00-2228-030-00 T-Handle Extractor

00-5044-012-00 1/4 in. Jacob’s Chuck to Zimmer

Adapter, Qty=1

00-2228-090-00 Sterilization case

00-2228-90-00 Sterilization Case

Includes the following components:

00-2228-091-00 Base

00-2228-092-00 18.0mm to 22.0mm Reamer Tray

00-2228-093-00 12.0mm to 17.5mm Reamer Tray

00-2228-094-00 5.0mm to 11.5mm Reamer Tray

00-2228-096-00 Case Lid

00-9975-011-00 Pressure Sentinel Reamer ZMR® Set

Includes the following components:

8.0mm-27.0mm Flexible reamers in .5mm increments (1 ea.)

00-9965-081-10 ZMR Flexible Reamer

Diameter Gauge

00-9975-099-00 Case Lid

00-2228-040-00 ZMR Flexible Reamer Metal Case

* Set includes case and contents without the

00-9975-099-00 Case Lid. The Case Lid must

be ordered separately.

Optional Instruments

Prod. No. Description

00-2255-008-00 Guide Wire 2.4mm, Ball-Tip,

70cm box (required for 5.0mm-7.5mm

Pressure Sentinel Reamers)

47-2255-008-01 Guide Wire 3.0mm, Ball-Tip, 100cm

Sterile/box (required for 8.0mm and

larger Pressure Sentinel Reamers)

00-2255-008-01 Guide Wire 3.0mm, Ball-Tip, 100cm box

(required for 8.0mm and larger Pressure

Sentinel Reamers)

21

M/DN® Femoral Interlocking & Recon Nail Intramedullary Fixation

Contact your Zimmer representative or visit us at www.zimmer.com

97-2252-002-01 Rev. 7 MC 120710 6-1-2015 ©2015 Zimmer, Inc.

The CE mark is valid only if it is also printed on the product label.

DISCLAIMER:

This documentation is intended exclusively for physicians and is not intended for laypersons. Information on

the products and procedures contained in this document is of a general nature and does not represent and does

not constitute medical advice or recommendations. Because this information does not purport to constitute any

diagnostic or therapeutic statement with regard to any individual medical case, each patient must be examined

and advised individually, and this document does not replace the need for such examination and/or advise in

whole or in part.

Please refer to the package inserts for important product information, including, but not limited to, indications,

contraindications, warnings, precautions, and adverse effects.