NCB Large Fragment System Surgical Technique

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NCB®

Large Fragment

System

Surgical Technique

NCB® Large Fragment System – Surgical Technique 3

Table of Contents

Introduction 4

System Features 7

Indications and Contraindications 10

NCB Large Fragment Plate Positioning and Screw Fixation 10

NCB Screw Insertion 12

NCB Curved Femur Shaft Plate – Surgical Technique 14

NCB Straight Narrow Shaft Plate – Surgical Technique 19

Tips and Tricks for the NCB Large Fragment System 24

Post-Operative Treatment 25

Implant Removal 25

Product Information – Implants 26

Product Information – Instruments 29

Planning Aid 31

4NCB® Large Fragment System – Surgical Technique

NCB Curved Femur Shaft Plate

NCB Straight Narrow Shaft Plate

Introduction

The NCB (Non-Contact Bridging) Large

Fragment System is a line of polyaxial

locking plates for the treatment of femur,

tibia and humerus shaft fractures. It con-

sists of a Curved Femur Shaft plate and a

Straight Narrow Shaft plate.

The NCB Curved Femur Shaft plate is also

included in the NCB Periprosthetic Femur

Polyaxial Locking Plate System.

NCB® Large Fragment System – Surgical Technique 5

Non

contact

NCB 30° Cone Polyaxiality Angular stability with the NCB Locking Caps

NCB Non-Contact Bridging

Blind screw insert

Locking cap ∅ 8mm

Spacer 1 to 3 mm

30°

The NCB System Technology allows for

polyaxial screw placement (30° cone)

with screw locking achieved through the

use of locking caps that are threaded into

the plate holes. The locking construct

allows for improved stability especially

in osteopenic bone. Before locking,

the screws can act as lag screws and

be used for fracture reduction; a benefit

which is not offered with standard

locking systems.

In the locked mode, the NCB Large Frag-

ment

Plate acts as an internal fixator

without contact between the plate and

the bone surface, which may reduce the

risk of periosteal blood supply impair-

ment. This Non-Contact Bridging concept

can also be controlled specifically

through the use of 1, 2, or 3mm spacers,

which are threaded into the plate holes

prior to plate insertion.

6NCB® Large Fragment System – Surgical Technique

The surgical technique is based on well-

known standard plate osteosynthesis

techniques, which give the surgeon

tactile feedback regarding bone quality

during drilling and tightening of the

screws. In addition, with the use of

locking caps the screws can be locked

and made angularly stable.

The NCB Large Fragment System allows

for extensive flexibility in the treatment of

simple shaft fractures including peripros-

thetic fractures in the shaft. The polyaxial

NCB Plate technology, may allow for

bicortical screw fixation around the stem

of the implanted prosthesis. In this way,

the surgeon can achieve better construct

stability than with cables with less

damage to the soft tissue. And because

of the Non-Contact Bridging concept, the

risk to the periosteal blood supply may

be reduced.

Additionally, fixation using cables and

cable buttons is possible for those cases

where bicortical screw fixation cannot be

achieved. Both techniques (locking

screws and cables) may also be com-

bined. Blunt tip unicortical NCB Screws

are also available, creating a system

which offers comprehensive solutions for

these difficult fractures.

Fixation using uni- and

bicortical screws,

as well as cables and

cable buttons

Bicortical screw anchorage

(with or without IM device

inside) with NCB Screws

NCB® Large Fragment System – Surgical Technique 7

System Features

NCB Curved Femur Shaft Plate and

NCB Straight Narrow Shaft Plate

Symmetric Design

One plate for left and right long bones

due to symmetric design.

The NCB Straight Narrow Shaft Plate can

either be used for the tibia or humerus.

Whereas the NCB Curved Femur Shaft

Plate is specifically designed for the

femur.

Compression Slots

Two compression slots allow 1mm

of compression each.

K-Wire Holes

Two k-wire holes at each end of the plate

allow easier preliminary plate fixation.

Articulated Tension Device Holes

(only NCB Curved Femur Shaft Plate)

One hole at each end of the plate allows

for connection of the Articulated Tension

Device to achieve additional compression,

if needed.

Screw Options

Broad Screw Options

Three different NCB Screw types are

offered with the NCB Large Fragment

System, to allow both bicortical and

unicortical fixation.

3.5mm cortical screws are included for

additional fixation outside the NCB

Plates.

Specific Instruments for Periprosthetic

Fractures

Slightly oversized drill bits and drill guides

are offered with the NCB Large Fragment

System, to reduce the risk of cracks in

the cement mantle when placing screws

around a cemented prosthesis.

K-Wire Holes

Articulated Tension Device Hole

NCB Instruments for overdrilling into cement

Broad Screw Options ∅ mm Description

5 NCB Screws

5 NCB Unicortical Screws

4 NCB Screws

3.5 Cortical Screws

Articulated Tension Device Hole

Compression Slots

8NCB® Large Fragment System – Surgical Technique

Two NCB Bone Spacers used

in the diaphyseal area of

a NCB Plate, to avoid contact

of the plate with the bone

(Non Contact Bridging)

NCB Bone Spacers (Optional)

Use at least two bone spacers in the

diaphyseal area of all NCB Plates, to

avoid contact of the plate with the bone

surface reducing the risk of periosteal

blood supply impairment.

The spacers may also be used if the

fracture has been reduced using a cable,

to avoid contact between the

plate and the cable.

The spacers are available in 1mm, 2mm

and 3mm (REF 02.03150.311 to 313)

sizes.

Note: Insert the bone spacers into the

NCB Plate or Screw holes before plate

insertion. The spacers are single use only,

and they can be removed after locking

the screws.

NCB Blind Screws inserted in

a NCB Plate to prevent bone

ingrowth

NCB Blind Screw Inserts (Optional)

To prevent bone ingrowth into empty NCB

Screw holes, use the NCB Blind Screw

inserts (REF 02.03150.310).

Note: Hand tighten only.

Blind screw insert

Spacer 1 to 3 mm

NCB® Large Fragment System – Surgical Technique 9

Cable Fixation Options

The following products from the Zimmer®

Cable-Ready® Cable Grip

System are compatible with the NCB

Large Fragment System:

Cable Fixation with

Hex Button

Cable Fixation Options

NCB Locking Plate

Cable Button, 2.5mm, Hex Drive

• Sterile

• Material: Ti-6Al-4V

(Tivanium® Alloy)

REF 47-2232-060-01

Application

This Cable Button is threaded

directly into the NCB Plate to

provide a positioning point for

the Cable

Hex Button, 3.5mm

• Sterile

• Material: C.P. Titanium

REF 00-2232-002-35

Application

This Hex Button fits into the

standard hex in the screw head

(3.5mm hex). Therefore, it can

be inserted into the NCB Screw

head, or into the NCB Locking Cap

Cable Assembly Cerclage,

1.8mm

• Sterile

• Material: CoCr

REF 00-2232-002-28

REF 00-2232-004-18

Cable Fixation with

Cable Button

10 NCB® Large Fragment System – Surgical Technique

Indications

The NCB Periprosthetic Femur Polyaxial

Locking Plate System is indicated for

temporary internal fixation and stabiliza-

tion of fractures and osteotomies of long

bones, including:

• Periprosthetic fractures

• Comminuted fractures

• Supracondylar fractures

• Fractures in osteopenic bone

• Nonunions

• Malunions

Indications and Contraindications

The NCB Straight Narrow Shaft Plate

is indicated for temporary internal

fixation and stabilization of humeral and

tibial

shaft fractures and osteotomies,

including:

• Periprosthetic fractures

• Comminuted fractures

• Fractures in osteopenic bone

• Nonunions

• Malunions

Contraindications

• All concomitant diseases that may

impair the fixation of the implant and/

or the success of the intervention

• Lack of bone substance or poor bone

quality which makes stable seating of

the implant impossible

• Acute or chronic, local or systemic

infections

• Allergy to the implanted materials

• Severe muscular, neural or vascular

diseases that endanger the extremities

involved

• Loose prosthesis, which requires

immediate revision.

Recommended Plate Positioning

• Ensure that the length of the NCB

Curved Femur Shaft Plate or NCB

Straight Narrow Shaft Plate allows for

screw placement proximal and distal of

the fracture zone and if present around

the existing prosthesis.

NCB Large Fragment Plate Positioning and Screw Fixation

NCB® Large Fragment System – Surgical Technique 11

Recommended NCB Screw

Fixation

The NCB Large Fragment System offers

three different types of polyaxial locking

screws, two of them are designed for

bicortical purchase, and one of them is

designed for unicortical purchase.

Recommended NCB Screw usage for NCB

Curved Femur Shaft Plate:

• Wherever possible, use 5.0mm bicorti-

cal NCB Screws.

• In periprosthetic fractures use two

bicortical 5.0mm NCB Screws close to

the fracture on each side of the frac-

ture.

• For thin cortical bone near the prosthe-

sis, the 4.0mm NCB Screws may be

used.

Screw Type Cortical

5mm

Cortical

4mm

Cortical

Blunt Tip

Cortical

3.5mm

Outer ∅5mm 4mm 5mm 3.5mm

Core ∅4.4mm 3.4mm 4.4mm 2.4mm

Length 22–85mm 20–70mm 10–20mm 20–40mm

REF

REF Sterile

02.03150.0xx

02.02150.0xx

02.03155.0xx

02.02155.0xx

02.03151.0xx

02.02151.0xx

00-4935-0xx-01

47-4935-0xx-01

Application Close to the fracture

area, in the shaft

area, or in case of a

periprosthetic fracture

where there is

no risk of hitting the

prosthesis

In tibia or humerus

bone and in case of a

periprosthetic fracture

away from the fracture

area to achieve bicorti-

cal fixation around the

prosthesis

For use when

bicortical fixation

cannot be achieved

Warning

If only unicortical

screws are used,

the use of cables is

required

Fixation of additional

bone fragments

Note: These screws can

be placed only outside

of the NCB Plates

NCB Screw portfolio for the NCB Large Fragment System

NCB Screws – Bicortical Unicortical

Recommended NCB Screw usage for NCB

Straight Narrow Shaft Plate:

• Use 4.0mm bicortical NCB Screws

wherever possible.

Drill Bit ∅4.3 / 4.5mm 3.3 / 3.5mm 4.3 / 4.5mm 2.5 / 3.5mm

Drill Bit REF 02.00024.002

02.00024.330

02.00024.118

02.00024.325

02.00024.002

02.00024.330

00-4806-110-25

00-4806-110-35

Drill Guide REF 02.00024.011

02.00024.331

02.00024.111

02.00024.326

02.00024.011

02.00024.331

00-4808-035-01

Tap REF 02.00024.341 02.00024.340 02.00024.341 00-4811-110-35

12 NCB® Large Fragment System – Surgical Technique

NCB Screw Insertion

For All Types of NCB Screws and

NCB Locking Caps

• Take care to avoid collision of the

screws by choosing the appropriate

plate holes and screw lengths.

• Press the NCB Drill Guide into the plate

hole perpendicular to the plate and

then tilt it in the preferred direction.

The drill guide needs to be in constant

contact with the bottom ring of the

hole. The guide limits the angulation to

15° from the perpendicular axis of the

plate or a cone of 30° for placing a

locked NCB Screw. Always use the drill

guide since it prevents selection of an

excessive screw angle and failure of

subsequent locking.

• Screws may be inserted under power

but should be final tightened by hand

only.

Note: Screws should not be locked until

both sides of the fragment have been

fixed.

• Lock the construct, insert and

tighten the NCB Locking Caps

(REF 02.03150.300) by using the NCB

Torque Limiting Screwdriver, 6Nm

(REF 02.00024.021) until a click sound

is heard. Make sure the screwdriver

is not tilted during its usage. If the

driver is tilted, it could damage the

hex drive and might complicate the

extraction of the implants.

Note: If using the NCB Straight Narrow

Shaft Plate for humerus shaft fractures

the use of NCB Torque Limiting Screw-

driver 4Nm (REF 02.00024.022) is also

acceptable.

• In case of periprosthetic fractures do

not hit the prosthesis with the tip of the

drill, tap or screw.

NCB Screw ∅ 5.0mm

1. To insert a 5.0mm NCB Screw

(REF 02.03150.xxx) use the 4.3mm

NCB Drill Guide (REF 02.00024.011)

and drill with the 4.3mm drill bit

(REF 02.00024.002).

In case of hard cortical bone or the

presence of a cement mantle, tap the

cortex with the 5.0mm NCB Tap

(REF 02.00024.341). Remove the

4.3mm NCB Drill Guide before using

the NCB Tap.

Note: Inserting screws in the presence of

a cement mantle can cause cracks, which

may cause loosening of the prosthesis.

Overdrilling by using a drill bit of a

slightly larger diameter (0.2mm) may

reduce cracking in the cement mantle

during screw insertion. Instead of the

4.3mm drill bit, use the 4.5mm drill bit

(REF 02.00024.330) and its corresponding

drill guide (REF 02.00024.331).1

2. Use the NCB Measuring Device

(REF 02.00024.005) to determine the

appropriate screw length and insert

the NCB Screw using the NCB Hexagonal

Screwdriver (REF 02.00024.023) or

screwdriver shaft (REF 02.00024.024).

3. To lock the construct, insert the NCB

Locking Caps (REF 02.03150.300) as

described at the beginning of this section.

NCB Unicortical Screw ∅ 5.0mm

1. To insert a 5.0mm NCB Unicortical

Screw (REF 02.03151.0xx) use

the 4.3mm NCB Drill Guide

(REF 02.00024.011) and drill with the

4.3mm drill bit (REF 02.00024.002).

In case of hard cortical bone or the

presence of cement mantle, tap the

cortex with the 5.0mm NCB Tap

(REF 02.00024.341). Remove the

4.3mm NCB Drill Guide before using

the NCB Tap.

Note: Inserting screws in the presence of

a cement mantle can cause cracks,

which may cause loosening of the

prosthesis. Overdrilling by using a drill bit

of a slightly larger diameter (0.2mm) may

reduce cracking in the cement mantle

during screw insertion. Instead of the

4.3mm drill bit, use the 4.5mm drill bit

(REF 02.00024.330) and its corresponding

drill guide (REF 02.00024.331).1

2. Use the NCB Measuring Device

(REF 02.00024.005) to determine the

appropriate screw length and

insert the NCB Unicortical Screw using

the NCB Hexagonal Screwdriver

(REF 02.00024.023).

Note: When using the NCB Measuring

Device to measure the length of the NCB

Unicortical Screw needed, the device will

not hook the far cortex of the bone. Use

the screw length measured. Do not use a

longer screw.

3. To lock the construct, insert the NCB

Locking Caps (REF 02.03150.300) as

described at the

beginning of this section.

1 J. Kampshoff et al.: The treatment of periprosthetic fractures with locking plates:

effect of drill and screw type on cement mantles: a biomechanical analysis,

Archives of Orthopedic and Trauma Surgery, Springer, March 2009.

NCB® Large Fragment System – Surgical Technique 13

NCB Screw ∅ 4.0mm

1. To insert a 4.0mm NCB Screw

(REF 02.03155.0xx) use the 3.3mm

NCB Drill Guide (REF 02.00024.111)

and drill with the 3.3mm drill bit

(REF 02.00024.118).

In case of hard cortical bone or the

presence of the cement

mantle, tap the

cortex with the 4.0mm

NCB

Tap

(

REF

02.00024.340). Remove the 3.3mm

NCB

Drill Guide before using the

NCB

Tap.

Note:

Inserting screws in the presence

of a cement mantle can cause cracks,

which may cause loosening of the pros-

thesis. Overdrilling by using a drill bit

of a slightly larger diameter (0.2mm) may

reduce cracking in the cement mantle

during screw insertion. Instead of the

3.3mm drill bit, use the 3.5mm drill bit

(

REF

02.00024.325) and its corresponding

drill guide (

REF

02.00024.326).

1

2. Use the

NCB

Measuring Device

(

REF

02.00024.005) to determine the

appropriate screw length and insert

the

NCB

Screw using the

NCB

Hexagonal

Screwdriver (

REF

02.00024.023) or

screwdriver shaft (

REF

02.00024.024).

3. To

lock the construct

, insert the

NCB

Locking Caps (

REF

02.03150.300) as

described at the

beginning of this section.

1 J. Kampshoff et al.: The treatment of periprosthetic fractures with locking plates:

effect of drill and screw type on cement mantles: a biomechanical analysis,

Archives of Orthopedic and Trauma Surgery, Springer, March 2009.

14 NCB® Large Fragment System – Surgical Technique

Preoperative Planning and

Patient Positioning

Preoperative Planning

Preoperative planning with adequate

x-rays and x-ray templates for

the NCB Curved Femur Shaft Plate

(Lit 06.02026.000) is strongly

recommended.

Patient in the lateral position

Patient in the supine position

NCB Curved Femur Shaft Plate – Surgical Technique

This allows determination of the proper

plate length, and the appropriate type

and position of screws, particularly in

the presence of prosthesis to prevent any

interference with the stem.

Determine which prosthesis has been

implanted by studying the x-rays, or using

the previous surgeon’s operative notes to

be prepared in case of revision, and

assess the stability of the prosthesis. If

the prosthesis is loose, the surgical plan

may change to include revision.

Patient Positioning

Lay the patient in the lateral position

or the supine position on a radiolucent

table. Support the knee, but allow the

leg to move freely. Perform the reduction

as necessary.

If intra-op fluoro is to be used, ensure

the fluoro machine is not blocked by

radioopaque bars of the operating table.

+H84406020260001/$100501E10K

© 2010. All rights reserved.

Zimmer GmbH, CH-8404 Winterthur,

Switzerland

Lit.No. 06.02026.000 – Ed. 5/2010 WL

NCB

®

Curved Femur Shaft Plate

0086

10 cm 15 cm5 cm

Magnification

1.15:1

20 cm

15 cm

5 cm

25 cm

30 cm

35 cm

10 cm

10 cm 15 cm

5 cm

12 holes

14 holes

10 holes

12 holes

10 holes

14 holes

NCB Screw Polyaxiality NCB Screw

5 mm

30°

NCB® Large Fragment System – Surgical Technique 15

Incision and Intra-operative

Planning

Incision

Make the incision using the lateral

subvastus approach or incorporate the

existing incision, if applicable.

Avoid excessive stripping of the soft

tissues and keep the periosteum in-

tact.

Intra-operative Planning

Take complete x-rays of the femur in the

A/P and lateral view and if necessary,

also in the contra-lateral view, or a CT if

osteolysis is present to determine the

length of the prosthesis, as well as the

correct plate length to be implanted.

If desired, the NCB Curved Femur Shaft

Plate Provisional (REF 02.00024.358)

can be used to determine the suitable

implant length. Provisional is semi

radiolucent and intended to be used in

the open technique.

Warning:

Do not implant or bend the provisional.

There is only one provisional which

represents the 12 hole NCB Curved Femur

Shaft Plate. To use the provisional for the

next shorter implant size (10 hole plate),

two square holes are included:

– the proximal square hole indicates the

most proximal NCB Plate hole of the

next shorter implant size

– the distal square hole indicates the

most distal NCB Plate hole of the next

shorter implant size.

Incision

Exessive stripping of the

soft tissue avoided and

periosteum kept intact

NCB Curved Femur Shaft

Plate Provisional used for

intra-operative planning

(optional)

Next shorter

implant size

Last NCB Plate hole

Last NCB Plate hole

10 hole plate

Provisional

12 hole plate

Square holes are included

to indicate the next

shorter implant size

16 NCB® Large Fragment System – Surgical Technique

Reduction and Preliminary

Fixation

Reduce the fracture prior to inserting the

plate. Bone fragments may be secured with

2.0mm k-wires (REF 290.20.280) or clamps

such as pointed reduction forceps. Make

sure that preliminary fixation devices do

not interfere with the future location of the

plate and screws, or with the prosthesis.

Insertion of the NCB Curved Femur

Shaft Plate

The following example shows a case

without a prosthesis in-situ.

The NCB Curved Femur Shaft Plate is

placed on the lateral femur centered over

the fracture.

Temporarily fix the plate with two 2.0mm

k-wires (REF 290.20.280), one proximally

and one distally.

NCB Curved Femur Shaft Plate

centered over the fracture

and temporarily fixed with two

2.0mm k-wires

Compression guide placed so

that the drill hole is at the

end of the compression slots

farthest from the fracture site.

Correct orientation of the

concave Bending Press

insert: with the word “TOP”

etched on the top of the

insert

Note:

The NCB Curved Femur Shaft Plate is

anatomically shaped.

If additional contouring is

required, use the Bending Press

Inserts (REF 02.00024.315/6) and the

corresponding Bending Press

(REF 100.06.010).

Be aware that bending the plate may

decrease its fatigue strength.

Furthermore, the locking mechanism of

the NCB Screw hole may be damaged

and, therefore, may no longer function.

Do not use a hole that has been altered

by contouring for locking.

NCB® Large Fragment System – Surgical Technique 17

Insertion of the NCB Screws

The NCB Curved Femur Shaft Plate has two

compression slots to allow for axial

adjustment while positioning the plate,

as well as for axial compression.

Note: It is possible to get 1 or 2mm of

axial compression with the NCB Curved

Femur Shaft Plate. For 2mm of compres-

sion, insert the NCB Screws into the com-

pression holes first (like in the example

shown in this surgical technique).

For 1mm of compression, insert a NCB

Screw into a NCB Plate hole, and then use

the compression slot on the opposite side

of the fracture. If more compression is

needed, use the Articulated Tension Device

(REF 00-4817-005-00) after only one side

of the plate has been fixed. This instrument

can be attached to the bone, using a

4.0mm NCB Screw.

For screw selection and insertion, please

refer to pages 12–13.

Note: Screws should not be locked until

both sides of the fragment have been

fixed.

1. For 2.0mm of axial compression, drill

the first hole in one of the two compres-

sion slots in the compression position

using the NCB Compression Drill Guide for

5.0mm NCB Screws (REF 02.00024.335)

and the 4.3mm drill bit (REF 02.00024.002).

Place the compression guide so that the

drill hole is at the end of the compression

slots farthest from the fracture site.

Partially insert a 5.0mm NCB Screw into

the compression slot but do not tighten it.

First 5.0mm NCB Screw

partially inserted in one of

the two compression

slots without tightening it

Second 5.0mm NCB Screw

partially inserted in the

other compression slot with-

out tightening it, and k-wires

removed

18 NCB® Large Fragment System – Surgical Technique

2. Partially insert a 5.0mm NCB Screw into

the other compression slot, also in the

compression position, but do not tighten it.

3. Remove the two 2.0mm k-wires.

To achieve axial compression, tighten the

NCB Screws in the two compression slots

by using the NCB Hexagonal Screwdriver

(REF 02.00024.023).

4. Insert additional 5.0mm NCB Screws

as necessary, first near the fracture site

and then proximal/distal to the fracture,

ensuring purchase in a minimum of six

cortices on each side of the fracture,

spaced on the entire length of the plate.

If desired, slightly loosen the 5.0mm NCB

Screws in the two compression slots to

avoid contact between the plate and the

bone.

K-wires removed and axial

compression achieved

by tightening the 5.0mm

NCB Screws in the two com-

pression slots

Additional 5.0mm NCB

Screws inserted as necessary

first near the fracture site

and then proximal/distal to

the fracture, ensuring

purchase in a minimum of

six cortices with the screws

on each side of the fracture

spaced on the entire length

of the plate

NCB® Large Fragment System – Surgical Technique 19

Preoperative Planning and

Patient Positioning

Preoperative Planning

Preoperative planning with adequate

x-rays and x-ray templates for

the NCB Straight Narrow Shaft Plate

(Lit 06.02263.000) is strongly

recommended.

NCB Straight Narrow Shaft Plate – Surgical Technique

This allows determination of the proper

plate length, and the appropriate type

and position of screws, particularly in the

presence of prosthesis to prevent any

interference with the stem.

In periprosthetic fractures determine

which prosthesis has been implanted by

studying the x-rays, or using the previous

surgeon’s operative notes to be prepared

in case of revision, and assess the stabili-

ty of the prosthesis. If the prosthesis is

loose, the surgical plan may change to

include revision.

Patient Positioning

Tibia – Lay the patient in the supine

position on a radiolucent table. Support

the knee, but allow the leg to move freely.

Perform the reduction as necessary.

Humerus – The patient is placed on the

operating table in the beachchair posi-

tion or supine position. After the patient

is in the correct position, the C-arm must

be adjusted so as to achieve the widest

possible view of the humerus.

If intra-op fluoro is to be used, ensure the

fluoro machine is not blocked by radioo-

paque bars of the operating table.

Patient in the beachchair position

Patient in the supine position

20 NCB® Large Fragment System – Surgical Technique

Incision and Intra-operative

Planning

Incision

Tibia: The anterior approach is the stan-

dard approach to the tibia, located 1cm

lateral to its anterior crest. Take care not

to compromise the great saphenous vein

and nerve.

Humerus: Plating of humeral shaft frac-

tures may be performed through the

anterolateral approach.

Intra-operative Planning

Take complete x-rays of the tibia or the

humerus respectively in the A/P and lat-

eral view and if necessary, also in the

contra-lateral view, or a CT if osteolysis is

present to determine the length of the

prosthesis, as well as the correct plate

length to be implanted.

If desired, the NCB Straight Narrow Shaft

Plate Provisionals (REF 02.00024.401 / REF

02.00024.402) can be used to determine

the suitable implant length. Provisionals

are semi radiolucent and intended to be

used in the open technique.

Warning:

Do not implant or bend the provisional.

Each provisional represents the implant

sizes it is labeled for, e.g. 10 or 16 holes.

To use the provisional for the next shorter

implant size (e.g. 8 or 14 hole plate), a

square hole is included:

– the square hole indicates the last

NCB hole of the next shorter implant

size.

Last NCB Plate hole

Square holes are included

to indicate the next shorter

implant size.

NCB Straight Narrow Shaft Plate Provisional

used for intraoperative planning.

8 holes 10 holes 10 holes

Provisional

NCB® Large Fragment System – Surgical Technique 21

Reduction and Preliminary

Fixation

Reduce the fracture prior to inserting the

plate. Bone fragments can be secured

with 2.0mm k-wires (REF 290.20.280) or

clamps such as pointed reduction for-

ceps. Make sure that preliminary fixation

devices do not interfere with the future

location of the plate and screws, or with

the prosthesis.

Insertion of the NCB Straight

Narrow Shaft Plate

The following example shows a tibia case

without a prosthesis in-situ. All steps are

also applicable for humerus shaft frac-

tures.

The NCB Straight Narrow Shaft Plate is

placed on the medial tibia or lateral

humerus centered over the fracture.

Temporarily fix the plate with two 2.0mm

k-wires (REF 290.20.280), one proximally

and one distally.

NCB Straight Narrow Shaft

Plate centered over the

fracture and temporarily fixed

with two 2.0mm k-wires

Compression guide placed so

that the drill hole is at the

end of the compression slots

farthest from the fracture site.

Correct orientation of the

concave Bending Press

insert: with the word “TOP”

etched on the top of the

insert

Note:

If contouring is required, use the Bending

Press Inserts (REF 02.00024.315/6) and

the corresponding Bending Press

(REF 100.06.010).

Alternatively, the large bending iron

(REF 02.00000.003) can be used as well.

Be aware that bending the plate may

decrease its fatigue strength.

Furthermore, the locking mechanism of

the NCB Screw hole may be damaged

and, therefore, may no longer function.

Do not use a hole that has been altered

by contouring for locking.

22 NCB® Large Fragment System – Surgical Technique

Insertion of the NCB Screws

The NCB Straight Narrow Shaft Plate has

two compression slots to allow for axial

adjustment while positioning the plate, as

well as for axial compression.

Note: If using the compression slots inser-

tion of 4mm NCB Screws is required.

Note: It is possible to get 1 or 2mm of

axial compression with the NCB Straight

Narrow Shaft Plate. For 2mm of compres-

sion, insert the NCB Screws into the com-

pression holes first (like in the example

shown in this surgical technique). For

1mm of compression, insert a NCB Screw

into a NCB Plate hole, and then use the

compression slot on the opposite side

of the fracture.

For screw selection and insertion, please

refer to pages 12–13.

Note: Screws should not be locked until

both sides of the fragment have been

fixed.

1. For 2.0mm of axial compression, drill the

first hole in one of the two compression

slots in the compression position

using the NCB Compression Drill Guide for

4.0mm NCB Screws (REF 02.00024.336)

and the 3.3mm drill bit (REF 02.00024.002).

Place the compression guide so that the

drill hole is at the end of the compression

slots farthest from the fracture site. Partial-

ly insert a 4.0mm NCB Screw into the com-

pression slot but do not tighten it.

First 4.0mm NCB Screw

partially inserted in one of

the two compression

slots without tightening it

Second 4.0mm NCB Screw

partially inserted in the

other compression slot with-

out tightening it, and k-wires

removed

NCB® Large Fragment System – Surgical Technique 23

2. Partially insert a 4.0mm NCB Screw into

the other compression slot, also in the

compression position, but do not tighten it.

3. Remove the two 2.0mm k-wires. To

achieve axial compression, tighten the

NCB Screws in the two compression slots

by using the NCB Hexagonal Screwdriver

(REF 02.00024.023).

4. Insert additional 4.0mm NCB Screws as

necessary, first near the fracture site and

then proximal/distal to the fracture, ensur-

ing purchase in a minimum of six cortices

on each side of the fracture, spaced on

the entire length of the plate.

If desired, slightly loosen the 4.0mm NCB

Screws in the two compression slots to

avoid contact between the plate and the

bone.

K-wires removed and axial

compression achieved

by tightening the 4.0mm

NCB Screws in the two com-

pression slots

Additional 4.0mm NCB

Screws inserted as necessary

first near the fracture site

and then proximal/distal to

the fracture, ensuring

purchase in a minimum of

six cortices with the screws

on each side of the fracture

spaced on the entire length

of the plate

24 NCB® Large Fragment System – Surgical Technique

1 J. Kampshoff et al.: The treatment of periprosthetic fractures with locking

plates: effect of drill and screw type on cement mantles: a biomechanical

analysis, Archives of Orthopedic and Trauma Surgery, Springer, March 2009.

Drilling into Cement Mantle

In patients with cemented prostheses,

the insertion of screws may occur in the

presence of a cement mantle. This can

cause cracks, which may cause loosening

of the prosthesis. Be careful not to hit

the prosthesis when tapping, drilling and

inserting screws.

Tips, which may Mitigate this Risk

• Use a lower speed for drilling into the

cement mantle to prevent overheating

and avoid cement melting

• Use a higher feed rate (increased drill

force)

• Use only new sharp drill bits. Change

drills frequently and do not use worn

ones

• Titanium nitride coated (gold) drill bits

are available:

• 3.5mm drill bit (REF 02.00024.325)

• 4.5mm drill bit (REF 02.00024.330)

• Use taps

• Overdrilling by using drill bits of a

slightly larger diameter (0.2mm) may

reduce cracking in the cement mantle

during screw insertion. In the NCB

Large Fragment set a 3.5mm drill bit

(REF 02.00024.325) can be used in

place of the 3.3mm drill bit, and a

4.5mm drill bit (REF 02.00024.330) can

be used in place of the 4.3mm drill bit.

These drill bits are available together

with their corresponding drill guides.

Note: Overdrilling the cement mantle by

0.2mm does reduce pull out strength

by about 20%. However, within the

cement mantle pull out strength is still

more than 2000 N.1

Drilling into Cortical Bone

In order to go around the stem of the

prosthesis and achieve bicortical

fixation, it may be necessary to drill

completely into cortical bone, which can

lead to heat necrosis of the bone.

Warning: Drilling and inserting screws

into the outer edge of the cortical bone

may also lead to cortical fracture.

Tips, which may Mitigate these Risks

• Use only new sharp drill bits. Change

drills frequently and do not use worn

ones

• Pull the drill bit out often and

clean its flutes

• Use extensive irrigating fluid (i.e.

saline water) directed at the point of

penetration of the cortex

• Use taps

• In case of thin bone cortex, away from

the fracture area, use NCB screws

of a smaller diameter like the 4.0mm

NCB Screws.

Metal Abrasion Wear

Metal abrasion wear due to contact

between screws, plates, prostheses,

cable buttons, and cables may occur.

Tip, which may Mitigate this Risk

Use only Zimmer products compatible

with the NCB Large Fragment System,

which are described in this

surgical technique.

Tips and Tricks for the NCB Large Fragment System used in periprosthetic fractures

NCB® Large Fragment System – Surgical Technique 25

To remove the NCB Large Fragment

Plates, first remove all locking caps

(REF 02.03150.300). Then, loosen all the

NCB Screws without completely removing

them (this prevents rotation of the

bone plate when removing the last

screw). Finally, completely remove all

NCB Screws.

Note: Make sure that the tip of the

NCB Hexagonal Screwdriver

(REF 02.00024.023) is correctly placed

in the hex drive of the locking caps and/

or NCB Screws. Failure to do so could

damage the hex drive and complicate the

extraction of the implant.

Removal Tip

In case of difficulties while loosening the

NCB Screws, tighten the screws slightly

before loosening them.

Post-operative treatment with locking

plates does not differ from conventional

internal fixation procedures. If there is

concern about stability, consider using

additional external fixation devices and/

or a cast/brace. Early range of motion

exercises of the involved joints may also

be beneficial. However, it is the respon-

sibility of the surgeon to determine

the most suitable post-operative care

depending on each patient’s health con-

dition.

Post-Operative Treatment

Implant Removal

26 NCB® Large Fragment System – Surgical Technique

Product Information – Implants

NCB Curved Femur Shaft Plates

REF REF Sterile Holes Length mm

02.03265.010 02.02265.010 10 210

02.03265.012 02.02265.012 12 249

02.03265.014 02.02265.014 14 289

NCB Straight Narrow Shaft Plate

REF REF Sterile Holes Length mm

02.03267.008 02.02267.008 8 118

02.03267.010 02.02267.010 10 146

02.03267.012 02.02267.012 12 174

02.03267.014 02.02267.014 14 202

02.03267.016 02.02267.016 16 230

02.03267.018 02.02267.018 18 258

Plates

Materials

NCB® Periprosthetic Plates and Screws are made of titanium alloy TiAlV,

Protasul®-64, ISO 5832-3, ASTM F136

NCB® Large Fragment System – Surgical Technique 27

NCB Locking Caps, Spacers, Blind Screw Inserts

REF REF Sterile Description

02.03150.300 02.02150.300 Locking cap

02.03150.310 02.02150.310 Blind screw insert

02.03150.311 02.02150.311 Spacer 1mm

02.03150.312 02.02150.312 Spacer 2mm

02.03150.313 02.02150.313 Spacer 3mm

NCB Screws, ∅ 5.0mm

REF REF Sterile Length mm

02.03150.022 02.02150.022 22

02.03150.024 02.02150.024 24

02.03150.026 02.02150.026 26

02.03150.028 02.02150.028 28

02.03150.030 02.02150.030 30

02.03150.032 02.02150.032 32

02.03150.034 02.02150.034 34

02.03150.036 02.02150.036 36

02.03150.038 02.02150.038 38

02.03150.040 02.02150.040 40

02.03150.042 02.02150.042 42

02.03150.044 02.02150.044 44

02.03150.046 02.02150.046 46

02.03150.048 02.02150.048 48

02.03150.050 02.02150.050 50

02.03150.055 02.02150.055 55

02.03150.060 02.02150.060 60

02.03150.065 02.02150.065 65

02.03150.070 02.02150.070 70

02.03150.075 02.02150.075 75

02.03150.080 02.02150.080 80

02.03150.085 02.02150.085 85

Screws*

Materials

NCB® Periprosthetic Plates and Screws are made of titanium alloy TiAlV,

Protasul®-64, ISO 5832-3, ASTM F136

* Compatible screw scope, may vary from screw scope in existing

NCB Instrument sets.

∅ 4.4 ∅ 6.2∅ 5

1.75

L

NCB Unicortical Screws, ∅ 5.0mm

REF REF Sterile Length mm

02.03151.010 02.02151.010 10

02.03151.012 02.02151.012 12

02.03151.014 02.02151.014 14

02.03151.016 02.02151.016 16

02.03151.018 02.02151.018 18

02.03151.020 02.02151.020 20

∅ 4.4 ∅ 6.2

∅ 5

L

1.75

NCB Screws, ∅ 4.0mm

REF REF Sterile Length mm

02.03155.020 02.02155.020 20

02.03155.022 02.02155.022 22

02.03155.024 02.02155.024 24

02.03155.026 02.02155.026 26

02.03155.028 02.02155.028 28

02.03155.030 02.02155.030 30

02.03155.032 02.02155.032 32

02.03155.034 02.02155.034 34

02.03155.036 02.02155.036 36

02.03155.038 02.02155.038 38

02.03155.040 02.02155.040 40

02.03155.042 02.02155.042 42

02.03155.044 02.02155.044 44

02.03155.046 02.02155.046 46

02.03155.048 02.02155.048 48

02.03155.050 02.02155.050 50

02.03155.055 02.02155.055 55

02.03155.060 02.02155.060 60

02.03155.065 02.02155.065 65

02.03155.070 02.02155.070 70

∅ 3.4 ∅ 6.2∅ 4

L

1.75

28 NCB® Large Fragment System – Surgical Technique

Cortical Screws, ∅ 3.5mm

REF REF Sterile Length mm

00-4935-020-01 47-4935-020-01 20

00-4935-022-01 47-4935-022-01 22

00-4935-024-01 47-4935-024-01 24

00-4935-026-01 47-4935-026-01 26

00-4935-028-01 47-4935-028-01 28

00-4935-030-01 47-4935-030-01 30

00-4935-032-01 47-4935-032-01 32

00-4935-034-01 47-4935-034-01 34

00-4935-036-01 47-4935-036-01 36

00-4935-038-01 47-4935-038-01 38

00-4935-040-01 47-4935-040-01 40

∅ 5.9∅ 3.5∅ 2.4

1.25

L

Cortical Screws, ∅ 3.5mm (EMEA only)

REF REF Sterile Length mm

02.03131.020 – 20

02.03131.022 – 22

02.03131.024 – 24

02.03131.026 – 26

02.03131.028 – 28

02.03131.030 – 30

02.03131.032 – 32

02.03131.034 – 34

02.03131.036 – 36

02.03131.038 – 38

02.03131.040 – 40

∅ 5.9∅ 3.5∅ 2.4

1.25

L

Compatible Zimmer Products with the NCB Large Fragment System

REF sterile Description

47-2232-060-01

NCB Polyaxial Locking Plate Cable Button, 2.5mm Hex Drive, Material: Ti-6Al-4V (Tivanium® Alloy)

00-2232-002-35 Hex Buttons, 3.5mm Hex, Material: C.P. Titanium

00-2232-002-28 Cable-Ready Cable Assembly Cerclage, ∅ 1.8mm, L. 914mm, Material: CoCr

00-2232-004-18 Cable-Ready Cable Assembly Cerclage, ∅ 1.8mm, L. 635mm, Material: CoCr

NCB® Large Fragment System – Surgical Technique 29

Product Information – Instruments

The NCB Straight Narrow Shaft plate and the NCB Curved Femur Shaft plate can be implanted using the following existing

instrument sets.

NCB Straight Narrow Shaft Plate NCB Curved Femur Shaft Plate

Anatomical Location Humeral Tibial Femoral

Systems Available

• NCB Proximal Humerus System

• NCB Periprosthetic

Femur Plate System

• NCB Proximal Tibial System

• NCB Periprosthetic

Femur Plate System

• NCB Distal Femur System

• NCB Periprosthetic

Femur Plate System

NCB Proximal

Humerus System

NCB Proximal Tibia

System

NCB Distal Femur

System

NCB Periprosthetic

Femur System

NCB Shaft Plate

Add-On Set

∅ 4.0mm NCB Screws,

14–65mm length

∅ 4.0mm NCB Screws,

14–90mm length

∅ 5.0mm NCB Screws,

14–85mm length

∅ 3.5mm Cortical

(for lagging outside

plate only,

50–85mm length)

∅ 4.0mm NCB Screws,

20–65mm length

∅ 5.0mm NCB Screws,

22–100mm length

∅ 5.0mm unicortical

NCB Screws,

10–20mm length

∅ 3.5mm Cortical

(for lagging outside

plate only,

20–40mm length)

Screw availability in NCB Instrument Sets

NCB Shaft Plate Add-On Set

REF sterile Description

00-4806-110-25 Drill Bit, Q/C, 2.5mm Dia, 110mm

00-4806-110-35 Drill Bit, Q/C, 3.5mm Dia, 110mm

00-4808-035-01 3.5mm/2.5mm Double Drill Sleeve

00-4809-035-00 Countersink, Q/C, for 3.5mm and 4.0mm screws

00-4810-002-01 Small Depth Gauge

00-4811-110-35 3.5mm Tap (2.5 Core Diameter)

00-4812-000-00 Self-holding screw forceps

00-4812-035-00 Small Hex Screwdriver, 2.5mm Hex

00-2360-165-25 Small Hex Screwdriver Shaft, with Q/C, 2.5mm Hex, 140mm

00-4812-035-05 Small Holding Sleeve for Small Hex Screwdriver

02.00024.336

NCB

Compression Drill Guide 4.0mm Screws

02.00024.360

NCB

Drill Bit ∅ 4.0mm, with quick coupling, L. 245mm

02.00024.361

NCB

Drill Guide ∅ 4.0mm, long

NCB Provisionals

REF Description

02.00024.358 NCB Curved Femur Shaft Plate Provisional, 10/12/14 hole plates

02.00024.401 NCB Straight Narrow Shaft Plate Provisional, 8/10/12 hole plates

02.00024.402 NCB Straight Narrow Shaft Plate Provisional, 14/16/18 hole plates

Optional Instruments

If using non-sterile plates the NCB Shaft Plate Add-On Set needs to be provided as well. Outside lag screw instrumentation can

also be found in the NCB Shaft Plate Add-On Set if needed.

30 NCB® Large Fragment System – Surgical Technique

NCB Instruments for Overdrilling into Cement for NCB Screws ∅ 4.0mm and 5.0mm

REF Description

02.00024.325 NCB Drill Bit ∅ 3.5mm, with quick coupling, L. 195mm

02.00024.326 NCB Drill Guide ∅ 3.5mm

02.00024.330 NCB Drill Bit ∅ 4.5mm, with quick coupling, L. 195mm

02.00024.331 NCB Drill Guide ∅ 4.5mm

NCB Compression Drill Guides

REF Description

02.00024.335 NCB Compression Drill Guide for ∅ 5.0mm screws

REF Description

02.02024.344 NCB Drill Bit ∅ 3.3mm, with quick coupling, L=245mm

02.02024.346 NCB Drill Bit ∅ 4.3mm, with quick coupling, L=245mm

02.02024.360 NCB Drill Bit ∅ 4.0mm, with quick coupling, L=245mm

Sterile Instruments

REF Description

00-5900-099-00 Generic Stackable Lid Assembly

02.00024.930 NCB Shaft Plate Add-On Set

02.00024.931 NCB Shaft Plate Add-On Set – Base

02.00024.932 NCB Shaft Plate Add-On Set – Screw Caddy

02.00024.933 NCB Shaft Plate Add-On Set – Top Tray

02.00024.934 NCB Shaft Plate Add-On Set – Bottom Tray

Graphic Cases for the NCB Shaft Plate Add-On Set

NCB Long Instruments

REF Description

02.00024.340 NCB Tap ∅ 4.0mm, with quick coupling, L. 250mm

02.00024.341 NCB Tap ∅ 5.0mm, with quick coupling, L. 250mm

02.00024.344 NCB Drill Bit ∅ 3.3mm, with quick coupling, L. 245mm

02.00024.345 NCB Drill Guide ∅ 3.3mm, long

02.00024.346 NCB Drill Bit ∅ 4.3mm, with quick coupling, L. 245mm

02.00024.347 NCB Drill Guide ∅ 4.3mm, long

Additional Instruments

NCB® Large Fragment System – Surgical Technique 31

Planning Aid

NCB Curved Femur Shaft Plate X-ray Template

Lit.No. 06.02026.000

Lit.No. 97-2370-050-03 (US only)

NCB Straight Narrow Shaft Plate X-ray Template

Lit.No. 06.02263.000

Lit.No. 97-2370-007-00 (US only)

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

Copyright 2012 by Zimmer GmbH Printed in Switzerland Subject to change without notice

Lit.No. 06.02256.012 – Ed. 2012-10 ZHUB

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 advice in whole or in part.

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

warnings, precautions, and adverse effects.