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

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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 2

Implant Overview 2

Indications 2

Contraindications 2

Surgical Technique 2

Preoperative Planning 2

Patient Positioning 3

Reduction 3

Starting Point Location 3

Proximal Reaming 4

Shaft Reaming 4

Implant Selection 4

Nail Assembly and Insertion 4

Lag Screw Placement 6

Distal Targeting For Short Nails 9

Final Implant Placement 10

Postoperative Care 10

Nail Extraction 10

Cephalomedullary Short Nail Details 12

Product Information 12

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

Nail Lengths: 21.5cm (short)

CCD Angles: 125°, 130°, 135°

Lag Screw Diameter: 10.5mm

Lag Screw Lengths: 70 to 130mm in

5mm increments

Distal Screw Diameter: 5.0mm

Distal Screw Lengths: 20 to 60mm in

2.5mm increments, 65 to 100mm in

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.

Indications for the Cephalomedullary

nails include:

• Compoundandsimpleshaftfractures

• Proximal,metaphysealanddistalshaft

fractures

• Segmentalfractures

• Comminutedfractures

• Fracturesinvolvingosteopenicand

osteoporotic bone

• Pathologicalfractures

• Fractureswithboneloss

• Pseudoarthrosis,non-union,mal-

union and delayed union

• Periprostheticfractures

• Surgicallycreateddefectssuchas

osteotomies

• Intertrochantericandsubtrochanteric

fractures

Contraindications

• Amedullarycanalobliteratedbya

previous fracture or tumor

• Boneshafthavingexcessivebowor

deformity

• 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

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.

Surgical Technique

Preoperative Planning

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.

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.

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

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.

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. 1

Fig. 2

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.

Fig. 3

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

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.

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.

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.

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.

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.

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.

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.

Fig. 4

Fig. 5

Fig. 6

Fig. 7

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.

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

Fig. 8

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 push-

and-twist motion when inserting the

hole indicators to help ensure that

they stay in place.

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

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.

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.

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).

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. 10

Fig. 11

1AOPrinciplesofFractureManagement,Thieme,2000

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

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

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).

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 mis-

targeting. 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).

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.

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.

Fig. 12

Fig. 13

Fig. 14

Fig. 15

Fig. 16

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.

 AOPrinciplesofFractureManagement,Thieme,2000

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

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

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.

AttachtheLAGSCREWtotheLAGSCREW

NSERTERusingtheLAGSCREWRETAINING

SHAFTtofullysecurethescrewtothe

inserter(Fig.17).

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. 17

Fig. 18

Fig. 19

Fig. 20

Fig. 21

NOTE: Remove the ANTIROTATION PIN (if

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).

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.

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

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.

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

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

Fig. 22

Instrument Type Standard

8.0mmScrewCannula  Green 

4.3mmDrillSleeve  Green–Red

4.3mmDrillBit  Green–Red

Screwdriver  Green 

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 (00-2490-

048-50) 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.

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.

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.*

Nail Extraction

Forextraction,pleasereferencesurgical

technique for both the small and standard,

97-2493.005.00 and 97-2493-002-00.

Fig. 23

* 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

4o Proximal Lateralization Angle

10, 11.5, 13, 14.5mm shaft diameters

60 to65mm

from tip

43 to 55mm

from tip

(Dynamic Slot)

Clothespin tip (for nails

11.5mm in diameter and larger)

15.5mmProximalHead

58mm Proximal

Body Length

1275mm

AnteriorBowRadius

35 to 39mm from tip (3.0mm Pin)

42 to 54mm from tip (10.5mm Lag Screw)

Lag Screw

10.5mm Diameter

6.6mm Minor Diameter

10.2mm Drill

2.8mm Tip Length

5.0mm Screw

8mmDiameterHead

3.8mmHeadHeight

4.3mm Minor Diameter

4.3mm Drill

2.0mm Tip Length

BlueRing

5.0mm

Screws

15o Anteversion

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

125o/130o/135o CCD Angle

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

Cephalomedullary Short Nails

Product Information

Item Number Product Description

47-2493-210-10 CephalomedullaryShortNail10mmX21.5cm125CCD

Right Ti-6Al-4V Alloy

47-2493-211-10 CephalomedullaryShortNail10mmX21.5cm125CCD

Left Ti-6Al-4V Alloy

47-2493-212-10 CephalomedullaryShortNail10mmX21.5cm130CCD

Right Ti-6Al-4V Alloy

47-2493-213-10 CephalomedullaryShortNail10mmX21.5cm130CCD

Left Ti-6Al-4V Alloy

47-2493-214-10 CephalomedullaryShortNail10mmX21.5cm135CCD

Right Ti-6Al-4V Alloy

47-2493-215-10 CephalomedullaryShortNail10mmX21.5cm135CCD

Left Ti-6Al-4V Alloy

47-2493-210-11 CephalomedullaryShortNail11.5mmX21.5cm125CCD

Right Ti-6Al-4V Alloy

47-2493-211-11 CephalomedullaryShortNail11.5mmX21.5cm125CCD

Left Ti-6Al-4V Alloy

47-2493-212-11 CephalomedullaryShortNail11.5mmX21.5cm130CCD

Right Ti-6Al-4V Alloy

47-2493-213-11 CephalomedullaryShortNail11.5mmX21.5cm130CCD

Left Ti-6Al-4V Alloy

47-2493-214-11 CephalomedullaryShortNail11.5mmX21.5cm135CCD

Right Ti-6Al-4V Alloy

47-2493-215-11 CephalomedullaryShortNail11.5mmX21.5cm135CCD

Left 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

47-2493-212-13 CephalomedullaryShortNail13mmX21.5cm130CCD

Right Ti-6Al-4V Alloy

47-2493-213-13 CephalomedullaryShortNail13mmX21.5cm130CCD

Left Ti-6Al-4V Alloy

47-2493-214-13 CephalomedullaryShortNail13mmX21.5cm135CCD

Right Ti-6Al-4V Alloy

47-2493-215-13 CephalomedullaryShortNail13mmX21.5cm135CCD

Left Ti-6Al-4V Alloy

47-2493-210-14 CephalomedullaryShortNail14.5mmX21.5cm125CCD

Right Ti-6Al-4V Alloy

47-2493-211-14 CephalomedullaryShortNail14.5mmX21.5cm125CCD

Left Ti-6Al-4V Alloy

47-2493-212-14 CephalomedullaryShortNail14.5mmX21.5cm130CCD

Right Ti-6Al-4V Alloy

47-2493-213-14 CephalomedullaryShortNail14.5mmX21.5cm130CCD

Left Ti-6Al-4V Alloy

47-2493-214-14 CephalomedullaryShortNail14.5mmX21.5cm135CCD

Right Ti-6Al-4V Alloy

47-2493-215-14 CephalomedullaryShortNail14.5mmX21.5cm135CCD

Left Ti-6Al-4V Alloy

Item Number Product Description

47-2485-070-10 10.5mm Lag Screw 70mm Length Ti-6Al-4V Alloy

47-2485-075-10 10.5mm Lag Screw 75mm Length Ti-6Al-4V Alloy

47-2485-080-10 10.5mm Lag Screw 80mm Length Ti-6Al-4V Alloy

47-2485-085-10 10.5mm Lag Screw 85mm Length Ti-6Al-4V Alloy

47-2485-090-10 10.5mm Lag Screw 90mm Length Ti-6Al-4V Alloy

47-2485-095-10 10.5mm Lag Screw 95mm Length Ti-6Al-4V Alloy

47-2485-100-10 10.5mm Lag Screw 100mm Length Ti-6Al-4V Alloy

47-2485-105-10 10.5mm Lag Screw 105mm Length Ti-6Al-4V Alloy

47-2485-110-10 10.5mm Lag Screw 110mm Length Ti-6Al-4V Alloy

47-2485-115-10 10.5mm Lag Screw 115mm Length Ti-6Al-4V Alloy

47-2485-120-10 10.5mm Lag Screw 120mm Length Ti-6Al-4V Alloy

47-2485-125-10 10.5mm Lag Screw 125mm Length Ti-6Al-4V Alloy

47-2485-130-10 10.5mm Lag Screw 130mm Length Ti-6Al-4V Alloy

10.5mm Lag Screws

Item Number Product Description

47-2483-020-50 5.0mm Cortical Screw 20mm Length Ti-6Al-4V Alloy