Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique Standard Zimmer Compact

2016-04-04

: Pdf Zimmer Natural Nail System Cephalomedullary Nail Surgical Technique-Compact Zimmer_Natural_Nail_System_Cephalomedullary_Nail_Surgical_Technique-Compact 4 2016 pdf

Open the PDF directly: View PDF .
Page Count: 20

Download
Open PDF In Browser	View PDF

Zimmer
Natural Nail
System
®

Cephalomedullary Nail
Surgical Technique
Compact Case - Short Nails Only

STANDARD

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

Zimmer Natural Nail
System Cephalomedullary
Nail Surgical Technique Compact Case - Short Nails
Only - Standard

Table of Contents
Product Overview

Implant Overview

Indications

Contraindications

Surgical Technique

Preoperative Planning

Patient Positioning

Reduction

Starting Point Location

Proximal Reaming

Shaft Reaming

Implant Selection

Nail Assembly and Insertion

Lag Screw Placement

Distal Targeting For Short Nails

Final Implant Placement

Postoperative Care

Nail Extraction

Cephalomedullary Short Nail Details

Product Information

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

Product Overview
The Zimmer Natural Nail System is a
system of intramedullary nails, screws,
instruments and other associated
implants that are designed to provide
stable internal fixation for fractured long
bones. The nails have been designed
for specific applications to help restore
the shape of the fractured bone to its
natural, pre-injured state.
The Cephalomedullary Nail was
designed to help treat fractures of the
femur, especially intertrochanteric
and subtrochanteric fractures. The nail
features a small proximal section that
is designed to minimize the amount
of bone that must be removed for nail
insertion. A lag screw is placed through
the nail into the femoral head to secure
the nail in place proximally and help
control the different segments of the
bone while healing occurs. Screws are
placed through the nail distally to further
secure the implant in place and maintain
length and alignment while healing
occurs.
A choice of nails of different diameters
and center-column-diaphyseal (CCD)
angles are available to best match the
individual anatomy of the patient.

Implant Overview
Nail Diameters: 10, 11.5, 13, 14.5

5mm increments
Distal Screws available in fully- and
partially-threaded configurations
Materials: Ti-6Al-4V alloy
Precision instrumentation is provided
to help implant the nail. Many of the
instruments and implants feature a color
coding system to help the surgical team
use the system. Certain instruments are
not color coded. The color coding system
is referenced in the technique. A wall
chart (97-2493-015-00) is also available
to help explain the color coding system.

Indications
The Zimmer Natural Nail System is
intended for temoraty fracture fixation
and stabilization of the bone.

• Lack of bone substance or bone
quality, which makes stable seating of
the implant impossible
• All concomitant diseases that can
impair the functioning and the
success of the implant
• Infection
• Insufficient blood circulation
• Skeletally immature patients

• Proximal, metaphyseal and distal shaft
fractures

Surgical Technique

• Segmental fractures

Preoperative Planning

• Comminuted fractures

Preoperative planning is recommended
before beginning the surgical procedure.
An A/P and Lateral x-ray of the injured
femur should be taken preoperatively
and evaluated for length, canal size
and implant suitability. A/P and Lateral
x-rays of the contralateral uninjured
femur can also be taken preoperatively
to provide insight into the characteristics
of the pre-injured femur.

• Fractures involving osteopenic and
osteoporotic bone
• Pathological fractures
• Fractures with bone loss

CCD Angles: 125°, 130°, 135°

• Periprosthetic fractures

Lag Screw Diameter: 10.5mm

• Surgically created defects such as
osteotomies

Distal Screw Lengths: 20 to 60mm in
2.5mm increments, 65 to 100mm in

• Bone shaft having excessive bow or
deformity

• Compound and simple shaft fractures

Indications for the Cephalomedullary
nails include:

• Pseudoarthrosis, non-union, malunion and delayed union

Distal Screw Diameter: 5.0mm

• A medullary canal obliterated by a
previous fracture or tumor

WARNING: This nail should only be used
to treat a periprosthetic fracture if the in
situ device is firmly fixed. When treating
a periprosthetic fracture, the nail should
be positioned so that it does not come in
contact with the in situ device.

Nail Lengths: 21.5cm (short)

Lag Screw Lengths: 70 to 130mm in
5mm increments

Contraindications

• Intertrochanteric and subtrochanteric
fractures

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

Patient Positioning
Patients can be positioned either supine
or in a lateral decubitus position. As the
C-arm will be used during the procedure,
care should be taken to orient the patient
to allow for A/P and Lateral imaging of
the proximal femur, the fracture and
the distal femur. The use of a fracture
table can be beneficial in helping to
reduce fractures as well as to facilitate
intraoperative imaging with a C-arm. The
patient should be positioned to allow
for easy access to the greater trochanter
of the femur with instrumentation.
Adduction of the affected leg can also be
helpful, especially in the supine position.
Drape the patient appropriately to allow
the surgeon to work around the hip and
full length of the femur (to the knee).

Reduction
It is critical to achieve anatomic
reduction before beginning any of the
steps to place the Intramedullary Nail.
Traction should be used as necessary to
help achieve fracture reduction. Several
instruments are available to assist in
fracture reduction including clamps, ball
spike pushers and Steinmann pins.

of the trochanter. The pin should not
be on the lateral portion of the greater
trochanter, it must be on the tip. A
starting point slightly medial to the tip of
the trochanter is also acceptable.
Note: A starting point lateral to the
tip of the greater trochanter may lead
to a varus malreduction following nail
insertion.

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 GUIDE WIRE GRIPPER and
mallet to remove the guide wire from the
nail.

Drive the pin through the tip of the greater
trochanter down to the level of the lesser
trochanter. Use the 8mm ENTRY REAMER
through the ENTRY CANNULA to ream
an entry portal into the proximal femur
through the starting point on the tip of
the greater trochanter (Fig 1). Remove the
reamer and 3.0mm pin.
Alternatively, a CANNULATED AWL can be
used to find the entry point and create
the entry portal (Fig. 2). Widening of
the fracture side and varus tilting of the
proximal fragment should be avoided.
Place a 3.0mm x 100cm BALL TIP GUIDE
WIRE or TEAR DROP GUIDEWIRE through
the ENTRY CANNULA, all the way into
the distal femur (Fig. 3). To aid in
manipulation, bend the tip of the GUIDE
WIRE at about a 10o angle 5cm from the
end.

Fig. 2

Starting Point Location
Palpate the greater trochanter manually.
Incise the skin starting about 2cm
proximal to the tip of the greater
trochanter and extending proximally 2
to 3 cm. Dissect through the tissues
splitting the fascia lata down to the
bone. In large patients and/or when
using the standard guide, a more
proximal incision may be appropriate.
Place the 3.0mm PIN through the ENTRY
CANNULA. Use the C-arm to visualize the
pin’s position from an A/P and Lateral
view. The pin should be inserted at
the tip of the greater trochanter in the
posterior portion of the middle third

Fig. 3

Fig. 1

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

NOTE: If the GUIDE WIRE becomes lodged
within the reamer use the GUIDE WIRE
PUSHER to push the GUIDE WIRE back into
the IM Canal.

If you plan to ream the canal of the femur,
the GUIDE WIRE should be embedded in
the distal femur at the level of the distal
epiphyseal scar using the GUIDE WIRE
GRIPPER and a MALLET (Fig. 4). Care
should be taken not to drive the wire
through the knee joint.

Implant Selection
The diameter and length of the nail have
already been determined (using nail
length gauge and last size of reamer
utilized). Visualizing the reduced femur
and/or the contralateral femur, determine
which CCD angle is appropriate for the
patient.

Proximal Reaming
Use the 15.5mm TAPERED REAMER (BLUE)
to prepare the proximal femur for the
proximal portion of the nail (Fig. 5). The
C-arm should be used to visualize the
depth of the reamer in the proximal femur.
Care should be taken to keep the reamer
in line with the shaft of the femur to avoid
reaming through the cortex of the femur.
The 15.5mm TAPERED REAMER has
three grooves on it. The most proximal
groove indicates the final position of the
top of the nail. The two distal grooves
help visualize the placement of the lag
screw. Visualizing a line between these
grooves on each side of the reamer (under
fluoroscopic visualization) will indicate
where a 130° CCD angle lag screw would
be placed in the femoral neck and head.

Nail Assembly and Insertion
The color code for the cephalomedullary
nail is BLUE. Ti-6Al-4V alloy nails, the
TARGETING GUIDE and the CONNECTING
BOLT all have blue colors on them, as well
as the word BLUE on them.
Fig. 5

Shaft Reaming
Reaming should be performed through
the ENTRY CANNULA. To reduce the risk
of enlarging the entry hole laterally, push
the ENTRY CANNULA medially. Start with a
small reamer. Increase the diameter of the
reamer by 0.5 - 1.0mm depending on the
amount of resistance felt while reaming.
(Fig. 6). When cortical chatter occurs, stop
reaming. Choose a nail that is 1.5 - 2.0mm
smaller than the last reamer used. It is only
necessary to ream the proximal 21.5cm of
the canal.

Both a MODULAR STANDARD
(00-2490-003-10) and STANDARD
(00-2490-003-00) TARGETING GUIDE
exist. When implanting a short nail
the STANDARD TARGETING GUIDE
(Fig. 7) must be used.

Fig. 7

Fig. 4

Fig. 6

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

Place the CONNECTING BOLT through the
barrel of the TARGETING GUIDE (Fig. 8).
The arrow on the nail (with an R for a Right
Nail or an L for a Left Nail) will line up with
the arrow on the barrel of the guide when
the nail is correctly aligned.

Fig. 8

Begin threading the CONNECTING BOLT
(by hand or using the CONNECTING BOLT
INSERTER) into the proximal portion of
the nail. Orient the proximal portion
of the nail so that the slots in the nail
match up with the corresponding tines
on the barrel of the TARGETING GUIDE.
Completely tighten the CONNECTING
BOLT using an 11mm WRENCH to secure
the nail to the guide.
Lay the guide attached to the nail over
the femur. Confirm that the bow of the
nail is anterior similar to the bow of the
femur. Confirm also that the lag screw

hole in the nail is oriented to guide a
lag screw into the femoral head. Care
must be taken to ensure that the correct
nail is selected and that it is assembled
correctly to the guide. If this is not
the case, loosen and reattach the nail
appropriately or choose the correct nail
and attach it to the guide.
Use a LAG SCREW CANNULA and the
LAG SCREW REAMER or a CANNULA,
DRILL SLEEVE AND DRILL to verify
that the guide will target all required
holes in the nail correctly. Hole
indicators can be placed in static
(ST) and dynamic (DY) holes of the
targeting guide and in holes for CCD
angles that will not be used to avoid
the accidental use of those holes
during the surgery. Use a pushand-twist motion when inserting the
hole indicators to help ensure that
they stay in place.

If the nail does not pass down the canal
easily, attach the IMPACTION HEAD to the
TARGETING GUIDE. Using the MALLET,
impact gently on the IMPACTION HEAD
(Fig. 9).
CAUTION: Do not strike excessively as
damage to the guide and bone may result.
Verify that the CONNECTING BOLT is tight
while, and after, impacting. Do not impact
on any portion of the TARGETING GUIDE as
this may break the guide or cause it to lose
its accuracy.

The STANDARD TARGETING GUIDE
is designed to target the transverse
distal static (ST) and dynamic (DY)
holes in SHORT nails. As the guide is
designed to work with both left and
right ST and DY holes, care must be
taken to ensure that the correct ST/
DY holes will be used for the surgery
(use the left holes when using a left
nail, and vice versa). The holes that
will be used to place screws into the
distal portion of SHORT NAILS are on
the anterior side of the guide when
the patient is in a supine position.
Insert the nail over the GUIDE WIRE with
the arm of the guide facing anteriorly.
As the nail passes through the canal,
it will naturally turn approximately 90°
until the anterior bow of the nail is in line
with the bow of the femur. Monitor the
progression of the nail down the canal
using the C-arm, especially as the nail is
passing through or near the fracture site.
CAUTION: Do not pry excessively on the
targeting guide as damage may result.

Fig. 9

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

If the nail will not advance with impaction,
remove the nail and ream the canal to a larger
diameter at additional 0.5 mm increments or
consider using a smaller diameter nail.
Anteversion can be verified by placing a
threaded guide pin through the skin and soft
tissue along the anterior axis of the femoral
neck.
Remove the TIP GUIDE WIRE from the nail
using the GUIDE WIRE GRIPPER.
If it is desired to utilize an antirotation pin
to assist in stabilizing the femoral head
during lag screw preparation and insertion,
a 3mm PIN can be placed using a freehand
technique anterior to the nail and into the
femoral neck and head.1,2
The holes proximal to the lag screw
cannula holes in the STANDARD
TARGETING GUIDE are used merely as a
general reference for the pin placement
through the implant antirotation pin
hole and must not be solely relied upon
to accurately place the pin.

Lag Screw Placement
For the STANDARD TARGETING GUIDES,
corresponding instruments marked BLUE are
utilized to place the LAG SCREW. Marks on
the targeting guides near the holes indicate
the color of cannula that should be passed
through that specific hole. The chart below
details the color coded instruments that are
used to target and place the lag screw.
Instrument Type

Standard

Lag Screw Cannula

Blue

Lag Screw Reamer

Blue

Lag Screw Inserter

Blue

Lag Screw Retaining Shaft

Blue

Lag Screw Pin Sleeve

Blue

CAUTION: Retighten the CONNECTING
BOLT to the nail to maintain targeting
accuracy.
The Tip-Apex Distance (TAD), the sum of
the distances of the tip of the lag screw to

the apex of the femoral head in the A/P
and Lateral x-ray views, has been shown
to be a key indicator in reducing cut-out
of lag screws in the femoral head. The
TAD should be less than 25mm.3
Position the TARGETING GUIDE so
that the trajectory of the LAG SCREW
CANNULA will place the lag screw in the
appropriate position in the femoral head
and neck. PINS can be held over the skin
in line with the LAG SCREW CANNULA to
help estimate this position and correct
CCD angle.

Another A/P C-arm image can be taken at
this point to ensure that the TARGETING
GUIDE is still aligned correctly by
visualizing a line extending from the
center of the cannula into the femoral
head. Insert the 3.2mm LAG SCREW PIN
SLEEVE. Insert a 3.2mm PIN through the
PIN SLEEVE. Under fluoroscopy, drill the
GUIDE PIN to the level of the subchondral
bone of the femoral head without
penetrating the femoral cortex (Fig. 11).

NOTE: If planning to use an
ANTIROTATION PIN to further stabilize
the femoral head, insert the DOUBLE
CANNULA instead of the LAG SCREW
CANNULA.
Pass the LAG SCREW CANNULA through
the correct hole in the TARGETING GUIDE
for the chosen CCD angle. The lag screw
hole labeled 125 is designed to be used
with the short nails containing a 125o
CCD angle, the lag screw hole labeled
130o is designed to be used with the
short nails containing a 130o CCD angle,
and the lag screw hole labeled 135o is
designed to be used with the short nails
containing a 135o CCD angle. Make a
small skin incision, then dissect through
the fascia and other soft tissues down to
the bone. Advance the cannula through
the guide down to the bone (Fig. 10).

Fig. 10

CAUTION: Do not impact on the cannula,
as the tip of the cannula may skive along
the bone and prevent accurate targeting
CAUTION: Both 3.0mm and 3.2mm
instruments (guide pins, depth gauges,
reamers, pin sleeves) are available.
The 3.2mm versions of the instruments
can easily be distinguished as they
have gold coating on them. The 3.0mm
and 3.2mm instruments can not be
used interchangeably. Mixing of these
instruments can lead to lag screw
mis-measurement which could result
in patient injury and/or damage to the
instruments. This technique describes use
of the 3.2mm instruments. The 3.0mm
instruments can be used in an identical
fashion.

Fig. 11

AO Principles of Fracture Management, Thieme, 2000

Browner, Bruce et. al., Skeletal Trauma, 2 Vol Set, “Basic Science, Management, and Reconstruction”, 2003, p 1929 - 1931

Baumgaerther et. al., The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg AM, 1995:77:1058-1064

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

Assess the position of the PIN using the
C-arm in the A/P and Lateral planes. If
the PIN is appropriately placed, proceed
with the next steps.
NOTE: If the PIN is not appropriately
placed, remove it, adjust the guide
under fluoroscopy and replace the pin
correctly.
TECHNIQUE TIP – If the PIN appears to be
changing direction at the point it enters
the lateral cortex of the femur, remove
the pin and pin sleeve and perforate
the lateral cortex using the lag screw
reamer. Replace the pin sleeve in the
cannula and drive the pin as previously
stated to the level of the subchondral
bone in the femoral head.
If it is desired to utilize an ANTIROTATION
PIN to assist in stabilizing the femoral
head during lag screw insertion, a
3.0mm ANTIROTATION PIN can be placed
into the femoral neck and head using
a DOUBLE CANNULA. Use the smaller
sleeve of the DOUBLE CANNULA to place
this pin at this time. The pin is passed
so that it does not penetrate the femoral
cortex in the femoral head or neck (Fig.
12). Place pin to appropriate depth beyond
fracture site to provide stabilization.
NOTE: Place the 3.2mm PIN prior to
the ANTIROTATION PIN to reduce mistargeting. Position the ANTIROTATION
PIN slightly proximal to the center-line
of the femoral neck.

Alternatively, the pin can be placed using
a freehand technique anterior to the nail
and into the femoral neck and head. 4, 5
NOTE: Insert 3.2mm pin anterior to the
nail. Inserting them posterior to the nail
may cause damage to the neurovascular
structures.
Remove the 3.2mm LAG SCREW PIN
SLEEVE from the LAG SCREW CANNULA.
Slide the CANNULATED DEPTH GAUGE over
the 3.2mm GUIDE PIN down to the bone
(Fig. 13).

Fig. 14

Fig. 13

Confirm that the depth gauge is touching the
lateral cortex of the femur using fluoroscopy
to accurately determine the length of lag
screw to be used. The end of the PIN in the
depth gauge indicates the length of lag
screw to be used.
Slide the LAG SCREW STOP ASSEMBLY
onto the LAG SCREW REAMER (Fig.14).
Place the window in the stop over the
number measured with the CANNULATED
LAG SCREW DEPTH GAUGE (Fig. 15). If the
measurement was between markings on
the cannulated depth gauge, set the stop
to the smaller number.

Fig. 12

Attach the LAG SCREW REAMER to the
drill. Ream over the PIN to the level of the
subchondral bone (Fig. 16). While drilling,
use the C-arm intermittently to verify
position of the reamer and to make sure
that the PIN is not migrating through the
femoral head. Remove the reamer. Push the
end of the PIN while withdrawing the power
tool.

AO Principles of Fracture Management, Thieme, 2000

Browner et.al., Skeletal Trauma Vol. 2, Basic Science, Management and Reconstruction, p.1929 – 1931, 2003

The lag screw is self tapping. If preferred,
tap the hole for the lag screw over the
PIN. The stop can be used to indicate the
appropriate depth to tap.

Fig. 15

Fig. 16

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

NOTE: Remove the ANTIROTATION PIN (if
used).

Select the appropriate length LAG SCREW
based on previous measurements. The
SCREW DEPTH GAUGE can also be used
to verify the length of lag screw that
should be used.

A SET SCREW (included in the lag screw
package or packaged separately) must
be used to prevent the lag screw from
rotating post-operatively. Insert the tip
of the FLEXIBLE CAPTURED SET SCREW
DRIVER or 3.5mm HEX SCREWDRIVER into
the 3.5mm hex end of the SET SCREW
(Fig. 20).

Attach the LAG SCREW to the LAG SCREW
INSERTER using the LAG SCREW RETAINING
SHAFT to fully secure the screw to the
inserter (Fig. 17).

Fig. 18

The SET SCREW is then passed through
the CONNECTING BOLT into the proximal
portion of the nail (Fig. 21).
NOTE: If using the FLEXIBLE CAPTURED
SET SCREW DRIVER make sure that it is
not used at an angle greater than 40˚. If
it is used at an angle greater than 40˚, it
may be damaged.

Fig. 17

Fig. 20

Insert the LAG SCREW over the PIN
and into the femur (Fig. 18). Confirm
placement using the C-arm. The handle
on the LAG SCREW INSERTER must be
parallel or perpendicular to the axis of
the guide (indicated by colored dots
between the holes for the lag screw
cannulas). Rotate the LAG SCREW
INSERTER up to 90° in order to correctly
orient the handle to the guide (Fig. 19).
NOTE: Do not overtighten the lag screw,
The distal edge must protrude laterally
through the femur to ensure that sliding
can occur.
TECHNIQUE TIP: If using an
ANTIROTATION PIN through the nail,
position the T-handle perpendicular
to the guide. This reduces the risk
of interference when removing the
ANTIROTATION PIN.

Fig. 19

Fig. 21

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

NOTE: Do not drive the set screw into the
nail under power as damage to the set
screw or the nail could result.
The SET SCREW should be tightened
down into the groove in the lag screw. As
noted above, the LAG SCREW INSERTER
must be positioned so that the handle on
the inserter is parallel or perpendicular
to the colored dots on the TARGETING
GUIDE in order for the SET SCREW and
LAG SCREW grooves to engage properly.
To verify engagement, attempt to twist
the LAG SCREW INSERTER. If it cannot
be rotated using a reasonable amount
of force, the construct is in the correct
position. If rotation is possible, adjust
the position of the LAG SCREW (rotate
slightly) so that the set screw can enter
the groove in the LAG SCREW (Fig. 22).
NOTE: To achieve sliding, tighten
the SET SCREW and then rotate the
FLEXIBLE CAPTURED SET SCREW DRIVER
counterclockwise one quarter turn. Do
not unscrew the SET SCREW more than

one quarter turn. Make sure that the SET
SCREW is still engaged in the groove by
checking that it is still not possible to
turn the LAG SCREW with the LAG SCREW
INSERTER.
Disengage the LAG SCREW INSERTER
from the LAG SCREW. A 3.5mm HEX
SCREWDRIVER may be used to disengage
the LAG SCREW RETAINING SHAFT from the
LAG SCREW.
TECHNIQUE TIP: The LAG SCREW CANNULA
can be left in place to aid in stabilizing
the construct during distal screw
placement in the short nails, if desired.
Remove the SET SCREW DRIVER and set
aside.

Distal Targeting For Short Nails
Color coded instruments are also used
for distal targeting of short nails. For the
STANDARD TARGETING GUIDE, instruments
marked GREEN are utilized to place the
distal screws. The chart below details
the color coded instruments that are
used for distal targeting and distal screw
placement.
Instrument Type

Fig. 22

Standard

8.0mm Screw Cannula

Green

4.3mm Drill Sleeve

Green–Red

4.3mm Drill Bit

Green–Red

Screwdriver

Green

The STANDARD TARGETING GUIDE is
designed to target the distal static
(ST) and dynamic (DY) holes in SHORT
nails. As the guide is designed to
work with both left and right ST
and DY holes, care must be taken
to ensure that the correct targeting
holes (left or right) are used for
drilling and screw placement. At
this point in the surgery, with the
guide oriented horizontally and
the nail in place, the correct holes
are on the top (anterior) side of the
guide. A YELLOW CAUTION SYMBOL
is engraved on the face of the guide

near the ST/DY holes to remind the
surgeon to take note of the placement
of the screw. Additionally, the words
“LEFT” and “RIGHT” are embossed in
green on the appropriate side of the
guide where the SCREW CANNULAS
should be placed to insert these
screws.
Assemble the 4.3mm DRILL SLEEVE to
the 8.0mm SCREW CANNULA. Pass the
CANNULA through the appropriate hole in
the TARGETING GUIDE to target the distal
hole or slot. The hole is labeled ST is for the
Static Hole. The hole labeled DY is for the
Dynamic Slot.
After pressing the tip of the SCREW CANNULA
against the skin, make a small incision at
that point through the skin and fascia lata.
Spread the soft tissue down to the bone.
Advance the CANNULA down to the bone.
CAUTION: Do not impact on the cannula, as
the tip of the cannula may skive along the
bone and prevent accurate targeting.
Utilize the 4.3mm DRILL BIT to drill through
both cortices of bone. The depth of the hole
can be measured using calibrations on the
DRILL BIT.
CAUTION: In cases where hard cortical
bone is encountered, or at the surgeon’s
preference, a LONG 5.0mm TAP (00-2490048-50) can be used to ease insertion of
the screws.
The nail utilizes a 5.0mm screw distally.
The screw packages are labeled with the
color RED.
Choose the appropriate length screw based
on the DRILL BIT reading. Use the 3.5mm
HEX SCREWDRIVER to place the screw
bicortically through the bone.
CAUTION: Do not drive the screws into the
bone under power, as damage to the bone,
screws and nail could result.

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

Remove the screwdriver and cannula. If
desired, repeat these steps to place another
screw in the other hole or slot. If not
previously done, remove the LAG SCREW
CANNULA.

Nail Extraction
For extraction, please reference surgical
technique for both the small and standard,
97-2493.005.00 and 97-2493-002-00.

Final Implant Placement
Observe the depth of the nail in the proximal
femur. Ridges at 5 and 10mm from the end
of the targeting guide barrel indicate nail
depth.
It is recommended to use a nail cap to close
the proximal part of the nail to prevent bone
ingrowth.
Place a 2.0mm GUIDE PIN through the
CONNECTING BOLT and into the proximal
portion of the NAIL. Loosen and remove the
CONNECTING BOLT from the nail taking care
to leave the 2.0mm GUIDE PIN in place. If a
NAIL CAP will not be used, do not introduce
the 2.0mm GUIDE PIN.
TECHNIQUE NOTE: The 0mm height NAIL CAP
can be placed through the TARGETING GUIDE
following removal of the CONNECTING BOLT.
Other NAIL CAPS cannot be placed until the
TARGETING GUIDE is also removed.
Choose the appropriate height of NAIL CAP.
Secure the selected NAIL CAP to the NAIL
CAP INSERTER using the NAIL CAP RETAINING
SHAFT (Fig. 23).
Place the NAIL CAP over the 2.0mm GUIDE
WIRE and thread it into the top of the NAIL.
Using the C-arm, verify that the cap is
completely seated in the top of the nail.

Fig. 23

Disengage the NAIL CAP INSERTER from the
NAIL CAP. Remove the 2.0mm GUIDE PIN.
Close all wounds and apply the appropriate
dressings.

Postoperative Care
Early range of motion exercises of the knee
and ankle are encouraged. Allow toe-touch
weight bearing to progress to full weight
bearing as fracture callus increases on the
x-ray films.*

* It is the responsibility of the surgeon to determine what is the most suitable postoperative
care depending on each patient’s health condition.

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

Cephalomedullary Short Nail Details
15o Anteversion
4o Proximal Lateralization Angle
15.5mm Proximal Head

58mm Proximal
Body Length

Blue Ring

35 to 39mm from tip (3.0mm Pin)
42 to 54mm from tip (10.5mm Lag Screw)
125o/130o/135o CCD Angle

Lag Screw
10.5mm Diameter

10, 11.5, 13, 14.5mm shaft diameters

6.6mm Minor Diameter

1275mm
Anterior Bow Radius

10.2mm Drill
2.8mm Tip Length

60 to65mm
from tip
43 to 55mm
from tip
(Dynamic Slot)

5.0mm
Screws

5.0mm Screw
8mm Diameter Head
3.8mm Head Height
4.3mm Minor Diameter
4.3mm Drill
2.0mm Tip Length

Clothespin tip (for nails
11.5mm in diameter and larger)

NOTE: There is no locking tab for the (StabiliZe Technology) Cephalomedullary Short Nails.

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

Product Information
Cephalomedullary Short Nails

10.5mm Lag Screws
Item Number

Product Description

47-2485-070-10

10.5mm Lag Screw 70mm Length Ti-6Al-4V Alloy

Item Number

Product Description

47-2493-210-10

Cephalomedullary Short Nail 10mm X 21.5cm 125 CCD
Right Ti-6Al-4V Alloy

47-2485-075-10

10.5mm Lag Screw 75mm Length Ti-6Al-4V Alloy

47-2493-211-10

Cephalomedullary Short Nail 10mm X 21.5cm 125 CCD
Left Ti-6Al-4V Alloy

47-2485-080-10

10.5mm Lag Screw 80mm Length Ti-6Al-4V Alloy

47-2493-212-10

Cephalomedullary Short Nail 10mm X 21.5cm 130 CCD
Right Ti-6Al-4V Alloy

47-2485-085-10

10.5mm Lag Screw 85mm Length Ti-6Al-4V Alloy

47-2493-213-10

Cephalomedullary Short Nail 10mm X 21.5cm 130 CCD
Left Ti-6Al-4V Alloy

47-2485-090-10

10.5mm Lag Screw 90mm Length Ti-6Al-4V Alloy

47-2493-214-10

Cephalomedullary Short Nail 10mm X 21.5cm 135 CCD
Right Ti-6Al-4V Alloy

47-2485-095-10

10.5mm Lag Screw 95mm Length Ti-6Al-4V Alloy

47-2493-215-10

Cephalomedullary Short Nail 10mm X 21.5cm 135 CCD
Left Ti-6Al-4V Alloy

47-2485-100-10

10.5mm Lag Screw 100mm Length Ti-6Al-4V Alloy

47-2493-210-11

Cephalomedullary Short Nail 11.5mm X 21.5cm 125 CCD
Right Ti-6Al-4V Alloy

47-2485-105-10

10.5mm Lag Screw 105mm Length Ti-6Al-4V Alloy

47-2493-211-11

Cephalomedullary Short Nail 11.5mm X 21.5cm 125 CCD
Left Ti-6Al-4V Alloy

47-2485-110-10

10.5mm Lag Screw 110mm Length Ti-6Al-4V Alloy

47-2493-212-11

Cephalomedullary Short Nail 11.5mm X 21.5cm 130 CCD
Right Ti-6Al-4V Alloy

47-2485-115-10

10.5mm Lag Screw 115mm Length Ti-6Al-4V Alloy

47-2493-213-11

Cephalomedullary Short Nail 11.5mm X 21.5cm 130 CCD
Left Ti-6Al-4V Alloy

47-2485-120-10

10.5mm Lag Screw 120mm Length Ti-6Al-4V Alloy

47-2493-214-11

Cephalomedullary Short Nail 11.5mm X 21.5cm 135 CCD
Right Ti-6Al-4V Alloy

47-2485-125-10

10.5mm Lag Screw 125mm Length Ti-6Al-4V Alloy

47-2493-215-11

Cephalomedullary Short Nail 11.5mm X 21.5cm 135 CCD
Left Ti-6Al-4V Alloy

47-2485-130-10

10.5mm Lag Screw 130mm Length Ti-6Al-4V Alloy

47-2493-210-13

Cephalomedullary Short Nail 13mm X 21.5cm 125 CCD
Right Ti-6Al-4V Alloy

47-2493-211-13

Cephalomedullary Short Nail 13mm X 21.5cm 125 CCD
Left Ti-6Al-4V Alloy

Item Number

Product Description

47-2493-212-13

Cephalomedullary Short Nail 13mm X 21.5cm 130 CCD
Right Ti-6Al-4V Alloy

47-2483-020-50

5.0mm Cortical Screw 20mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2493-213-13

Cephalomedullary Short Nail 13mm X 21.5cm 130 CCD
Left Ti-6Al-4V Alloy

47-2483-022-50

47-2493-214-13

Cephalomedullary Short Nail 13mm X 21.5cm 135 CCD
Right Ti-6Al-4V Alloy

5.0mm Cortical Screw 22.5mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-025-50

47-2493-215-13

Cephalomedullary Short Nail 13mm X 21.5cm 135 CCD
Left Ti-6Al-4V Alloy

5.0mm Cortical Screw 25mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-027-50

5.0mm Cortical Screw 27.5mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2493-210-14

Cephalomedullary Short Nail 14.5mm X 21.5cm 125 CCD
Right Ti-6Al-4V Alloy

47-2483-030-50

47-2493-211-14

Cephalomedullary Short Nail 14.5mm X 21.5cm 125 CCD
Left Ti-6Al-4V Alloy

5.0mm Cortical Screw 30mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-032-50

47-2493-212-14

Cephalomedullary Short Nail 14.5mm X 21.5cm 130 CCD
Right Ti-6Al-4V Alloy

5.0mm Cortical Screw 32.5mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-035-50

5.0mm Cortical Screw 35mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2493-213-14

Cephalomedullary Short Nail 14.5mm X 21.5cm 130 CCD
Left Ti-6Al-4V Alloy

47-2483-037-50

5.0mm Cortical Screw 37.5mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2493-214-14

Cephalomedullary Short Nail 14.5mm X 21.5cm 135 CCD
Right Ti-6Al-4V Alloy

47-2483-040-50

47-2493-215-14

Cephalomedullary Short Nail 14.5mm X 21.5cm 135 CCD
Left Ti-6Al-4V Alloy

5.0mm Cortical Screw 40mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-042-50

5.0mm Cortical Screw 42.5mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-045-50

5.0mm Cortical Screw 45mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-047-50

5.0mm Cortical Screw 47.5mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-050-50

5.0mm Cortical Screw 50mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

5.0mm Screws (for distal screw holes)

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

47-2483-052-50

5.0mm Cortical Screw 52.5mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2484-065-50

5.0mm Cortical Screw 65mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2483-055-50

5.0mm Cortical Screw 55mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2484-070-50

5.0mm Cortical Screw 70mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2483-057-50

5.0mm Cortical Screw 57.5mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2484-075-50

5.0mm Cortical Screw 75mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2483-060-50

5.0mm Cortical Screw 60mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2484-080-50

5.0mm Cortical Screw 80mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2483-065-50

5.0mm Cortical Screw 65mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2484-085-50

5.0mm Cortical Screw 85mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2483-070-50

5.0mm Cortical Screw 70mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2484-090-50

5.0mm Cortical Screw 90mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2483-075-50

5.0mm Cortical Screw 75mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2484-095-50

5.0mm Cortical Screw 95mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2483-080-50

5.0mm Cortical Screw 80mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2484-100-50

5.0mm Cortical Screw 100mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2483-085-50

5.0mm Cortical Screw 85mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-090-50

5.0mm Cortical Screw 90mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-095-50

5.0mm Cortical Screw 95mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

47-2483-100-50

5.0mm Cortical Screw 100mm Length Ti-6Al-4V Alloy
Partially Threaded 3.5mm Hex Head

Nail Caps / Set Screw
Item Number

Product Description

47-2487-002-00

Cephalomedullary Nail Cap 0mm Height Ti-6AL-4V Alloy

47-2487-002-05

Cephalomedullary Nail Cap 5mm Height Ti-6AL-4V Alloy

47-2484-020-50

5.0mm Cortical Screw 20mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2487-002-10

47-2484-022-50

5.0mm Cortical Screw 22.5mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2487-002-15

47-2484-025-50

5.0mm Cortical Screw 25mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2493-000-00

47-2484-027-50

5.0mm Cortical Screw 27.5mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-030-50

5.0mm Cortical Screw 30mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-032-50

5.0mm Cortical Screw 32.5mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-035-50

5.0mm Cortical Screw 35mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-037-50

5.0mm Cortical Screw 37.5mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-040-50

5.0mm Cortical Screw 40mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-042-50

5.0mm Cortical Screw 42.5mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-045-50

5.0mm Cortical Screw 45mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-047-50

5.0mm Cortical Screw 47.5mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-050-50

5.0mm Cortical Screw 50mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-052-50

5.0mm Cortical Screw 52.5mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-055-50

5.0mm Cortical Screw 55mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-057-50

5.0mm Cortical Screw 57.5mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

47-2484-060-50

5.0mm Cortical Screw 60mm Length Ti-6Al-4V Alloy
Fixed Angle 3.5mm Hex Head

Cephalomedullary Nail Cap 10mm Height Ti-6AL-4V
Alloy
Cephalomedullary Nail Cap 15mm Height Ti-6AL-4V
Alloy
Cephalomedullary Nail Set Screw Ti-6AL-4V Alloy

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

Instruments
KT-2490-003-11 – STANDARD Compact
Cephalomedullary Nail Instrument Set
Item Number

Product Description

00-2490-000-41

Hole Indicator

00-2490-003-00

Instruments Available Separately
Qty

Item Number

Product Description

Qty.

00-2490-048-50

Long 5.0mm Tap

Cephalomedullary Standard Targeting Guide

00-2490-012-11

Guide Wire Gripper

00-2490-003-02

Standard Cephalomedullary Connecting Bolt

00-2490-031-05

11mm Hex/Pin Wrench

00-2490-032-44

Long Cephalomedullary Lag Screw Reamer 3.2mm ID

00-2490-032-05

Slotted Mallet

00-2490-003-45

Cephalomedullary Lag Screw Stop Assembly

00-2490-046-20

2.0mm Pin

00-2490-003-50

Long Cephalomedullary Lag Screw Inserter

00-2490-003-49

Cephalomedullary Lag Screw Compression Device

00-2490-003-51

Long Cephalomedullary Lag Screw Retaining Shaft

00-2490-012-30

3.0mm Threaded Pin By 305mm

00-2490-013-00

Entry Cannula

00-2490-014-15

Tapered Reamer 15.5mm

00-2490-032-80

Optional Instruments
Item Number

Product Description

00-2490-010-00

Long Cannulated Awl

Cephalomedullary Connecting Bolt Inserter 8.0mm

00-2490-010-01

Short Cannulated Awl

00-2490-035-07

Cephalomedullary Flexible Captured Set Screw Driver
Standard

00-2490-014-80

Entry Reamer, 8mm

00-2490-035-40

Long Modular 3.5 Hex Screwdriver

47-2490-030-04

Standard Antirotational Pin

00-2490-040-10

Long Cephalomedullary Lag Screw Cannula

00-2490-032-00

Impaction Head

00-2490-040-80

Long Screw Cannula 8.0mm

00-2490-041-04

Standard Double Barrel Cannula

00-2490-043-32

Long Cephalomedullary Lag Screw Pin Sleeve 3.2mm

00-2490-050-02

Modular T-Handle

00-2490-043-43

Long Drill Sleeve 4.3mm

00-2490-044-43

Calibrated Drill 4.3mm Long

00-2490-047-32

3.2mm Threaded Pin x 508mm

00-2490-050-01

Modular Handle AO

00-2490-080-00

Nail Cap Inserter

00-2490-080-03

Nail Cap Retaining Shaft

00-5900-099-00

Generic Stackable Lid

002490-003-80

Lag Screw Cannulated Depth Gauge

Product Description

00-2490-037-01

Cephalomedullary Compact Case - Stainless Steel

Tear Drop Guide Wire (available separately)
Item Number

Product Description

47-2490-097-00

3.0mm x 100cm Tear Drop Guide Wire (Sterile)

47-2490-098-00

3.0mm x 70cm Tear Drop Guide Wire (Sterile)

47-2490-097-01

2.4mm x 100cm Tear Drop Guide Wire (Sterile)

47-2490-098-01

2.4mm x 70cm Tear Drop Guide Wire (Sterile)

Surgical Technique: 97-2493-013-00

Instrument Case
Item Number

Qty

Qty.
1

x-ray Templates: 06.02075.00/97-2493-051-00 (US only)
Wall Chart: 97-2493-015-00

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard

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.

Contact your Zimmer representative or visit us at www.zimmer.com
The CE mark is valid only if it is also printed on the product label.

Source Exif Data:

File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
PDF Version                     : 1.4
Linearized                      : Yes
Create Date                     : 2012:12:10 09:54:20-06:00
Creator                         : Adobe InDesign CS6 (Windows)
Modify Date                     : 2015:12:02 10:47:15-05:00
Tagged PDF                      : Yes
XMP Toolkit                     : Adobe XMP Core 5.4-c005 78.147326, 2012/08/23-13:03:03
Format                          : application/pdf
Modified                        : 2014:10:27 20:57:17.419Z
Subject                         : null
Title                           : Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique - Standard
Size                            : 3253441
Extracted                       : 2014:09:16 21:45:07.982-05:00
Sha 1                           : edb8fd2918beea51cab9726140e315c10ece4666
Metadata Date                   : 2015:12:02 10:47:15-05:00
Creator Tool                    : Adobe InDesign CS6 (Windows)
Rendition Class                 : proof:pdf
Document ID                     : xmp.id:8236B6D2E142E2118BE8BFCE4E0D6DA5
Original Document ID            : adobe:docid:indd:f71345fc-3b2f-11df-bb13-bbc71103e144
Instance ID                     : uuid:d81c8788-bffb-b842-991c-3fb1de5ccd3d
Derived From Rendition Class    : default
Derived From Instance ID        : xmp.iid:8136B6D2E142E2118BE8BFCE4E0D6DA5
Derived From Document ID        : xmp.did:8136B6D2E142E2118BE8BFCE4E0D6DA5
Derived From Original Document ID: adobe:docid:indd:f71345fc-3b2f-11df-bb13-bbc71103e144
History Action                  : converted
History Software Agent          : Adobe InDesign CS6 (Windows)
History Parameters              : from application/x-indesign to application/pdf
History When                    : 2012:12:10 09:54:20.000-06:00
History Changed                 : /
Producer                        : Adobe PDF Library 10.0.1
Trapped                         : False
Tags                            : zimmer-web:website/healthcare-professionals/surgical-techniques/trauma, zimmer-web:website/healthcare-professionals/surgical-techniques/other
Page Count                      : 20

EXIF Metadata provided by EXIF.tools

Zimmer® Natural Nail® System Cephalomedullary Nail Surgical Technique Standard Zimmer Compact

Navigation menu

Versions of this User Manual:

Views

Navigation