S3 Prox Humerus Surgical Technique

2016-04-01

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Surgical Technique

Proximal Humerus

Plating System

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One Surgeon. One Patient.

Contents

Introduction .................................................................................................................................................................. 3

S3 Proximal Humerus Plating System .......................................................................................................................... 4

Deltopectoral Approach ............................................................................................................................................... 6

Surgical Technique ....................................................................................................................................................... 8

Ordering Information .................................................................................................................................................. 14

S3 Proximal Humerus Plating System

Biomet’s experience in developing implants for fracture

ﬁxation through locked plating technology has been used

to design the S3 plate for the management of proximal

humerus fractures. The S3 Proximal Humerus Plate takes

full advantage of the principle of spatial subchondral

support successfully applied in the design of its sister

product, the DVR Crosslock distal volar radiuwws plate.

The S3 system is designed around the natural anatomy

of the proximal humerus to address varus collapse.

Convergent and divergent ﬁxed angle pegs are centered

around the natural 135° neck-shaft angle of the proximal

humerus. The central guiding k-wire provides visual

conﬁrmation for plate positioning, ensuring that the pre-

determined peg trajectories will provide consistent spatial

distribution within the humeral dome. This unique concept

of humeral ﬁxation helps resist varus forces throughout the

full range of motion.

The S3 plate has been designed to help prevent subacromial

impingement. The unique design of the S3 allows the

plate to be positioned more distally, minimizing the risk of

impingement.

The S3 pegs and screws utilize blunt smooth ends so that

ﬁxation can be provided directly below the hard articular

shell. Engaging the subchondral bone with blunt ﬁxation

and the use of a manually inserted blunt-tipped drill bit

reduces the risk for articular surface penetration.

Indications

The S3 Proximal Humerus Plate is indicated for fractures

and fracture dislocations, osteotomies, and non-unions of

the proximal humerus.

Surgical Approach

Proximal Humeral fractures are treated with the

S3 Proximal Humerus Plating System through the

deltopectoralapproach.

Introduction

135˚

S3 Proximal Humerus Plating System

Provides Strong and Secure Fixation

• The proximal end of the S3 plate has ﬁxed angle

locking pegs/screw holes. Its parametric design

of convergent and divergent screw peg trajectories

ensures a consistent spatial distribution of the

pegs within the entire humeral head. This particular

distribution provides spatial subchondral support to

resist varus forces throughout the full range of motion.

• 4.0 mm blunt tipped subchondral support smooth

or threaded pegs provide stability while preventing

protrusion through the articularsurface.

• Proximal and distal locking pegs and screws provide

a strong interface for a stable ﬁxation.

3.0 cm

Minimizes Subacromial Impingement

• The S3 plate is designed to be positioned

approximately 3.0 cm distal to the greater tuberosity

helping to prevent subacromial impingement

Minimizes Varus Collapse

• The parametric design of the pegs distribute the loads

more anatomically through the full range of motion by

maintaining the neck shaft angle of 135º minimizing

the risk of varus collapse.

Central K-wire

Central K-wire hole provides a guide for initial plate

positioning through the use of fluoroscopy and

temporary fixation.

F.A.S.T. Guide Technology

The S

plate comes preloaded with Fixed

Angle Screw Targeting Guides – F.A.S.T. Guide

Technology – facilitating accurate drilling and easy

plate identification (left vs right).

Suture Holes

Suture holes allow for simplified tuberosity repairs

after humeral head fixation through frontal and

lateral access.

User Friendly System Design

Intuitive set layout and simple instrumentation

allow for convenience in surgery.

Ease of Use

S3 Proximal Humerus Plating System

Cephalic vein

Deltopectoral Approach

Patient positioning and approach

The procedure can be performed in the beach-chair

position or supine position (Figure1) as per the surgeon’s

discretion. If necessary, a sterile mayo stand can be used

to assist duringdissection.

Assess the fracture ﬂuoroscopically.

Examine the fracture based on intraoperative ﬂuoroscopy.

Internal rotation, external rotation and sometimes axillary

views are necessary (Figure 2).

Exposure

Make an incision approximately 12–14 cm over the

coracoid process, extending down to the deltoid insertion

in an oblique fashion. Identify and retract the cephalic vein

(Figure 3).

Note: Taking the cephalic vein medially provides additional

protection against perforation during drilling.

Figure 1

Figure 2

Figure 3

Identify the Biceps Tendon

Gently retract the coracobrachialis medially. Find the

pectoralis insertion at the ﬂoor of the deltoid pectoralis

interval (Figure 4). If necessary, release the proximal third

of the pectoralis tendon to expose the biceps.

Complete Exposure

Develop the subacromial space and mobilize the proximal

deltoid (Figure 5).

Note: Use of a large, blunt humeral head depressor can

facilitate exposure.

Fracture Debridement and Reduction

Reduce the humeral head fragments using traction and

manipulation and check the reduction under ﬂuoroscopy

(Figure 6).

Note: In the case of severe comminution, suturing the

rotator cuff together will help reduce the tuberosities. To

facilitate healing, bone graft should be considered.

Figure 4

Figure 5

Figure 6

S3 Proximal Humerus Plating System

Surgical Technique

Plate Positioning

Select the appropriate side plate (lime=left; rose=right)

and length (3, 4, 6, 8, 11 or 14 hole) (Figure 7).

Position the plate 2.5–3.0 cm distal to the greater

tuberosity. The anterior border of the plate (straight border)

should be immediately lateral to the bicepital groove

(Figure 8).

Drill Central K-Wire

Drill the 2.0 mm K-wire (KW20SS) through the central

K-wire hole on the proximal portion of the plate aiming the

center of the humeral head (Figure 9).

Figure 7 Figure 8

Figure 9

135˚

Verify Central K-Wire

Check the trajectory of the central K-wire under ﬂuoroscopy.

If there’s a deviation from the center of the humeral head

remove the K-wire and redrill until the center is reached

(Figure 10).

Note: Verify the positioning of the central k-wire, it should

be in the center/ center position and centered on Anterior

Posterior and Laterial views.

Note: Other distal K-wire holes can be used to aid in

fracture reduction and provisionally ﬁx the plate to the bone.

Distal Plate Provisional Fixation

Drill through the oblong hole of the plate shaft with the

2.8 mm Drill Bit (DB28) using the Soft Tissue Protector

(SSTG) (Figure 11).

Determine the required screw depth using the Depth

Gauge (SBDG) (Figure 12).

Figure 10

Figure 11

Figure 12

S3 Proximal Humerus Plating System

and posterior inferior peg holes ﬁrst, and then ﬁnish

by drilling the remaining proximal holes in a crisscross,

opposing fashion (Figure 14).

Manual Drill for Subchondral Support Pegs

To prevent the drill from protruding through the rear cortex

the following step should be made by manual drilling

(Figure 15).

With the 4.0 mm Long Drill Bit (FDB40L or FDS40)

attached to the Driver Handle (QCH), advance through the

proximal plate hole F.A.S.T. Guide inserts until resistance

from subchondral bone is felt. This will ensure the peg

engages subchondral bone for optimal ﬁxation.

Note: Do not use powered drilling for inserting the

subchondral pegs. When manual drilling for smooth pegs

use the Long Drill Bit (FDB40L). When manual drilling for

partially threaded pegs use the Step Drill Bit (FDS40).

Note: Make multiple passes with the hand drill (FDB40L)

to remove all material before inserting pegs.

Fix the plate into place with a 3.8 mm Multidirectional

Cortical Screw (MD20-MD38) using the Hex Driver (FHDS)

(Figure 13).

Note: Do not fully tighten the screw to allow for later plate

adjustments.

Note: Insert the second kickstand k-wire and/or the screw

in the oblong hole, to reduce the possibility of the plate

and fragments moving.

Proximal Plate Fixation

Drill through the inferior anterior F.A.S.T. Guide inserts

with the 4.0 mm Short Drill Bit (FDB40S), and perforate

the cortex. The drill bit has a stop that will only allow it to

penetrate the near cortex.

Note: The K-wire can be bent to avoid drill bitobstruction.

Note: Fully seat the FDB40S (Short drill bit) into the F.A.S.T

Guide before turning on power

Note: To aid with peg engagement, start with the anterior

Figure 13

Figure 14

Figure 15

Determine Peg Length

Once resistance is felt, ﬂuoroscopy imaging should verify

that the tip of the manual drill is close to the subchondral

bone (Figure 16). Care should be taken not to penetrate

the subchondral bone. Use the appropriate side of the

dual scale drill bit to determine the correct peg size.

Note: If a F.A.S.T. Guide insert was removed before the

screw length was recorded, insert the 4.0mm Drill Guide

(DRGSH) and measure using the appropriate side of the

dual scale stepped Depth Gauge (FSDGS).

Peg Insertion

Remove and discard the respective F.A.S.T. Guide inserts

(Figure 17) and insert the appropriate size peg using the

Hex Driver (FHDS) (Figure 18).

Note: If the pegs do not engage initially, re-insert the

F.A.S.T. Guide insert or drill guide (DRGSH) and drill again

using the hand drill (FDB40L)

Figure 16 Figure 18

Figure 17

S3 Proximal Humerus Plating System

Attach Tuberosities to Plate

Secure the tuberosities to the plate by passing the needles

close to the insertion of the tendon and then through to

side, front or top loading wire attachment points found on

the proximal end of the plate (Figure 19).

Note: An alternate approach is to apply the sutures to

the plate prior to placing the subchondral support pegs.

This may aid in reduction.

Insert Distal Screws

Use the appropriate end of the Soft Tissue Protector

(SSTG) and drill to the far cortex with the 2.8 mm Drill Bit

(DB28) (Figure 20). Measure with the Barrel Depth Gauge

(SBDG).

Fix the remaining Shaft Cortical Screws with either 90º

Locking Screws (NL20-NL38; NLSS) or Multidirectional

Screws (MD20-MD38) (Figure 21).

Use a Set Screw (NLSS) to lock each 90º Screw to the

plate. Do not use a set screw when using Multidirectional

Screws.

Figure 19 Figure 21

Figure 20

Final Veriﬁcation

Evaluate the humerus under ﬂuoroscopy to assess

the reduction and to conﬁrm proper plate positioning

(Figure 22 & 23).

Figure 22 Figure 23

S3 Proximal Humerus Plating System

Ordering Information

Smooth Peg, Locking

Provide spatial subchondral support.

Cat No: Size:

STP20 20 mm

STP25 25 mm

STP30 30 mm

STP325 32.5 mm

STP35 35.5 mm

STP375 37.5 mm

STP40 40 mm

STP425 42.5 mm

STP45 45 mm

STP475 47.5 mm

STP50 50 mm

STP525 52.5 mm

STP55 55 mm

STP575 57.5 mm

STP60 60 mm

STP625 62.5 mm

STP65 65 mm

Threaded Pegs, Locking

Help to capture and lag the humeral head.

Cat No: Size:

STPT20 20 mm

STPT25 25 mm

STPT30 30 mm

STPT325 32.5 mm

STPT35 35 mm

STPT375 37.5 mm

STPT40 40 mm

STPT425 42.5 mm

STPT45 45 mm

STPT475 47.5 mm

STPT50 50 mm

STPT525 52.5 mm

STPT55 55 mm

STPT575 57.5 mm

STPT60 60 mm

STP625 62.5 mm

STP65 65 mm

Pegs and Screws

90˚ Cortical Screws, Non-locking

Provide bi-cortical fixation while locking to the

plate using the NLSS set screws.

Cat No: Size:

NL20 20 mm

NL22 22 mm

NL24 24 mm

NL26 26 mm

NL28 28 mm

NL30 30 mm

NL32 32 mm

NL34 34 mm

NL36 36 mm

NL38 38 mm

Multi-directional Cortical Screws,

Non-Locking

Provide multi-directional fixation when used

through the oblong hole.

Cat No: Size:

MD20 20 mm

MD22 22 mm

MD24 24 mm

MD26 26 mm

MD28 28 mm

MD30 30 mm

MD32 32 mm

NL34 34 mm

NL36 36 mm

MD38 38 mm

90˚ Locking Set Screw

Secures the 90˚ lock distal screws to the plate.

Cat No: NLSS

S3 Plate, 3 Holes:

16 mm x 71 mm

SSPL3 / SSPR3

S3 Plate, 4 Holes:

16 mm x 84 mm

SSPL4 / SSPR4

S3 Plate, 6 Holes:

16 mm x 108 mm

SSPL6 / SSPR6

S3 Plate, 8 Holes:

16 mm x 150 mm

SSPL8 / SSPR8

S3 Plate, 11 Holes:

16 mm x 190 mm

SSPL11 / SSPR11

S3 Plate, 14 Holes:

16 mm x 236 mm

SSPL14 / SSPR14

S3 Proximal Humerus Plating System Options

Lime=Left; Rose=Right

The S3 plate, pegs and screws are manufactured from 316L Stainless Steel.

S3 Proximal Humerus Plating System

Top Tray

1 SSTG Soft Tissue Guide

2 DB28 Drill Bit 2.8 mm

3 SBDG Depth Gauge

4 FHDS Hex Driver

5 FDB40S Drill Bit 4.0 mm Short

6 DRGSH Drill Guide 4.0 mm

7 FDS40 Drill Bit 4.0 mm Step

8 QCH Quick Connect Handle

9 FDB40L Drill Bit Fast 4.0 mm Long

10 SDI Square Driver Insert 2.0mm

11 FSDGS Depth Gauge Step Shoulder Fast

12 MQC Mini Quick Connect Handle

KW20SS K-wire 2.0 mm SS

1 2

Bottom Tray

SSPL03 3 Hole Plate, Left

14 SSPL04 4 Hole Plate, Left

15 SSPL06 6 Hole Plate, Left

SSPL08 8 Hole Plate, Left

16 SSPL14 14 Hole Plate, Left

17 SSPL11 11 Hole Plate, Left

SSPR03 3 Hole Plate, Right

18 SSPR04 4 Hole Plate, Right

19 SSPR06 6 Hole Plate, Right

SSPR08 8 Hole Plate, Right

20 SSPR11 11 Hole Plate, Right

21 SSPR14 14 Hole Plate, Right

S3 Proximal Humerus Plating Modular Tray

1716

15 19

20 21

• The SNP Anatomic Plate Module Tray contains all SNP Anatomic Plate components

• All other instruments and pegs/screws are found in the S3 Proximal Humeral Tray System

The SNP Proximal Humeral Plating System provides the surgeon with a less invasive option than the S3 Proximal Humerus plate for fractures of

the proximal humerus. The SNP combines the proximal stability of fixed angle locking pegs and suture attachments with the minimal soft tissue

disruption of an intramedullary nail.

SNP Shoulder Nail Plate

S3 Proximal Humerus Plating System

Indications:

The S3 Shoulder FIxation System is indicated for fractures

and fracture dislocations, osteotomies, and non-unions of

the proximal humerus.

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.

This material is intended for health care professionals and the Biomet sales

force only. Distribution to any other recipient is prohibited. All content herein is

protected by copyright, trademarks and other intellectual property rights owned

by or licensed to Biomet Inc. or its aliates unless otherwise indicated. This material

must not be redistributed, duplicated or disclosed, in whole or in part, without the

express written consent of Biomet.

Check for country product clearances and reference product specic instructions

for use. For complete product information, including indications, contraindications,

warnings, precautions, and potential adverse eects, see the package insert and

Biomet’s website.

This technique was prepared in conjunction with a licensed health care professional.

Biomet does not practice medicine and does not recommend any particular

orthopedic implant or surgical technique for use on a specic patient. The surgeon

is responsible for determining the appropriate device(s) and technique(s) for each

individual patient.

Not for distribution in France.

Legal Manufacturer

Biomet Trauma

56 East Bell Drive

P.O. Box 587

Warsaw, Indiana 46581

USA

www.biomet.com

Authorised Representative

Biomet UK Ltd.

Waterton Industrial Estate

Bridgend, South Wales

CF31 3XA

0086

S3 Prox Humerus Surgical Technique

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