Zimmer ITST® Intertrochanteric/ Subtrochanteric Fixation System MIS And Standard Surgical Technique ITST Intertroch Subtroch

: Pdf Zimmer Itst Intertroch Subtroch Mis Standard Surgical Technique Zimmer_ITST_Intertroch_Subtroch_MIS__Standard_Surgical_Technique 3 2016 pdf

Open the PDF directly: View PDF .
Page Count: 32

Zimmer® ITST ®

Intertrochanteric/

Subtrochanteric

Fixation System

MIS and Standard

Surgical Technique

ITST® System MIS and Standard Surgical Technique 1

Surgical Technique

for Fixation with ITST

Intramedullary

Nail System

This technique is written for standard

or MIS procedure. Differences between

the standard and MIS techniques

are noted.

Table of Contents

Indications 2

Surgical Technique 3

Preoperative Planning 3

Patient Positioning 3

Reduction 4

Radiographic Control 4

Prep and Drape 4

Starting Point and Steinman Pin Insertion and Incision

Using Long Cannulated Awl 5

Incision 5

Creating the Entry Portal 5

Guide Wire Placement 6

Measure 6

Reaming 7

Guide Assembly 8

Nail Assembly 8

Nail Insertion 9

Monitoring Insertion 10

Screw Options 10

Lag Screw Positioning 11

Lag Screw Preparation 12

Lag Screw Insertion with ITST Compression Device 15

Standard Lag Screw Insertion (Optional) 16

Anti-Rotation Screw Insertion 17

Distal Screw Fixation –

180mm/Short Nails 18

Distal Screw Fixation –

Long Nails – Freehand Technique 20

Completion 22

Closure and Postoperative Care 24

Extraction 24

Implant and Instrument Case Options 25

ITST® System MIS and Standard Surgical Technique

2

The ITST Intramedullary Nail System

is designed to treat comminuted,

proximal and distal fractures of the

femur, including, the Intertrochanteric

and Subtrochanteric regions. The

implant supports the anatomic

reduction and internal fixation of the

femoral head and neck.

The ITST Intramedullary Nail System

features a sliding or non-sliding Lag

Screw. System includes options for

dynamic and static distal locking.

Indications

The ITST Intramedullary Nail is indicated

for use in a variety of femoral fractures,

such as:

• Subtrochanteric Fractures

• Intertrochanteric Fractures

• Comminuted Fractures

• Segmental Fractures

• Fractures with Bone Loss

• Proximal and Distal Fractures

• Nonunions

WARNING: The surgeon should be

aware that use in osteoporotic bone,

or improper placement of the nail-

screw construct could increase the

risk of failure or cut out of the implant.

ITST® System MIS and Standard Surgical Technique 3

Surgical Technique

Preoperative Planning

The ITST Fixation System implants are

designed to place the Lag Screw at

130°, with 15° of anteversion on the

long nails, to accommodate the most

common anatomic femoral neck angle.

A/P and lateral C-arm images should be

obtained prior to the surgical procedure.

NOTE: The suitability of this implant

for the patient should be determined

by templating prior to surgery using

X-rays of the affected femur.

An A/P preoperative X-ray should be

taken of the contralateral hip or of

the affected limb once an anatomic

reduction has been achieved.

X-rays taken at a 36-inch distance from

the source result in 10-15 percent

magnification of the bone. An Ossimeter,

which takes this magnification into

account, should be used to help

determine the actual nail length and

diameter to be used. The angle of the

intersection of the femoral shaft axis

andfemoral neck axis should be

observed. The ITST Implant Templates

reflect a 15 percent magnification of

actual size.

Patient Positioning

The patient may be placed in either the

supine (free legged or traction)

or lateral (traction) position.

(1) SUPINE FREE LEGGED – Place the

patient supine on a radiolucent table

(Fig. 1). The table should not have a

central pole or metal sidebars. Place

the patient’s buttock next to the edge

of the table with a radiolucent bump

(not a bean bag) under the buttock.

The eccentric position and elevated

buttock improves starting site posi-

tion and reduces drape encroachment.

Furthermore, the elevated buttock

enhances fluoroscopic lateral

viewing of the femoral head and neck.

The ipsilateral upper trunk and

extremity should angle towards the

contralateral shoulder. The ipsilateral

arm should be placed above the chest

on an arm holder or on a pillow with

stockinet. This upper extremity

placement improves starting point

entry and unencumbered implant

insertion.

(2) SUPINE TRACTION ON FRACTURE

TABLE – Place the patient supine on the

fracture table (Fig. 2). Pad all areas of

potential pressure. Flex and abduct the

non-injured leg onto a well padded leg

holder. Or, place the non-injured

leg into a scissor type position.

Position the buttock of the injured

leg as close to the edge of the table

as possible. Some tables will allow

for an eccentric peroneal post

connection to the table. Make sure

the peroneal post is padded and wide

in order to dissipate the pressure on

the groin area.

Place the injured leg into skeletal

traction (distal femoral or proximal

tibial) or boot-traction. The ipsilateral

arm should be placed above the chest

on an arm holder or on a pillow with

stockinet.

(3) LATERAL TRACTION ON FRACTURE

TABLE – Use the radiolucent table with

a radiolucent peroneal post. Place the

traction boots on the patient during

anesthesia induction. Turn the patient

in a lateral position, with the operative

leg over the top of the peroneal post.

Attach the boots to the table with

straight traction applied through

the boots.

Fig. 1

Fig. 2

ITST® System MIS and Standard Surgical Technique

4

If heavy traction is necessary, a pin is

placed in the distal femur and the knee

is flexed, applying traction through

the pin. Flex and adduct the operative

leg. Straighten the non-operative

leg in line with the body. Rotate the

patella slightly inwards towards the

floor, to help prevent an external

rotation deformity. Bring the C-arm in

perpendicular to the long axis of the

femur. When moving proximally and

distally, the entire C-arm is moved, to

stay perpendicular to the long axis. To

visualize the proximal femur and the

head, rotate the C-arm 15° over the top

and tilted 45° cephalad.

Patient Positioning for

Standard Technique

The patient should be placed in

either the supine or lateral decubitus

position on the table. The sacral rest

and perineal post should be well

padded. In multiple trauma patients,

the supine position may be used for

easier access to the patient’s airway,

as well as to facilitate the treatment

of other injuries. The supine position

also facilitates fracture reduction

and rotational alignment of

the femur.

Reduction

It is critical to reduce the fracture before

beginning the surgical procedure. An

anatomic reduction or a slight valgus

reduction of the femoral head and

neck, should be seen in the A/P film.

Occasionally, a slight sag of the fracture

may be seen on the lateral view. This

should be taken into consideration

during the surgical procedure.

Occasionally, flexion of the injured

limb will facilitate sagittal reduction.

As a rule of thumb, intertrochanteric

fractures are locked into position with

internal rotation of the leg. The patella

should point towards the ceiling.

Prep and Drape

The prep includes the ipsilateral

axilla, trunk, buttock, hip, thigh

(circumferentially), and knee. The drape

should extend up to the axilla with

U-shaped drapes. The free trunk and

buttock skin improves nail insertion

and diminishes guide entrapment on

the drapes. Furthermore, the free area

increases the freedom for percutaneous

insertion and incision closure. The

drape should extend past the knee to

allow for distal interlock insertion.

Prep and Drape for

Standard Technique

Prep and drape similar to the MIS

technique, although it is only

necessary to drape proximally to the

distal portion of the thoracic cavity

for the standard technique, not all

the way to the axilla. If the patient is

obese, prep and drape to the axilla

and use a more proximal entry point.

Fracture Site Reduction After

Prep and Drape

An attempt at fracture site reduction

should be performed initially to

facilitate the starting site placement,

central reaming, and nail-screw

insertion. The rotation and alignment

should have been performed before the

prep and drape. In fractures with varus

alignment despite traction, placement

of the patient in a lateral position of the

percutaneous reduction instruments

can help assist the reduction. A spike

pusher or tenaculum clamp can be

inserted through a 25 to 30mm

incision to realign the proximal

fragment. The classic flexion,

abduction, and external rotation of the

proximal fragment requires reduction

at this time. A spike pusher or

tenaculum clamp in an anterior to

posterior direction will help

accomplish the reduction.

For Pertrochanteric or Subtrochaneric

fractures (especially with involvement

of the lesser trochanter) the fracture

is reduced with the leg in external

rotation. Oblique roll over or roll

back fluoroscopic views can assist

visualization of proper rotation. This is

most important when considering the

starting point of the Steinman Pins or

cannulated awl into the femur.

Radiographic Control

NOTE: 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 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.

ITST® System MIS and Standard Surgical Technique 5

Starting Point and Steinman

Pin Insertion and Incision Using

Long Cannulated Awl

Palpate the line of the femur starting

at the greater trochanter. Continue

this line of insertion proximally until

reaching the level approximating the

iliac crest (more proximal with obese

patients) (Fig. 3).

Using a sterile marking pen, mark the

line of intersection between these two

lines; this corresponds to the insertion

site. Insert the 3.2mm terminally

threaded Steinman pin through the

soft tissues. The correct starting point

on the AP view is the medial half of the

greater trochanter. The correct starting

point on the lateral view corresponds

to the central half of the femoral neck.

An optional cannula can also be used

to help guide the pin into the correct

position. The cannula is inserted

through a 25mm incision at the level of

the iliac crest. The cannula can also be

used to protect tissues while reaming.

Fig. 4

Fig. 3

Incision

Use a #15 blade to create an incision

centered around the Steinman pin.

The incision needs to be only

15mm-20mm in length.

Starting Point and Incision

for Standard Technique

Begin the skin incision 1cm proximal

to the tip of the greater trochanter,

and extend it proximally for about

5cm in a longitudinal direction.

Continue the incision down through

the subcutaneous tissues and

split the fascia lata.

Creating the Entry Portal

Insert the terminally threaded Steinman

pin through the greater trochanter

down to the level of the lesser

trochanter (about 8cm). Ream using the

8mm trochanteric reamer (for

comminuted fracture lines extending

into or around the insertion site)

followed by the 17mm trochanteric

reamer (initially for fractures without

fracture lines extending into the

starting site). The reamers can be

inserted freely through the soft tissues

or through the cannula. The entry

portal should be in line with the

planned nail insertion and should line

up with the femoral canal on the AP

and lateral views (not aiming to the

medial or anterior cortices).

OPTIONAL TECHNIQUE

A cannulated awl can be used instead

of a guide wire to create the entry

portal. Place the tip of the awl in the

selected starting point (confirm using

bi-planer fluoroscopy). Advance the

awl through the greater trochanter into

the canal in line with the planned nail

insertion (Fig. 4).

ITST® System MIS and Standard Surgical Technique

6

Fig. 7 Reduction Instruments

Reduction Finger

Balled Spiked Pusher

Bone Hook

Fig. 6

The surgeon determines the proper nail

length using the Nail Length Gauge.

Slide the gauge over the guide wire

until the tip rests along the proximal

aspect of the greater trochanter (Fig. 8).

The proper nail depth will be deter-

mined by individual anatomy, varus or

valgus reduction, and most importantly

by the position of the lag screw within

the central aspect of the femoral head.

Reaming

Fig. 8

Guide Wire Placement

On the back table, attach the 3.0mm

Bulb-tipped Guide Wire to the Wire Grip

T-Handle, and tighten (Fig. 5). To aid in

manipulation, bend the tip of the guide

wire at about a 10 degree angle 5cm

from the end.

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.

NOTE: If using a cannulated awl, the

3.0mm Bulb-Tipped Guide Wire may be

passed directly through the cannulated

awl without the 45° bend (Fig. 6).

Insert the Guide Wire through the

entry hole and manipulate it down the

proximal femur across the fracture site.

At the fracture site, manipulate the Guide

Wire under C-arm control across the

Bulb-tipped

Guide Wire

Fig. 5

Wire Grip

T-Handle

fracture site. If reductionof the abducted

and flexed hip is difficult, place pressure

on the proximal fragment, either with

the hand or directly with a reduction

rod or other instrument. An alternative

technique is to reduce the fracture using

the Reduction Instruments shown in

Figure 7.

The reduction finger can also be used to

assist in reduction if the surgeon creates

an initial oblique starting portal. Once

in the distal canal, pass the wire to the

distal epiphyseal scar. Gently tap the

guide wire into the dense distal bone, so

that the wire will not retract with reamer

removal.

Measure

ITST® System MIS and Standard Surgical Technique 7

Fig. 9

Pressure Sentinel

Reamer

Over-reaming the canal by one or two

millimeters may facilitate preparation

of the bone to accommodate the

implant. The trochanteric region

should be reamed to 17mm using the

Trochanteric Reamer for all patients to

accommodate the implant and avoid

separation or widening of known or

unknown fracture lines (Fig. 10). Use

caution in advancing the Taper Reamer.

An alternative to reaming with the

Taper reamer is to sequentially ream

with a Pressure Sentinel Intramedullary

Reamer to 17mm diameter.

Ream to the level of the lesser trochanter

(or about 8cm depth), to accommodate

the implant by advancing the Taper

reamer into the proximal canal opening

until the reamer flutes are sunk to the

level of the lesser trochanter (Fig. 11).

Confirm position using the C-arm.

Replace the Bulb-Tipped Guide Wire with

the Smooth Guide Wire through the

Exchange Tube.

If using a 3.0mm Ball-Tip Guide Wire

that has a gold-coated end [Part

numbers 00-2255-008-01 or 47-2255-

008-11 (sterile)], the Ball-Tip Guide

Wire can remain in place and removed

after nail insertion. Otherwise, replace

the Bulb-Tipped Guide Wire with

the Smooth Guide Wire through an

Exchange Tube.

NOTE: Reaming amounts will depend

on the quality of the bone present,

the minimum diameter of the femoral

shaft, and the amount of femoral

curvature present.

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.

The ITST MIS Cannula can be inserted

into the incision to protect the soft

tissue while reaming. Thread the

Centering Bushing into the Cannula

and place the Cannula firmly against

the bone. Remove Centering Bushing.

Ream the femoral canal sequentially

in 0.5mm increments using the Long

Pressure Sentinel® Intramedullary

Reaming System (Fig. 9). Ream until

cortical chatter is experienced. Based

on bone quality and curvature of

radius, nail diameter is 1-2mm less

than the last reamer used.

Taper

Reamer

Fig. 10

Fig. 11

ITST® System MIS and Standard Surgical Technique

8

Guide Assembly

Thread the connecting bolt all the way

through the blue Modular Targeting

Arm. Attach the blue Modular

Targeting Arm to the Barrel using

the Connecting Bolt. Tighten the

Connecting Bolt by hand (Fig. 12).

Twist the Targeting Arm Nut on to the

end of the Blue Targeting Guide in

preparation for lag screw insertion

(Fig. 13). The Nut should not be

tightened at this point.

Proximal

Targeting Guide

Assembly

Fig. 14

Locking Bolt

Nail Assembly

Select the appropriate size ITST

Femoral Nail.

Slide the ITST Locking Bolt through

the barrel (Fig. 14). Approximate

the nail to the external “keys” on

the barrel.

Fig. 12

Barrel

Fig. 13

Connecting Bolt

Targeting Arm

Targeting Arm Nut

ITST® System MIS and Standard Surgical Technique 9

Fig. 17

Correct Alignment:

arrow to arrow

Lag Screw

Bushing

Fig. 18

Guide Pin

Locking Bolt

Inserter

Fig. 16

Nail Insertion

NOTE: Prior to inserting the implant,

insert the two sets of Drill and Screw

Bushings into the appropriate holes

in the Targeting Guide. Slide a drill or

guide pin through the Bushings, and

through the screw holes in the implant

to assess correct instrument assembly

(Fig. 18).

Nail may be inserted by hand.

If insertion cannot be achieved by

hand, please see note on page 10.

Insert nail (assembled with targeting

guide) into the femoral canal.

Fig. 15

Key and

Keyway

NOTE: The Guide is universal and it is

critical that the nail be properly aligned

with the Guide for a Left or Right

implant. Line up the keys of the

Guide with the keyways of the nail

so that they fit snugly (Fig. 15).

Place the T-Handled Locking Bolt

Inserter into the guide barrel (Fig. 16).

Toggle and rotate the Inserter slightly

until it seats into the teeth of the

Locking Bolt. The etched arrow at the

proximal rim of the nail should be

exactly aligned with the arrow on the

distal rim of the Targeting Guide

(Fig. 17). Using downward pressure on

the Locking Bolt Inserter, thread the

Locking Bolt into the threads of the

proximal end of the nail until secured.

Completely tighten.

ITST® System MIS and Standard Surgical Technique

10

Monitoring Insertion

Monitor the progression of the nail

down the canal using a C-arm.

A percutaneous 3.2mm Threaded Guide

Pin may be placed along the anterior

axis of the femoral neck paralleling

the femoral neck on the AP and lateral

views to mark the correct anteversion.

Align the Targeting Guide parallel (on

the lateral view) to the percutaneous

pin to assure that accurate implant

anteversion has been achieved. Check

the final position of the implant using

C-arm. If the nail fails to progress easily

down the canal, remove it, and use a

smaller nail, or over-ream the canal in

0.5mm increments until the implant

passes more easily down the femoral

canal. The surgeon should also check

the status of the nail in the distal

femur. If the nail is too long, a shorter

nail should be used to avoid distal

femoral cortical or articular penetration.

If the curvature of the femur does

not accommodate the nail, using

a shorter or smaller nail will assist

nail placement.

NOTE: If nail insertion can not be

achieved by hand, thread the Small

or Long Threaded Driver on the Barrel

(Fig. 19). Insert the nail into the canal

using a series of gentle impactions, if

necessary, on the Threaded Driver until

the nail is seated at the desired depth.

Mallet

Fig. 19

Top of the Proximal

Targeting Guide

CAUTION: Do not impact directly on

the ITST Targeting Guide or Barrel.

Screw Options

The ITST Nail accommodates both an

11mm Lag Screw and a 6.5mm

Anti-Rotation Screw. The Anti-Rotation

Screw may be utilized in the case of

certain fractures, where the bone stock

and femoral neck/head bone stock is

able to accommodate it. If only one screw

is used, it must be the 11mm Lag Screw.

NOTE: The 6.5mm Anti-Rotation Screw

may be used to enhance fracture

stability if the femoral neck is able to

accommodate it; however, it should

not be used if there is any concern that

the femoral head or neck bone will not

accommodate it.

WARNING: Use of this system in

osteoporotic bone or improper

placement of the nail could increase the

risk of failure or cut out of the implant.

Remember the goal of lag screw

placement is perfect placement into

the central position of the femoral

head on the AP and lateral view.

ITST® System MIS and Standard Surgical Technique 11

Lag Screw Positioning

The projected path of the Lag Screw

into the Femoral Head should be

assessed using the C-arm (Fig. 20).

This may be verified using the Screw

Position Outrigger and the 3.2mm

Threaded Guide Pin. Assemble the

Outrigger into the Modular Targeting

Arm and place a Threaded Guide

Pin into the Anteversion Verification

Hole in the barrel (Fig. 21).

Verify under C-arm that the Guide Pin

appears in the center of the femoral

neck in a superior/lateral view.

This will help prevent any parallax error.

The outer aspect of the windowed arm

of the Outrigger, which lies directly

over the femoral neck, represents the

superior and inferior position of the

Lag and Anti-Rotation Screws (Fig. 22).

If the nail anteversion requires

adjustment, move the nail up or down

in the canal by hand or by gently

impacting the Threaded Driver until

the correct depth is achieved. Check

the position of the nail with the C-arm.

Adjusting nail depth may be useful in

accommodating various femoral

neck anatomies.

NOTE: If the C-arm is off axis, the

alignment of the Outrigger may not

accurately predict the position of Lag

and Anti-Rotation Screws. In the event

this occurs, adjust the position of the

C-arm until it is on axis.

Fig. 20

Lag Screw

Projected Path

Fig. 22

Inferior Lag

Screw Position

Superior Anti-rotation

Screw Position

Fig. 21

ITST® System MIS and Standard Surgical Technique

12

Fig. 25

3.2mm

Threaded

Guide Pin

Subchondral

Bone

Fig. 26

Screw Inserter

Adaptor

Fig. 24

Lag Screw Bushing

8.0mm Drill Bushing

3.2mm Threaded

Guide Pin Bushing

Lag Screw Preparation

NOTE: The 6.5mm Anti-Rotation Screw

may be used to enhance fracture

stability if the femoral neck is able to

accommodate it.

Remove the 3.2mm Guide Wire.

Assemble the Lag Screw Pin Bushing

and Lag Screw Bushing together and

place the assembly into the inferior

screw hole in the Targeting Arm

(Fig. 23). Assemble the 3.2mm Arm

Pin Bushing, the 5.0mm Drill Bushing

and the 8.0mm Screw Bushing and

insert the assembly into the superior

screw hole in the Targeting Arm

(Fig. 24). When both bushings are

inserted, the 8.0mm Drill Bushing will

slide freely in the Targeting Arm. Make

small incisions in the soft tissue and

through the iliotibial band, down to the

lateral cortex of the femur. Be certain

that the bushings are firmly seated on

the bone. Do not force the bushings

or impact.

Insert a 3.2mm Threaded Guide Pin into

the inferior set of bushings. Drill

the Guide Pin to the level of the

subchondral bone of the femoral head,

without penetrating the femoral head

cortex (Fig. 25). Insert a Guide Pin into

the superior set of bushings. The Screw

Inserter Adapter may be used with this

Guide Pin to prevent impingement on

the adjacent Guide Pin during insertion

(Fig. 26). Drill the Guide Pin to the level

of the subchondral bone of the femoral

head, without penetrating the femoral

head cortex. Assess the position of the

Guide Pins using C-arm in the A/P and

lateral planes.

NOTE: Ideally each Guide Pin should

be situated well inside the femoral

neck to allow adequate room for screw

placement without contacting the

cortical wall. If there is not sufficient

cortical wall surrounding the Guide

Pins on examination with the C-arm,

the nail may be repositioned and

implanted using only the Lag Screw.

Fig. 23

Lag Screw

Bushing

ITST® System MIS and Standard Surgical Technique 13

Remove the Lag Screw Pin Bushing.

Slide the Cannulated Depth Gauge

over the lag screw Guide Pin, (i.e. the

inferior of the two guide pins), until the

gauge contacts the lateral aspect of the

femur (Fig. 27). Assess that the Gauge

is seated against the bone using the

C-arm. Read and record the length of

the guide pin from the calibrated

depth gauge.

NOTE: This measurement designates

the correct length of the Lag Screw to

be implanted (Fig. 28).

Slide the Stop Assembly onto the ITST

Lag Screw Reamer, keeping the gold

portion of the Stop Assembly toward

the cutting end of the reamer (Fig. 29).

Move the Stop Assembly along the

incremented lengths listed on the

reamer. Align the threaded end of the

Stop Assembly with the notch denoting

the appropriate length.

Fig. 27

Cannulated

Depth Gauge

Fig. 28 Threaded

Guide Pin

Cannulated

Depth Gauge

Fig. 29

Stop Assembly

Lag Screw Reamer

Gold Knob Gold portion of Stop

Assembly pointed toward

gold cutting edge of reamer

Gold cutting

edge of reamer

ITST® System MIS and Standard Surgical Technique

14

When the Stop Assembly is fully seated,

the arrow on the Stop Assembly will

indicate the appropriate depth level.

This “length” corresponds to the

measurement obtained from the guide

pin (Fig. 30).

Place the ITST Lag Screw Reamer over

the Guide Pin and seat it against the

femoral cortex. Under power, advance

the reamer until the Stop Assembly

stops against the Lag Screw Bushing

(Fig. 31). Monitor progress of the reamer

using the C-arm. Remove the reamer.

If necessary, assemble the Lag Screw

Tap by locking the Stop Assembly at the

level of the appropriate measurement,

in the same fashion as the Lag Screw

Reamer. Place the Lag Screw Tap over

the Guide Pin and through the Lag

Screw Bushing. Advance the tap until

the Stop Assembly stops against the

collar of the Lag Screw Bushing (Fig. 32).

Confirm Tap position with the C-arm.

Fig. 30

Fig. 31

Fig. 32

Stop Assembly

Lag Screw

Reamer

Lag Screw

Bushing

Stop Assembly is flush

against the Lag Screw Bushing

Lag Screw Tap

T-Handle

Gold

ITST® System MIS and Standard Surgical Technique 15

Lag Screw Insertion With ITST

Compression Device

If not using the ITST Compression

Device, proceed to page 16.

Thread the Compressor onto the Lag

Screw Compression Device T-Handle.

Insert Compression Retainer through

the Lag Screw Compression Device

T-Handle (Fig. 33) and thread into

the appropriate Lag Screw until it is

securely fastened to the Lag Screw

Compression Device T-Handle. Pass

the Lag Screw Compression Device

assembly through the Lag Screw

Bushing and over the Guide Pin

(Fig. 34). Thread Lag Screw to within

5mm of the subchondral bone,

monitoring the Lag Screw advancement

with the C-arm.

If planning to use a Nail Cap which

prevents rotation or limits sliding,

rotate the Lag Screw Compression

Device T-Handle (Fig. 35) such that one

of the four etched lines is in line with

the vertical slot on the Targeting Guide.

After inserting the Lag Screw to the

appropriate depth, confirm Lag Screw

position using the C-arm. To begin

compression of the femoral neck,

advance the Compressor clockwise

against the Lag Screw Bushing

(Fig. 36). Continue to advance the

Compressor while monitoring femoral

neck compression using the C-arm,

until the desired fracture reduction

is achieved.

After reduction, unthread the

Compression Retainer from the Lag

Screw. After removing the Compression

Retainer, the Lag Screw Compression

Device Assembly can be removed.

Remove the Superior Guide Pin and

Bushings if used. If using ITST Global

Long Nail, remove Targeting Guide

using the Pin Wrench and Locking

Bolt Extractor.

Fig. 33

Lag Screw Compressor

Compression

Device T-Handle

Compression

Retainer

(Replacement Part 00-2258-097-01)

Fig. 34

Fig. 35

Proximal

Targeting

Guide

Indicator Line

Fig. 36

Rotate Clockwise

ITST® System MIS and Standard Surgical Technique

16

Standard Lag Screw Insertion

(Optional)

Thread the Inserter Link (Fig. 37) into

the Lag Screw until securely fastened.

Slide the Lag Screw Inserter Shaft over

the Inserter Link (Fig. 38).

Insert this assembly over the Guide Pin.

Thread the Lag Screw to within 5mm

of the Subchondral bone. Rotate the

Inserter Shaft (Fig. 39) and align one of

the four etch lines on the Inserter Shaft

with the vertical slot on the Targeting

Guide (Fig. 48). Check the Lag Screw

position using the C-arm. Leave the

Inserter Link attached to the

Lag Screw.

Fig. 37

Lag Screw

Inserter Link

Fig. 38

Fig. 39

Proximal Targeting

Guide Indicator Line

ITST® System MIS and Standard Surgical Technique 17

Anti-Rotation Screw Insertion

Remove the 3.2mm Pin Bushing. Slide

the Cannulated Depth Gauge over the

Guide Pin, until the Gauge contacts

the lateral aspect of the femur. Confirm

the position of the Depth Gauge using

the C-arm. Read the depth of the guide

pin from the Cannulated Depth Gauge.

The Anti-Rotation Screw length should

be 15mm to 20mm shorter than the

depth gauge measurement. This will

provide the proper screw placement

to help minimize femoral neck cutout1

(Fig. 40). Remove the Guide Pin. Under

C-arm control, drill into the femur

with the 5.0mm Drill until the correct

calibration on the drill is level with the

outer collar of the Drill Bushing.

Remove the 5.0mm Drill Bushing and

Drill. Insert the Anti-Rotation Screw

using the 5.0mm T-Handle Screwdriver

through the 8mm Screw Bushing and

into the femoral head until seated.

Placement of the screw should be

monitored using the C-arm.

Fig. 40

1 Baumgaertner, MR, et al., J Bone Joint Surg. AM.

1996 Sep; 78(9):1447-1448.

ITST® System MIS and Standard Surgical Technique

18

Distal Screw Fixation –

180mm / Short Nails

With the Proximal Targeting Guide still

in place, retighten the Locking Bolt if

necessary. Assemble the appropriate

Drill Bushing (see Table 1) into the

8.0mm Screw Bushing, and place

the nested bushings through one of

the distal targeting holes in the ITST

Modular Targeting Guide (Fig. 41).

Make a small incision through the skin

and fascia lata. Spread the soft tissue

down to the bone. Advance the bushing

until it contacts the lateral femoral

cortex. Advance the appropriate size

Drill through the bushings until both

cortices of bone have been penetrated.

NOTE: If using the Calibrated 3.7mm or

5.0mm Drill, read calibrations from end

of bushing to determine screw length.

Table 1.

ITST Global

Nails 180mm Diameter Distal Screw Drill Size

10mm Nail 4.5mm Screw 3.7mm Drill

11mm Nail 5.5mm Screw 5.0mm Drill

12mm Nail 5.5mm Screw 5.0mm Drill

13mm Nail 5.5mm Screw 5.0mm Drill

14mm Nail 5.5mm Screw 5.0mm Drill

15mm Nail 5.5mm Screw 5.0mm Drill

ITST Global

Nails 300-500mm

10mm Nail 4.5mm Screw 3.7mm Drill

11mm Nail 5.5mm Screw 5.0mm Drill

12mm Nail 5.5mm Screw 5.0mm Drill

13mm Nail 5.5mm Screw 5.0mm Drill

14mm Nail 5.5mm Screw 5.0mm Drill

Fig. 41

ITST® System MIS and Standard Surgical Technique 19

OPTIONAL TECHNIQUE

Remove the Drill and Drill Bushing,

and insert the ITST Screw Depth

Gauge through the 8.0mm Screw

Bushing until the gauge captures the

far cortex of bone.

Read the measurement for the screw

from the end of the depth gauge.

NOTE: Choose a screw length that is

at least 2.5mm longer than the depth

measured, to ensure that bicortical

screw fixation is attained.

If the bone quality is good, it may be

necessary to tap the channel using the

4.5mm Tap (Fig. 42).

Place the appropriate length Cortical

Screw onto the 3.5mm T-Handle Hex

Screwdriver and insert the screw into

the bone through the 8.0mm Screw

Bushing, until it is flush against the

lateral cortex of the femur (Fig. 43).

Confirm the position of the screw in the

A/P and lateral views with the C-arm.

Place the second distal locking screw in

the same fashion as the first.

Fig. 43

Fig. 42

Tap

ITST® System MIS and Standard Surgical Technique

20

Distal Screw Fixation – Long

Nails – Freehand Technique

The distal locking screws may be

inserted with a freehand technique

using the Freehand Targeting Device

(Fig. 44). Insert a 3.7mm Drill (Color

Code: Blue) for a 4.5mm screw, or

insert a 5.0mm Drill (Color Code: Green)

for 5.5mm screw into the Freehand

Targeting Device. Finger tighten the

set screw.

Choose the appropriate locking hole

based on the need for dynamization.

The superior locking hole on the ITST

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 dynamization later.

For success with this technique, proper

placement of the lateral X-ray beam

is critical. Position the C-arm so that

the locking hole of the nail appears

perfectly round on the monitor

(Fig. 45 & 46).

When this is achieved, bring the tip

of the 3.7mm Drill 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 the bone. Bring the tip of the

3.7mm Drill to the bone and center it

over the locking hole using the C-arm.

Align the 3.7mm Drill with the axis of

the X-ray beam. Drive the 3.7mm Drill

into the bone and across the hole in

the nail in line with the lateral X-ray

beam (Fig. 47). 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.

Fig. 44

Trocar Drill

Freehand

Targeting Device

Fig. 45

Incorrect

Correct

Incorrect

Correct

Fig. 46

Fig. 47

Bone Drill

ITST® System MIS and Standard Surgical Technique 21

Drill through the medial cortex (Fig. 48

& 49). Remove the Drill and insert the

Distal Screw Depth Gauge (Fig. 50).

The length of the screw is determined

by reading it directly off the Distal

Screw Depth Gauge.

NOTE: 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. 51).

If desired, insert the second screw

in the second locking hole of the nail

in an identical manner. Check the

position of both screws with the C-arm

in the A/P and lateral planes (Fig. 52).

Bushings are available that can be

used with the Freehand Targeting

Device. A separate radiolucent Bushing

Insert is available to aid in targeting.

Fig. 48

Lateral Cortex

Fig. 49

Medial Cortex

Fig. 50

Distal Screw

Depth Gauge

Fig. 51

Distal

Screwdriver

Bi-cortical

Fixation

Fig. 52

Example of

Static Locking

ITST® System MIS and Standard Surgical Technique

22

Completion

Remove the ITST Barrel Targeting Arm,

Threaded Driver and Locking Bolt using

the Locking Bolt Extractor. Take care

to leave the Lag Screw Inserter Link in

place for final Nail Cap seating.

Insert the appropriate Nail Cap: Neutral

Nail Cap (Fig. 53), Sliding Nail Cap

(Fig. 54), or Locking Nail Cap (Fig. 55)

with the Nail Cap Inserter (Fig. 57).

Fig. 53 Neutral Cap* (5mm shown)

Fig. 54 Sliding Cap* (0mm shown)

Fig. 55 Locking Cap* (15mm shown)

* All Nail Caps are available in 0, 5, 10, 15, and

20mm head sizes.

ITST® System MIS and Standard Surgical Technique 23

Fig. 57

Nail Cap Inserter

Nail Cap

Fig. 56

Lag Screw Inserter Shaft

Fig. 58

Tighten until fully seated. If using a

Sliding or Locking Cap, slide the Lag

Screw Inserter Shaft over the Insert Link

and into the Lag Screw (Fig. 57). Slowly

rotate the Lag Screw Inserter and Nail

Cap Inserter until the Nail Cap flange

can be felt seating into one of the four

lag screw shaft grooves (Fig. 56, 57).

Lag Screw/Nail Cap construct in situ.

ITST® System MIS and Standard Surgical Technique

24

Closure and Postoperative Care

Close the proximal wound and apply a

soft compression dressing.

Postoperative range of motion

exercises and weight bearing should be

individually determined by the surgeon

based on patient age, fracture pattern,

and surgeon evaluation.

Extraction

In order to extract the nail, remove any

existing distal screws with the 3.5mm

T-Handle Hex Screwdriver. Remove

the Nail Cap with the 5.0mm T-Handle

Screwdriver. Make a small incision

in the area of the existing proximal

incision to expose the ends of the Lag

Screw and Anti-Rotation Screw. Clear

any bony ingrowth away from the Lag

Screw hex, and thread the Retaining

Shaft into the Lag Screw. Slide the

Lag Screw Inserter into the Lag Screw,

and tighten the Extraction Knob.

Remove the lag screw, turning counter

clockwise, with a slight backward

pulling motion (Fig. 59). Once the Lag

Screw has been removed, use the

5.0mm T-Handled Hexdriver to remove

the Anti-Rotation Screw.

Attach the Extractor Bolt (00-2258-064-

00) into the nail (Fig. 60). Screw the

Slaphammer onto the Extractor Bolt

and remove the nail.

Extraction instruments are not included

in the Standard Set and must be

procured separately.

Fig. 59

Retaining Shaft

Fig. 60

Extractor Bolt

ITST® System MIS and Standard Surgical Technique 25

Implant and Instrument Case Options

Prod. No. Description Size

00-2257-000-07 ITST Asia Set

(contains the following)

00-2256-180-10 Univ L/R Fem IM Nail 10mmDX18cm

00-2256-180-11 Univ L/R Fem IM Nail 11mmDX18cm

00-2256-180-12 Univ L/R Fem IM Nail 12mmDX18cm

00-2256-180-13 Univ L/R Fem IM Nail 13mmDX18cm

00-2256-180-14 Univ L/R Fem IM Nail 14mmDX18cm

00-2256-180-15 Univ L/R Fem IM Nail 15mmDX18cm

00-2257-000-05 ITST Global Short Set

(contains the following)

00-2257-180-10 Univ L/R Fem IM Nail 10mmDX18cm

00-2257-180-11 Univ L/R Fem IM Nail 11mmDX18cm

00-2257-180-12 Univ L/R Fem IM Nail 12mmDX18cm

00-2257-180-13 Univ L/R Fem IM Nail 13mmDX18cm

00-2257-180-14 Univ L/R Fem IM Nail 14mmDX18cm

00-2257-180-15 Univ L/R Fem IM Nail 15mmDX18cm

00-2257-000-06 ITST Global Long Set

(contains the following)

00-2257-300-00 Left Fem IM Nail 10mmDX30cm

00-2257-300-01 Left Fem IM Nail 11mmDX30cm

00-2257-300-02 Left Fem IM Nail 12mmDX30cm

00-2257-300-03 Left Fem IM Nail 13mmDX30cm

00-2257-300-04 Left Fem IM Nail 14mmDX30cm

00-2257-300-10 Right Fem IM Nail 10mmDX30cm

00-2257-300-11 Right Fem IM Nail 11mmDX30cm

00-2257-300-12 Right Fem IM Nail 12mmDX30cm

00-2257-300-13 Right Fem IM Nail 13mmDX30cm

00-2257-300-14 Right Fem IM Nail 14mmDX30cm

00-2257-320-00 Left Fem IM Nail 10mmDX32cm

00-2257-320-01 Left Fem IM Nail 11mmDX32cm

00-2257-320-02 Left Fem IM Nail 12mmDX32cm

00-2257-320-03 Left Fem IM Nail 13mmDX32cm

00-2257-320-04 Left Fem IM Nail 14mmDX32cm

00-2257-320-10 Right Fem IM Nail 10mmDX32cm

00-2257-320-11 Right Fem IM Nail 11mmDX32cm

00-2257-320-12 Right Fem IM Nail 12mmDX32cm

00-2257-320-13 Right Fem IM Nail 13mmDX32cm

00-2257-320-14 Right Fem IM Nail 14mmDX32cm

00-2257-340-00 Left Fem IM Nail 10mmDX34cm

00-2257-340-01 Left Fem IM Nail 11mmDX34cm

00-2257-340-02 Left Fem IM Nail 12mmDX34cm

00-2257-340-03 Left Fem IM Nail 13mmDX34cm

00-2257-340-04 Left Fem IM Nail 14mmDX34cm

00-2257-340-10 Right Fem IM Nail 10mmDX34cm

00-2257-340-11 Right Fem IM Nail 11mmDX34cm

00-2257-340-12 Right Fem IM Nail 12mmDX34cm

00-2257-340-13 Right Fem IM Nail 13mmDX34cm

00-2257-340-14 Right Fem IM Nail 14mmDX34cm

00-2257-360-00 Left Fem IM Nail 10mmDX36cm

00-2257-360-01 Left Fem IM Nail 11mmDX36cm

00-2257-360-02 Left Fem IM Nail 12mmDX36cm

00-2257-360-03 Left Fem IM Nail 13mmDX36cm

00-2257-360-04 Left Fem IM Nail 14mmDX36cm

00-2257-360-10 Right Fem IM Nail 10mmDX36cm

00-2257-360-11 Right Fem IM Nail 11mmDX36cm

00-2257-360-12 Right Fem IM Nail 12mmDX36cm

00-2257-360-13 Right Fem IM Nail 13mmDX36cm

00-2257-360-14 Right Fem IM Nail 14mmDX36cm

00-2257-380-00 Left Fem IM Nail 10mmDX38cm

00-2257-380-01 Left Fem IM Nail 11mmDX38cm

00-2257-380-02 Left Fem IM Nail 12mmDX38cm

00-2257-380-03 Left Fem IM Nail 13mmDX38cm

00-2257-380-04 Left Fem IM Nail 14mmDX38cm

00-2257-380-10 Right Fem IM Nail 10mmDX38cm

00-2257-380-11 Right Fem IM Nail 11mmDX38cm

00-2257-380-12 Right Fem IM Nail 12mmDX38cm

00-2257-380-13 Right Fem IM Nail 13mmDX38cm

00-2257-380-14 Right Fem IM Nail 14mmDX38cm

00-2257-400-00 Left Fem IM Nail 10mmDX40cm

00-2257-400-01 Left Fem IM Nail 11mmDX40cm

00-2257-400-02 Left Fem IM Nail 12mmDX40cm

00-2257-400-03 Left Fem IM Nail 13mmDX40cm

00-2257-400-04 Left Fem IM Nail 14mmDX40cm

00-2257-400-10 Right Fem IM Nail 10mmDX40cm

00-2257-400-11 Right Fem IM Nail 11mmDX40cm

00-2257-400-12 Right Fem IM Nail 12mmDX40cm

00-2257-400-13 Right Fem IM Nail 13mmDX40cm

00-2257-400-14 Right Fem IM Nail 14mmDX40cm

00-2257-420-00 Left Fem IM Nail 10mmDX42cm

00-2257-420-01 Left Fem IM Nail 11mmDX42cm

00-2257-420-02 Left Fem IM Nail 12mmDX42cm

00-2257-420-03 Left Fem IM Nail 13mmDX42cm

00-2257-420-04 Left Fem IM Nail 14mmDX42cm

00-2257-420-10 Right Fem IM Nail 10mmDX42cm

ITST® System MIS and Standard Surgical Technique

26

00-2257-420-11 Right Fem IM Nail 11mmDX42cm

00-2257-420-12 Right Fem IM Nail 12mmDX42cm

00-2257-420-13 Right Fem IM Nail 13mmDX42cm

00-2257-420-14 Right Fem IM Nail 14mmDX42cm

00-2257-440-00 Left Fem IM Nail 10mmDX44cm

00-2257-440-01 Left Fem IM Nail 11mmDX44cm

00-2257-440-02 Left Fem IM Nail 12mmDX44cm

00-2257-440-03 Left Fem IM Nail 13mmDX44cm

00-2257-440-04 Left Fem IM Nail 14mmDX44cm

00-2257-440-10 Right Fem IM Nail 10mmDX44cm

00-2257-440-11 Right Fem IM Nail 11mmDX44cm

00-2257-440-12 Right Fem IM Nail 12mmDX44cm

00-2257-440-13 Right Fem IM Nail 13mmDX44cm

00-2257-440-14 Right Fem IM Nail 14mmDX44cm

00-2257-460-00 Left Fem IM Nail 10mmDX46cm

00-2257-460-01 Left Fem IM Nail 11mmDX46cm

00-2257-460-02 Left Fem IM Nail 12mmDX46cm

00-2257-460-03 Left Fem IM Nail 13mmDX46cm

00-2257-460-04 Left Fem IM Nail 14mmDX46cm

00-2257-460-10 Right Fem IM Nail 10mmDX46cm

00-2257-460-11 Right Fem IM Nail 11mmDX46cm

00-2257-460-12 Right Fem IM Nail 12mmDX46cm

00-2257-460-13 Right Fem IM Nail 13mmDX46cm

00-2257-460-14 Right Fem IM Nail 14mmDX46cm

00-2257-480-00 Left Fem IM Nail 10mmDX48cm

00-2257-480-01 Left Fem IM Nail 11mmDX48cm

00-2257-480-02 Left Fem IM Nail 12mmDX48cm

00-2257-480-03 Left Fem IM Nail 13mmDX48cm

00-2257-480-04 Left Fem IM Nail 14mmDX48cm

00-2257-480-10 Right Fem IM Nail 10mmDX48cm

00-2257-480-11 Right Fem IM Nail 11mmDX48cm

00-2257-480-12 Right Fem IM Nail 12mmDX48cm

00-2257-480-13 Right Fem IM Nail 13mmDX48cm

00-2257-480-14 Right Fem IM Nail 14mmDX48cm

00-2257-500-00 Left Fem IM Nail 10mmDX50cm

00-2257-500-01 Left Fem IM Nail 11mmDX50cm

00-2257-500-02 Left Fem IM Nail 12mmDX50cm

00-2257-500-03 Left Fem IM Nail 13mmDX50cm

00-2257-500-04 Left Fem IM Nail 14mmDX50cm

00-2257-500-10 Right Fem IM Nail 10mmDX50cm

00-2257-500-11 Right Fem IM Nail 11mmDX50cm

00-2257-500-12 Right Fem IM Nail 12mmDX50cm

00-2257-500-13 Right Fem IM Nail 13mmDX50cm

00-2257-500-14 Right Fem IM Nail 14mmDX50cm

Nail Caps

00-2259-007-00 ITST 1-Piece Slide Nail Cap 0mm

00-2259-007-05 ITST 1-Piece Slide Nail Cap 5mm

00-2259-007-10 ITST 1-Piece Slide Nail Cap 10mm

00-2259-007-15 ITST 1-Piece Slide Nail Cap 15mm

00-2259-007-20 ITST 1-Piece Slide Nail Cap 20mm

00-2259-008-00 ITST 1-Piece Lock Nail Cap 0mm

00-2259-008-05 ITST 1-Piece Lock Nail Cap 5mm

00-2259-008-10 ITST 1-Piece Lock Nail Cap 10mm

00-2259-008-15 ITST 1-Piece Lock Nail Cap 15mm

00-2259-008-20 ITST 1-Piece Lock Nail Cap 20mm

00-2259-009-00 ITST 1-Piece NTRL Nail Cap 0mm

00-2259-009-05 ITST 1-Piece NTRL Nail Cap 5mm

00-2259-009-10 ITST 1-Piece NTRL Nail Cap 10mm

00-2259-009-15 ITST 1-Piece NTRL Nail Cap 15mm

00-2259-009-20 ITST 1-Piece NTRL Nail Cap 20mm

00-2257-000-09 Anti-Rotation Screws

(contains the following)

00-2257-060-65 ITST Anti-Rotation Screw 6.5mmDX60mm

00-2257-065-65 ITST Anti-Rotation Screw 6.5mmDX65mm

00-2257-070-65 ITST Anti-Rotation Screw 6.5mmDX70mm

00-2257-075-65 ITST Anti-Rotation Screw 6.5mmDX75mm

00-2257-080-65 ITST Anti-Rotation Screw 6.5mmDX80mm

00-2257-085-65 ITST Anti-Rotation Screw 6.5mmDX85mm

00-2257-090-65 ITST Anti-Rotation Screw 6.5mmDX90mm

00-2257-095-65 ITST Anti-Rotation Screw 6.5mmDX95mm

00-2257-100-65 ITST Anti-Rotation Screw 6.5mmDX100mm

00-2257-105-65 ITST Anti-Rotation Screw 6.5mmDX105mm

00-2257-110-65 ITST Anti-Rotation Screw 6.5mmDX110mm

ITST Asia Lag Screws

00-2256-002-27 Asia 1-Piece Lag Screw 11mmDX70mm

00-2256-002-30 Asia 1-Piece Lag Screw 11mmDX75mm

00-2256-002-32 Asia 1-Piece Lag Screw 11mmDX80mm

00-2256-002-35 Asia 1-Piece Lag Screw 11mmDX85mm

00-2256-002-37 Asia 1-Piece Lag Screw 11mmDX90mm

00-2256-002-40 Asia 1-Piece Lag Screw 11mmDX95mm

00-2256-002-42 Asia 1-Piece Lag Screw 11mmDX100mm

00-2256-002-45 Asia 1-Piece Lag Screw 11mmDX105mm

00-2256-002-47 Asia 1-Piece Lag Screw 11mmDX110mm

00-2256-002-50 Asia 1-Piece Lag Screw 11mmDX115mm

00-2256-002-52 Asia 1-Piece Lag Screw 11mmDX120mm

ITST® System MIS and Standard Surgical Technique 27

ITST Standard Lag Screws

00-2259-001-27 1-Piece Lag Screw 11mmDX70mm

00-2259-001-30 1-Piece Lag Screw 11mmDX75mm

00-2259-001-32 1-Piece Lag Screw 11mmDX80mm

00-2259-001-35 1-Piece Lag Screw 11mmDX85mm

00-2259-001-37 1-Piece Lag Screw 11mmDX90mm

00-2259-001-40 1-Piece Lag Screw 11mmDX95mm

00-2259-001-42 1-Piece Lag Screw 11mmDX100mm

00-2259-001-45 1-Piece Lag Screw 11mmDX105mm

00-2259-001-47 1-Piece Lag Screw 11mmDX110mm

00-2259-001-50 1-Piece Lag Screw 11mmDX115mm

00-2259-001-52 1-Piece Lag Screw 11mmDX120mm

00-2258-000-11 ITST Nail Instrument Set

for use with Mod Targeting Guide

00-2258-007-00 ITST Short Nail Instrument Case Tray

00-2258-008-00 ITST Instrument Case Lid

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

00-2237-061-00 Cannulated Awl

00-2255-028-00 9/16 in. Pin Wrench

00-2255-038-00 T-Handle

00-2258-051-01 Locking Bolt Extractor

00-2258-051-02 Locking Bolt Inserter

00-2258-090-00 ITST Cannula

00-2258-091-00 ITST Centering Bushing

00-2258-092-03 MIS Nail Cap Inserter Link

00-2258-092-04 MIS Nail Cap Inserter

00-2258-096-00 U-Joint Sleeve

00-5791-049-00 Screw Inserter/Extractor

00-2258-054-00 Threaded Guide Pin Bushing

00-2258-056-00 Lag Screw Bushing

00-2258-058-00 Lag Screw Reamer

00-2258-059-00 Lag Screw Tap

00-2258-062-00 Stop Assembly (Qty: 2)

00-2258-068-32 ITST Pin Bushing 3.2mm

00-2258-068-50 ITST Drill Bushing 5.0mm

00-2258-068-80 ITST Screw Bushing 8.0mm (Qty: 2)

00-2258-069-50 ITST Femoral Drill 5.0mm

00-2258-097-00 ITST Lag Screw Compression Device

00-2258-000-06 ITST Modular Targeting Guide Set

(Standard and MIS Technique Options)

00-2258-052-03 ITST Standard Barrel

00-2258-052-04 ITST MIS Barrel

00-2258-052-05 ITST Targeting Arm

00-2258-052-06 Targeting Arm Nut

00-2258-052-09 Modular Connecting Bolt

00-2258-087-00 ITST Standard Locking Bolt

00-2258-087-01 ITST MIS Locking Bolt

00-2258-053-01 Modular Targeting Guide Outrigger

00-2255-060-01 8mm MIS Trochanteric Reamer

00-2258-050-02 Long ITST Taper Reamer

00-2258-067-01 Long 3.2mm Threaded Guide Pin

00-2258-057-01 Long Cannulated Depth Gauge

00-2258-006-50 ITST Short Nail Instrument Case Base

00-2258-000-03 ITST Accessory Instrument Set

(includes all of the following listed below)

00-2258-010-00 ITST Accessory Instrument Case

00-2237-043-00 5.0mm T-Handle Screwdriver

00-2237-062-00 Long Threaded Driver

00-2237-064-00 Nail Length Gauge

00-2255-015-01 Wand Insert

00-2255-015-02 Wand Set Screw

00-2255-015-03 Wand Handle

00-2255-018-00 Distal Screw Depth Gauge (short)

00-2255-033-37 3.7mm Distal Trocar Drill (Qty: 2)

00-2255-033-50 5.0mm Distal Trocar Drill (Qty: 2)

00-2255-034-00 Reduction Finger

00-2258-068-37 ITST 3.7mm Drill Bushing

00-2258-069-37 ITST 3.7mm Drill

00-2258-071-45 ITST 4.5mm Screw Tap

00-2258-072-00 ITST Screw Depth Gauge (long)

00-2258-077-00 Driver Extension

00-2258-078-00 Driver Extension Bolt (Qty: 1)

Optional ITST Instrumentation

00-4816-060-00 Straight Ball Spike Pusher

00-4817-011-00 Medium Bone Hook (Shoulder Hook)

00-2258-092-00 ITST One-Piece Nail Cap Inserter

00-2258-092-01 ITST Linked Nail Cap Inserter

00-2258-097-00 ITST Lag Screw Compression Assembly

(Note: 00-2258-097-00 includes:

Compression Device T-Handle, Compressor,

Compression Retainer.)

00-2258-097-01 Compression Retainer (Replacement Part)

00-2258-000-10 ITST Modular Targeting Guide Asia Set

(set includes all instruments and case)

00-2258-052-12 ITST Asia Barrel

00-2258-052-13 ITST Asia Targeting Arm

00-2258-052-06 Targeting Arm Nut

00-2258-052-09 Modular Connecting Bolt

00-2258-087-02 ITST Asia Locking Bolt

00-2258-053-01 Modular Targeting Guide Outrigger

00-2258-067-01 Long 3.2mm Threaded Guide Pin

00-2258-057-01 Long Cannulated Depth Gauge

00-2258-006-50 ITST Short Nail Instrument Case Base

ITST® System MIS and Standard Surgical Technique

28

Cortical Screws

Prod. No. Description

00-2253-020-45 Cortical Screw 4.5mmDX20mm

00-2253-022-45 Cortical Screw 4.5mmDX22.5mm

00-2253-025-45 Cortical Screw 4.5mmDX25mm

00-2253-027-45 Cortical Screw 4.5mmDX27.5mm

00-2253-030-45 Cortical Screw 4.5mmDX30mm

00-2253-032-45 Cortical Screw 4.5mmDX32.5mm

00-2253-035-45 Cortical Screw 4.5mmDX35mm

00-2253-037-45 Cortical Screw 4.5mmDX37.5mm

00-2253-040-45 Cortical Screw 4.5mmDX40mm

00-2253-042-45 Cortical Screw 4.5mmDX42.5mm

00-2253-045-45 Cortical Screw 4.5mmDX45mm

00-2253-047-45 Cortical Screw 4.5mmDX47.5mm

00-2253-050-45 Cortical Screw 4.5mmDX50mm

00-2253-052-45 Cortical Screw 4.5mmDX52.5mm

00-2253-055-45 Cortical Screw 4.5mmDX55mm

00-2253-057-45 Cortical Screw 4.5mmDX57.5mm

00-2253-060-45 Cortical Screw 4.5mmDX60mm

00-2253-062-45 Cortical Screw 4.5mmDX62.5mm

00-2253-065-45 Cortical Screw 4.5mmDX65mm

00-2253-067-45 Cortical Screw 4.5mmDX67.5mm

00-2253-070-45 Cortical Screw 4.5mmDX70mm

00-2253-072-45 Cortical Screw 4.5mmDX72.5mm

00-2253-075-45 Cortical Screw 4.5mmDX75mm

00-2253-077-45 Cortical Screw 4.5mmDX77.5mm

00-2253-080-45 Cortical Screw 4.5mmDX80mm

00-2253-082-45 Cortical Screw 4.5mmDX82.5mm

00-2253-085-45 Cortical Screw 4.5mmDX85mm

00-2253-087-45 Cortical Screw 4.5mmDX87.5mm

00-2253-090-45 Cortical Screw 4.5mmDX90mm

00-2253-020-55 Cortical Screw 5.5mmDX20mm

00-2253-022-55 Cortical Screw 5.5mmDX22.5mm

00-2253-025-55 Cortical Screw 5.5mmDX25mm

Prod. No. Description

00-2253-027-55 Cortical Screw 5.5mmDX27.5mm

00-2253-030-55 Cortical Screw 5.5mmDX30mm

00-2253-032-55 Cortical Screw 5.5mmDX32.5mm

00-2253-035-55 Cortical Screw 5.5mmDX35mm

00-2253-037-55 Cortical Screw 5.5mmDX37.5mm

00-2253-040-55 Cortical Screw 5.5mmDX40mm

00-2253-042-55 Cortical Screw 5.5mmDX42.5mm

00-2253-045-55 Cortical Screw 5.5mmDX45mm

00-2253-047-55 Cortical Screw 5.5mmDX47.5mm

00-2253-050-55 Cortical Screw 5.5mmDX50mm

00-2253-052-55 Cortical Screw 5.5mmDX52.5mm

00-2253-055-55 Cortical Screw 5.5mmDX55mm

00-2253-057-55 Cortical Screw 5.5mmDX57.5mm

00-2253-060-55 Cortical Screw 5.5mmDX60mm

00-2253-062-55 Cortical Screw 5.5mmDX62.5mm

00-2253-065-55 Cortical Screw 5.5mmDX65mm

00-2253-067-55 Cortical Screw 5.5mmDX67.5mm

00-2253-070-55 Cortical Screw 5.5mmDX70mm

00-2253-072-55 Cortical Screw 5.5mmDX72.5mm

00-2253-075-55 Cortical Screw 5.5mmDX75mm

00-2253-077-55 Cortical Screw 5.5mmDX77.5mm

00-2253-080-55 Cortical Screw 5.5mmDX80mm

00-2253-082-55 Cortical Screw 5.5mmDX82.5mm

00-2253-085-55 Cortical Screw 5.5mmDX85mm

00-2253-087-55 Cortical Screw 5.5mmDX87.5mm

00-2253-090-55 Cortical Screw 5.5mmDX90mm

00-2253-092-55 Cortical Screw 5.5mmDX92.5mm

00-2253-095-55 Cortical Screw 5.5mmDX95mm

00-2253-097-55 Cortical Screw 5.5mmDX97.5mm

00-2253-100-55 Cortical Screw 5.5mmDX1000m

97-2257-202-00 Rev. 4 7-29-15 ©2005, 2015 Zimmer, Inc.

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

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.

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