Zimmer® Natural Nail® System Retrograde Femoral Nail Zimmer Surgical Technique

2016-04-04

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Zimmer®

Natural Nail®

System

Retrograde Femoral Nail

Surgical Technique

Zimmer® Natural Nail® System - Retrograde Femoral Nail 1

Zimmer Natural Nail

System Retrograde Femur

Nail Surgical Technique

Table of Contents

Product Overview 2

Implant Overview 2

Indications 2

Contraindications 2

Surgical Technique 3

Preoperative Planning 3

Patient Positioning 3

Reduction 3

Starting Point Location 3

Distal Reaming 5

Shaft Reaming 5

Implant Selection 5

Nail Assembly and Insertion 5

Distal Screw Placement 8

Proximal Screw Placement: Short Nails 11

Proximal Screw Placement: Freehand Technique for Long Nails 12

Final Implant Placement 13

Postoperative Care 13

Nail Extraction 13

Retrograde Femur Long Nail Details 14

Retrograde Femur Short Nail Details 15

Product Information 16

Zimmer® Natural Nail® System - Retrograde Femoral Nail

Product Overview

The Zimmer Natural Nail System

is a system of intramedullary (IM)

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 Retrograde Femur nail is designed to

help treat various fractures of the femur.

Screws are placed through the nail to

secure the implant in place and maintain

length and alignment while healing

occurs. The nail has multiple screw holes

in the distal body to allow surgeons to

address different fracture types. The

proximal slot allows for compression or

dynamization across a fracture.

Several lengths and diameters are

available to match the individual

anatomy of the patient.

Implant Overview

Nail Diameters: 10, 11.5 and 13mm for

short and long nails

Nail Lengths: 16, 20 and 24cm for

short nails

28 to 44cm in 2cm increments for

long nails

Distal Screw Diameter: 6.0mm for

Oblique Interlocking and Transverse

Interlocking Screws

Distal Screw Lengths: 30 to 110mm in

5mm increments.

Screw Type: Fixed Angle Screws

Proximal Screw Diameter: 5.0mm for all

diameter nails

Proximal Screw Lengths: 20 to 60mm in

2.5mm increments

Screw Type: Fixed Angle Screws and

Partially Threaded Screws

Further available: nail caps (0mm, 5mm,

10mm and 15mm height), cortical nut

and washer

Materials: Ti-6Al-4V Alloy and UHMWPE

(cortical nut only)

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 universal

instruments are not color coded. The

color coding system is referenced in the

technique. A wall chart (97-2494-003-

00) is also available to help explain the

color coding system.

Indications

The Zimmer Natural Nail System is

intended for temporary fracture fixation

and stabilization of the bone.

Indications for use of the Retrograde

Femur Nails in the femur including:

• Compound and simple shaft fractures

• Proximal, metaphyseal, and distal

shaft fractures

• Segmental fractures

• Closed Supracondylar Fractures

• Severely comminuted supracondylar

fractures with articular involvement

• Fractures involving femoral condyles

• Comminuted fractures

• Fractures involving osteopenic and

osteoporotic bone

• Pathological fractures

• Fractures with bone loss

• Pseudoarthrosis, non-union, and

mal-union

• Periprosthetic fractures

• Poly trauma patients

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

This nail should only be used to treat

a periprothetic 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. The

nail will pass through an in situ opening

device greater than 13mm.

Zimmer® Natural Nail® System - Retrograde Femoral Nail 3

Surgical Technique

Preoperative Planning

Preoperative planning is recommended

before beginning the surgical procedure.

A/P and Lateral x-rays 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.

Patient Positioning

Place the patient in the supine position

with the knee flexed approximately

30 - 60 degrees. Prep the hip limb free,

circumferentially from the hemi pelvis to

the toes, to ensure access to the lesser

trochanter.

The use of a traction or fracture table

can be beneficial to help during

fracture reduction as well as to facilitate

intraoperative imaging with a C-arm.

The use of image intensification is

required. The image intensifier should

be sterile-draped and may be positioned

from either the contralateral or ipsilateral

side of the operating table. Positioning

from the contralateral side will facilitate

insertion of the proximal locking

screws. This will also allow the limb to

be externally rotated when obtaining

a lateral view of the proximal femur for

estimating the screw length. Confirm

visualization of the hip as well as the

shaft of the femur and knee using image

intensification before prepping and

draping.

Reduction

Nail insertion is facilitated by achieving

fracture reduction before beginning

any of the steps to place the IM Nail.

Traction should be used as necessary to

help achieve fracture reduction. Several

instruments are available to assist in

fracture reduction including clamps,

reduction tongs, ball spike pushers and

Steinman pins. Blocking screws are

another option in facilitating fracture

reduction and and ideal nail path.

Starting Point Location

Locating the entry portal is important

to avoid anterior placement of the nail,

involvement of the intercondylar notch,

femoral trochlea, mediolateral

mal-positioning, or posterior positioning

involving the posterior cruciate

ligaments.

Make a midline or medial parapatellar

longitudinal incision in line with the

femoral shaft. Incise the parapatellar

reticulum or peritenon to expose the

infrapatellar fat pad. It is not necessary

to expose the femoral condyles as

placement of the pin is determined

under C-arm control.

Insert the guide pin in the starting point.

Guide the pin to the notch region using

gentle pressure to avoid scoring of the

articular cartilage (Fig. 1).

Use the C-arm to visualize the pin’s

position from an A/P, intercondylar

notch and Lateral views. The starting

point should be in line with the femoral

canal on the A/P view, and just anterior

to where Blumensaat’s line intersects

the anterior intercondylar notch on the

lateral view. This can also be confirmed

on the intercondylar notch view.

When the proper position is confirmed,

apply firm pressure on the pin so the

tip engages and maintains its position.

Then adjust the angle of the pin so it

is aligned collinearly, with the femoral

canal on both AP and lateral images.

Continue to monitor the pins alignment

and progression (A/P and lateral C-arm

views) as the pin is advanced.

Advance the pin proximally until reduced

resistance is felt as the pin exits the

metaphyseal region. Make a final check

with A/P and lateral views.

Fig. 1

Zimmer® Natural Nail® System - Retrograde Femoral Nail

As an option to insert the guide pin,

assemble the STARTING POINT LOCATOR

inside the ENTRY CANNULA. Place the tip

of the STARTING POINT LOCATOR through

the incision down to the intercondylar

notch. Place the 3.0mm PIN through

the center hole of the STARTING POINT

LOCATOR. Use the steps indicated above

to obtain the correct starting point using

the C-arm (Fig. 2).

Use the 8mm ENTRY REAMER to ream an

entry portal over the guide pin into the

distal femur through the starting point.

Be sure to follow the path of the pin,

allowing the reamer to advance through

the metaphyseal bone without binding

on the pin and pushing it up the femoral

canal. Stop reaming when reduced

resistance is felt. Remove the reamer and

3.0mm pin (Fig. 3).

Alternatively, a 13.5mm TAPER REAMER

or SHORT CANNULATED AWL can be used

to initiate the entry portal. Do not place

the SHORT CANNULATED AWL over the

3.0mm pin (Fig. 4).

Place a 3.0mm x 100cm GUIDE WIRE

through the ENTRY CANNULA, all the

way into the proximal femur. 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 GUIDE WIRE GRIPPER and

mallet to remove the guide wire from the

nail.

The GUIDE WIRE must be placed through

the fracture site. At the fracture site,

manipulate the GUIDE WIRE under C-arm

control. If you plan to ream the canal

of the femur, the guide wire should be

embedded in the proximal femur canal

using the GUIDE WIRE GRIPPER and a

MALLET (Fig. 5).

A REDUCTION FINGER is included in the

set. The GUIDE WIRE can be fed retrograde

through the REDUCTION FINGER. The

REDUCTION FINGER can then be placed

into the femur and used to help reduce the

fracture from the inside as well as to help

facilitate passage of the guide wire across

the fracture site.

If a LONG NAIL is to be implanted,

assemble the TWO PIECE NAIL LENGTH

GAUGE. This step can be skipped if using a

short nail (16cm, 20cm or 24cm in length).

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 6a

Zimmer® Natural Nail® System - Retrograde Femoral Nail 5

Slide the tube portion of the gauge over

the 3.0mm x 100cm guide wire until

the tip of the tube is at the level of the

intercondylar notch (confirm position

using fluoroscopy). The distal end of the

GUIDE WIRE indicates the length of the

wire in the canal. When determining nail

length, consideration should be taken as

to how deep the nail will be inserted into

the femur based upon the shape of the

patient’s proximal femur. A ruler is also

included in the set which can be used to

radiographically determine nail length

(Figs. 6 and 6a).

Distal Reaming

Use the 13.5mm TAPER REAMER

(PURPLE) through the ENTRY CANNULA

to prepare the distal femur for the distal

portion of the nail. The C-arm should be

used to visualize the depth of the reamer

in the distal 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 (Figs. 7 and 7a).

The 13.5mm TAPER REAMER has a groove

on it. The most proximal groove indicates

the final position of the most distal

portion of the nail.

NOTE: This corresponds to the measurement

of the nail depth using the NAIL DEPTH

GAUGE and CONNECTING BOLT. Also, the

measurements correlate to the approximate

height of the nail cap if desired.

Shaft Reaming

Reaming should be performed through

the ENTRY CANNULA. Start with a small

Zimmer® Pressure Sentinal® Reamer.

Increase the diameter of the reamer by

0.5 - 1.0mm depending on the amount

of resistance felt while reaming. When

cortical chatter occurs, stop reaming.

Choose a nail that is 1.0 - 1.5mm smaller

than the last shaft reamer used. If a short

nail is to be used, it is only necessary

to ream the distal portion of the canal

(depending on intended nail length). If a

long nail is planned, ream the full length

of the canal. The GUIDE WIRE PUSHER can

help prevent the GUIDE WIRE from coming

out of the femur during reaming (Fig. 8).

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.

Fig. 6a

Fig. 7

Fig. 7a

Fig. 8

Implant Selection

Choose the appropriate length and

diameter of nail based on length and

diameter measurement (fluoroscopic or

based upon the last size reamer used).

If the length indicated is between two

available nail sizes, it is recommended

that the shorter nail be chosen. The nail

tip should not extend proximal to the

intertrochanteric region.

Fig. 9

Nail Assembly and Insertion

The color code for the retrograde femur

nails is PURPLE. Ti-6Al-4V Alloy nails, the

TARGETING GUIDE and the CONNECTING

BOLT all have PURPLE colors on them, as

well as the word PURPLE etched on them

(Fig. 10).

(For the OPTIONAL Modular Guide: Prior

to attaching the nail to the guide, remove

the modules) See Figure 9.

Fig. 10

Zimmer® Natural Nail® System - Retrograde Femoral Nail

Place the CONNECTING BOLT through

the barrel of the TARGETING GUIDE.

Begin threading the CONNECTING BOLT

into the distal portion of the nail. Orient

the distal 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.

The arrow on the nail will line up with the

arrow on the barrel of the guide when the

nail is correctly aligned. The bow of the

nail should be anterior to match the bow

in the femur (Fig. 11).

If using the 00-2490-004-30 RETROGRADE

FEMORAL MODULAR

TARGET GUIDE attach

the 00-2490-004-31 RETROGRADE

FEMORAL MODULAR TARGET and/or

GUIDE MODULE LEFT 00-2490-004-

32 RETROGRADE FEMORAL MODULAR

TARGET GUIDE MODULE RIGHT to confirm

that the guide holes target the nail holes.

Use a screw cannula, drill sleeve and drill

bit to verify that the holes in the guide

target the holes in the nail. If using a

SHORT NAIL, the appropriate PROXIMAL

TARGETING MODULE should be attached

to verify that the drills line up with the

proximal holes in the nail. Remove the

PROXIMAL TARGETING MODULE before

inserting the nail (Fig. 12).

Insert the nail over the guide wire.

Monitor the progression of the nail

using the C-arm, especially as the nail is

passing through or near the fracture site

(Fig. 13).

If the nail does not pass down the canal

easily, attach the IMPACTION HEAD to the

CONNECTING BOLT. Using the MALLET,

impact gently on the IMPACTION HEAD

(Fig. 14).

CAUTION: Do not strike excessively as

damage to the guide and the bone may

result. Verify that the CONNECTING BOLT

is tight while impacting. Do not impact

on any other portion of the TARGETING

GUIDE as this may break the guide or

cause it to lose its accuracy.

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.

Fig. 11

Fig. 12

Fig. 13

Fig. 14

Zimmer® Natural Nail® System - Retrograde Femoral Nail 7

Remove the GUIDE WIRE from the

nail using the GUIDE WIRE GRIPPER.

If possible, the guide wire should be

removed before the nail is completely

seated to reduce the potential for the

wire to get caught in the nail or bone

being impacted into the cannula of the

nail (Fig. 15).

Nail rotation is also critical with this nail

and should be verified by placing 3.0mm

PINS through the holes in the targeting

guide on either side of the connecting

bolt. Place the blue PROTECTIVE CAPS

on the pointed end of the 3.0mm PINS

before inserting into the Targeting Guide

to prevent them from falling on the floor.

Rotate the guide so that the pins are

parallel with the tibia shaft (Fig. 17).

Fig. 15

Note: If guide wire gets stuck during

removal, rotate wire 90 degrees as

force is applied to remove. This can be

accomplished by using the Guide Wire

Gripper.

It is recommended that the distal tip

of the nail be placed 3-5mm inside the

distal surface of the femur. However, the

nail can be placed deeper and nail cap

used to fill femoral canal. To verify depth,

advance the NAIL DEPTH GAUGE through

the guide. The NAIL DEPTH GAUGE

must be assembled before attaching

the IMPACTION HEAD. To ensure the

NAIL DEPTH GAUGE does not slide into

the femoral canal opening, place a blue

PROTECTIVE CAP over the distal end of

the NAIL DEPTH GAUGE. The IMPACTION

HEAD must remain assembled to the

CONNECTING BOLT in case the nail depth

needs to be adjusted. Compare the

distal tip of the RETROGRADE FEMUR

NAIL DEPTH GAUGE with the calibrated

etch lines on the CONNECTING BOLT to

determine nail depth. Confirm the depth

using a lateral x-ray. The nail depth is

a result of the depth prepared with the

13.5MM TAPER REAMER. If oblique

screws are to be used, verification of nail

depth is critical. To facilitate observation

of nail depth using fluoroscopy, the

C-Arm can be tilted 5-15 degrees off of

the true lateral plane to verify the end

of the nail to the Blumensatt’s Line.

A perfect circle should be observed

through the transverse hole to ensure

proper orientation (Fig. 16).

Fig. 17

Fig. 16

Zimmer® Natural Nail® System - Retrograde Femoral Nail

Distal Screw Placement

Use only 6.0mm FIXED ANGLE screws

through the appropriate distal holes in

the nail.

A fixed angle construct is created by

using 6.0mm fixed angle screws. The

instruments needed to place screws

through the distal portion of the nail are

color coded according to the chart below.

The retrograde femur guides use the

PURPLE instruments.

Note: 6.0mm fixed angle screws contain

the color/color name of BLACK on the

label and screw case. These colors

match the color rings on the drills.

If impaction was required, retighten the

CONNECTING BOLT to the nail (Fig. 18).

Only certain distal screw patterns

should be used. Use of all other screw

combinations may subject the device

to increased stresses, which could lead

to device failure. Please choose the

appropriate screw pattern from the table

below. These screw patterns are also

depicted on the targeting guide (Fig. 20).

Fig. 18

Fig. 20

Before placing any oblique screws, place

3.0mm PINS through the pin holes in the

targeting arms. Use the blue pin caps to

secure the pins in the holes. Place the

blue pin caps on the pointed end of the

3.0mm PINS. Take a lateral x-ray. The

position of the pins on the lateral x-ray

represents where the oblique screws will

be placed. If lateral imaging is difficult,

incline the C-arm beam 5 – 15 degrees

off the horizontal. The 3.0mm PINS

must be contained in the metaphyseal

region in any imaging in any plane. The

most distal transverse hole has to be

imaged as a perfect circle (Fig. 21).

Fig. 21

Two factors will primarily affect the

location of the two oblique screws: nail

insertion depth and nail rotation. It is

recommended that nail insertion depth

be adjusted first and then rotation of the

nail/targeting guide.

Insrument Type

Screw Cannula

Trocar/Tri-Flute Trocar

4.9mm Drill Sleeve

4.9mm Drill Bit

(solid or cannulated)

3.0mm Pin Sleeve

Screw Depth Gauge/

Cannulated Screw

Depth Gauge

Screwdriver

Standard

Purple

Purple/Black

Purple

(For the Optional Modular Guide: Attach

the modules to the guide for the distal

screw targeting. Do NOT impact on the

guide while the modules are attached).

See Figure 19.

Fig. 19

Zimmer® Natural Nail® System - Retrograde Femoral Nail 9

If a WASHER (can be used at any distal

hole) or CORTICAL NUT (used only at

most distal transverse hole) is desired,

please refer to the steps for placing these

items below.

After confirming appropriate nail

insertion depth and rotation, it is

suggested that the 3.0mm PIN be placed

in one of the transverse holes. This will

stabilize the nail and targeting guide in

the selected position.

Slide the TROCAR into the SCREW

CANNULA. Slide the SCREW CANNULA

through one of the transverse holes in

the TARGETING MODULE. Incise the

skin at the point the TROCAR touches

it and dissect through the tissue down

to the bone to make a path for the

SCREW CANNULA. Advance the SCREW

CANNULA until the tip of the TROCAR is

against the bone (Fig. 22).

CAUTION: Do not excessively impact

the SCREW CANNULA. Use appropriate

incision to seat the TROCAR/SCREW

CANNULA as impaction may cause loss

of accuracy (Fig. 23).

Fig. 22

Fig. 23

Remove the TROCAR. Before drilling,

use the PIN SLEEVE and drive in a guide

pin to preview targeting via fluoroscopy.

Confirm the rotational position of the nail

and guide, in addition to the nail depth

imaging the 3.0 pins in the targeting

guide. Then refer to the steps listed

below to insert the guide pin(s) in the

oblique holes (Fig. 24).

Fig. 24

Returning to the transverse hole,

remove the GUIDE PIN and PIN SLEEVE,

and insert the appropriate sized DRILL

SLEEVE through the CANNULA down

to the bone. Place the appropriate

sized solid DRILL BIT through the DRILL

SLEEVE. Before the DRILL BIT contacts

the bone, start the drill. (Cannulated

technique is described below.)

It is suggested that the first screw be

placed in one of the transverse holes

prior to the oblique holes.

For Transverse Screws

Advance the spinning DRILL BIT through

the bone bicortically. Use fluoroscopy

to verify the appropriate location of the

DRILL BIT in the bone. The tip of the drill

should be no more than 5mm through

the far cortex of the bone to reduce the

risk of complications associated with

screw protrusion.

With the DRILL BIT in place and the DRILL

SLEEVE pressed against the bone, the

length of screw needed is indicated by

the etch marks on the DRILL BIT where

it exits the DRILL SLEEVE. (Alternatively,

the DRILL BIT and DRILL SLEEVE can be

removed and the SCREW DEPTH GAUGE

used to measure the length of screw.)

Alternatively, the cannulated technique,

as described below for the oblique

screws, can be used.

For Oblique Screws

The cannulated technique must be used

for placement of the oblique screws.

Slide the TROCAR into the SCREW

CANNULA. Slide the SCREW CANNULA

through one of the selected holes in

the TARGETING MODULE. Incise the

skin at the point the TROCAR touches

it and dissect through the tissue down

to the bone to make a path for the

SCREW CANNULA. Advance the SCREW

CANNULA until the tip of the TROCAR is

against the bone.

Remove the TROCAR. Insert the 3.0mm

PIN SLEEVE through the CANNULA down

to the bone. Insert a 3.0mm PIN through

the bone (bicortical for transverse

screws, short of the far cortex for an

oblique screw). Remove the PIN SLEEVE.

Zimmer® Natural Nail® System - Retrograde Femoral Nail

Insert the CANNULATED DEPTH GAUGE

over the pin and observe the location

of the end of the pin in relation to

the etched calibration lines on the

CANNULATED DEPTH GAUGE to determine

length of screw. PLACE THE 4.9mm DRILL

SLEEVE in the CANNULA. Drill using the

4.9mm CANNULATED DRILL BIT through

the DRILL SLEEVE to the appropriate

depth, which is recommended to be at

least 10mm from the subchrondal bone

for bone that is less dense or severely

osteoporotic. It is recommended to use

a screw that would be at least 5mm from

the subchondral bone (Fig. 25).

Fig. 25

Measure the appropriate screw length

using the marks on the calibrated drill

or the depth gauge (ensure the tip of the

shaft engages with the far cortex of the

bone). The SCREW CANNULA must be

seated on the bone for the calibration

lines to be accurate.

Remove the DRILL BIT and DRILL

SLEEVE. Place the appropriate length

and diameter screw through the SCREW

CANNULA into the bone. Use the 3.5mm

HEX SCREWDRIVER to advance the screw

to achieve good thread purchase, care

should be taken using fluoroscopy to

prevent perforating the subchondral

bone (the screw head should sit on the

near cortex of the bone). An etch line on

the SCREWDRIVER indicates when the

screw head is at the bone surface (this

is to be used as a reference and not the

primary check for the screw head being

seated on the bone). The screws are

self tapping so tapping should not be

necessary (Fig. 26).

Fig. 26

CAUTION: When using any screwdriver

do not torque it beyond the calibration

line. Do not drive the screws into the

bone under power, as damage to the

bone, screws and nail could result. In

addition, avoid any excessive torque

or excessive force during final screw

seating.

Washers and Cortical Nuts

Washers can be used at any distal hole,

but CORTICAL NUTS may only be used

with the most distal TRANSVERSE SCREW.

(It is recommended to use the next

longest screw to ensure full engagement

with the cortical nut.) Follow the steps to

drill and measure for these screws. If a

washer and/or cortical nut will be used

add at least 3mm to the screw length.

Remove the DRILL SLEEVE after obtaining

appropriate screw length and insert the

3.0mm PIN SLEEVE. Place a 3.0mm PIN

through the PIN SLEEVE bicortically so

that it causes the medial skin to bulge.

Incise at the bulge and dissect down to

the bone. Attach the COUNTERBORE to

the T-HANDLE and advance through the

hole on the medial side of the guide.

Advance the COUNTERBORE over the

3.0mm PIN down to the bone.

Repeat this technique to place additional

distal screws as necessary.

Zimmer® Natural Nail® System - Retrograde Femoral Nail 11

Rotate the COUNTERBORE to remove

bone for the placement of the CORTICAL

NUT. The shoulder on the COUNTERBORE

should be advanced to the level of the

medial cortex (Fig. 27).

Fig. 27

NOTE: The corresponding COUNTERBORE

and CORTICAL NUT DRIVER are marked

with the color code PURPLE

CAUTION: Do not counterbore or drive

the cortical nut into the bone under

power, as damage to the bone, screws

and nail could result. In addition, using

the depth gauge after counterboring

can lead to error in screw length

measurement.

Remove the COUNTERBORE, 3.0mm PIN

and PIN SLEEVE. The screw cannula

can be inserted to help facilitate screw

insertion, keep cannula outside of skin,

insert screw into cannula, advance screw

out of exit end of cannula, load washer,

then insert cannula back into wound site

before screw insertion. Before the screw

enters the wound, insert a washer onto

the screw. Then begin driving the screw

into the bone and through the hole in the

nail. Attach the CORTICAL NUT DRIVER to

the T-HANDLE. Put a CORTICAL NUT into

the CORTICAL NUT DRIVER and pass it

through the hole on the medial side of

the guide over the screw until it seats

onto the cortex. Tighten the CORTICAL

NUT to the tip of the 6.0mm SCREW using

the CORTICAL NUT DRIVER. Use an image

intensifier to verify proper position.

CAUTION: Do not overtighten the nut.

Proximal Screw Placement –

Short Nails:

Use 5.0mm FIXED ANGLE SCREWS or

PARTIALLY THREADED SCREWS through

the appropriate proximal holes in the

nail.

There is no locking tab built in for short

nails proximally. Therefore either screw

type will result in a standard locking

construct.

Color coded instruments are also used

for proximal targeting of short nails. For

the RETROGRADE FEMUR TARGETING

GUIDE, instruments marked PURPLE are

utilized to place the proximal screws.

The chart below details the color coded

instruments that are used for proximal

targeting and screw placement.

Instrument Type

8.0mm Screw Cannula Purple

4.3mm Drill Bit Purple–Red

4.3mm Drill Sleeve Purple–Red

Screw Depth Gauge Purple

Screwdriver Purple

Screw Trocar Purple

The TARGETING GUIDE is designed

to target the proximal static (ST) and

dynamic (DY) holes in SHORT nails.

Assemble the appropriate TARGETING

MODULE (16cm, 20cm, or 24cm

correspond to SHORT nail length) to the

TARGETING GUIDE laterally (Figs. 28 and

28a).

Fig. 28

Fig. 28a

Zimmer® Natural Nail® System - Retrograde Femoral Nail

Slide the TROCAR into the SCREW

CANNULA. Slide the SCREW CANNULA

through one of the selected holes in

the TARGETING MODULE. Incise the

skin at the point the TROCAR touches

it and dissect through the tissue down

to the bone to make a path for the

SCREW CANNULA. Advance the SCREW

CANNULA until the tip of the TROCAR is

against the bone.

Remove the Screw Trocar and 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 (Fig. 29).

Fig. 29

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. Another

option is to remove the drill bit and the

drill sleeve and then use the SCREW

DEPTH GAUGE to measure the depth of

the hole.

The nail utilizes a 5.0mm screw

proximally. The screw packages are

labeled with the color RED.

Choose the appropriate length screw

based on the DEPTH GAUGE or DRILL

BIT reading. Use the 3.5mm HEX

SCREWDRIVER to place the screw

bicortically through the bone.

CAUTION: When using any screwdriver,

do not torque it beyond the calibration

line. Do not drive the screws into the

bone under power, as damage to the

bone, screws and nail could result.

Remove the screwdriver and cannula.

If desired, repeat these steps to place

another screw in the other hole or slot.

Proximal Screw Placement –

Freehand Technique for Long

Nails:

The chart below indicates the color

coding for proximal screws and their

associated drill bits for each nail

diameter.

Nail Diameter

All diameters

Screw Size

5.0mm

Drill Bit Size

4.3mm

Color Code

Red

Insert the FREEHAND 4.3mm DRILL BIT

(RED) into the FREEHAND TARGETING

WAND. Finger tighten the SET SCREW.

Position the C-arm in order to get an

AP view of the proximal femur. Adjust

the angle of the C-arm so that the hole

through the nail appears as a perfect

circle on the monitor. Bring the tip of the

drill bit to the skin and use the C-arm to

center it over the hole that you desire

to place a screw through. Make a stab

wound at this point and dissect down

to the bone. Place the tip of the drill bit

against the bone. Verify that the tip of

the drill bit is in the centre of the hole.

Align the drill bit with the C-arm beam.

Tap the drill bit into the bone using the

MALLET (Fig. 30).

Fig.30

Remove the FREEHAND TARGETING

WAND. Slide the FREEHAND TISSUE

PROTECTION SLEEVE over the DRILL

BIT. Attach the DRILL to the FREEHAND

4.3mm DRILL BIT and advance the drill

bit through the bone. Verify that the drill

bit has gone through the hole in the nail.

Remove the drill bit. Measure the depth

of the hole using the FREEHAND SCREW

DEPTH GAUGE. Choose a fixed angle

or partially threaded screw and insert

the appropriate length screw using the

screwdriver.

Zimmer® Natural Nail® System - Retrograde Femoral Nail 13

CAUTION: When using any screwdriver

do not torque it beyond the calibration

line. Do not drive the screws into the

bone under power, as damage to the

bone, screws and nail could result. In

addition, avoid any excessive torque

or excessive force during final screw

seating.

Repeat these steps to insert additional

proximal screws.

Finalize Implant Placement

Observe the depth of the nail in distal

femur. Ridges in the targeting guide

barrel indicate 5 and 10mm of depth.

Using the nail depth gauge technique

described earlier will also indicate the

nail depth.

Disconnect any TARGETING MODULES

from the TARGETING GUIDE and set

aside. Choose the appropriate height

cannulated NAIL CAP. If a NAIL CAP 5mm

or longer is chosen place a 2.0MM GUIDE

PIN through the CONNECTING BOLT down

to the level of the distal screws. Loosen

and remove the CONNECTING BOLT from

the nail. Remove the TARGETING GUIDE

HANDLE and set aside.

If a 0mm height NAIL CAP is used

insert using the CONNECTION BOLT

INSERTER. If a 5, 10 or 15mm height

cap is used, secure the selected NAIL

CAP to the NAIL CAP INSERTER using

the NAIL CAP RETAINING SHAFT. Ensure

an unobstructed pathway exists to the

distal end of nail to facilitate NAIL CAP

insertion. Slide the cannulated NAIL CAP

over the 2.0MM GUIDE PIN and tighten

to the nail. Using the C-arm, verify that

the cap is completely seated to 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.

It is the responsibility of the surgeon

to determine what is the most suitable

postoperative care depending on each

patient’s health condition.

Nail Extraction

Use the C-arm to locate any proximal

screws. Remove the proximal screws

using a 3.5mm HEX SCREWDRIVER.

Remove the nail cap (if one was inserted)

with a 5.0mm HEX SCREWDRIVER.

Expose the distal screws, cortical nut and

washer, use a 3.5mm HEX SCREWDRIVER

and a RETROGRADE FEMUR CORTICAL

NUT DRIVER to remove them. If bone has

grown into any of the screws, nail cap,

nail, or cortical nut/washer that would

inhibit implant removal, use instruments

such as rongeurs, dental picks or

drills to remove bone in-growth before

attempting implant removal. Take care

not to damage the implant itself while

removing ingrown bone.

To remove the nail, slide a 2.0mm PIN

through the nail. Insert the CANNULATED

EXTRACTION ADAPTER over the wire into

the top of the nail. Tighten the adapter to

the nail. Attach a SLAPHAMMER or other

impaction device and impact to back

out the nail. The nail should move with

each impaction. Periodically retighten

the adapter and/or SLAPHAMMER during

extraction as needed.

Zimmer also offers a Universal Extraction

System should one be required.

Zimmer® Natural Nail® System - Retrograde Femoral Nail

Retrograde Femur Long Nail Details

Anterior bevel on tip

45 to 51mm from Head

1270mm

Anterior Bow Radius

Lengths 28 through 44cm

10, 11.5, 13mm Shaft Diameters

Straight Flutes

37 to 44mm from Head (Oblique hole)

6.0mm Screw

8mm Diameter Head

3.4mm Head Height

4.8mm Minor Diameter

4.9mm Drill

2.8mm Tip Length

5.0mm Screw

8mm Diameter Head

3.9mm Head Height

4.3mm Minor Diameter

4.3mm Drill

2.1mm Tip Length

32 to 37mm from tip

Dynamic Slot 10 to 25mm from tip

23 to 30mm from Head (Oblique hole)

9 to 15mm from Head

59mm distal body length

13mm Head

Zimmer® Natural Nail® System - Retrograde Femoral Nail 15

Retrograde Femur Short Nail Details

Anterior bevel on tip

45 to 51mm from head

1270mm

Anterior Bow Radius

Lengths 16 through 24cm 10, 11.5, 13mm Shaft Diameters

Straight Flutes

37 to 44mm from head

(Oblique hole)

6.0mm Screw

8mm Diameter Head

3.4mm Head Height

4.8mm Minor Diameter

4.9mm Drill

2.8mm Tip Length

5.0mm Screw

8mm Diameter Head

3.9mm Head Height

4.3mm Minor Diameter

4.3mm Drill

2.1mm Tip Length

11 to 16mm from tip

Dynamic Slot 22 to 37mm from tip

43 to 48mm from tip

23 to 30mm from head

(Oblique hole)

9 to 15mm from head

59mm distal body length

13mm Head

NOTE: There is no locking tab for

retrograde femur short nails proximally.

Zimmer® Natural Nail® System - Retrograde Femoral Nail

Retrograde Femur Nails

Product Information

Part Number Description

47-2494-160-10 Retrograde Short Femoral Nail 10mm X

16cm Universal Ti-6Al-4V Alloy

47-2494-200-10 Retrograde Short Femoral Nail 10mm X

20cm Universal Ti-6Al-4V Alloy

47-2494-240-10 Retrograde Short Femoral Nail 10mm X

24cm Universal Ti-6Al-4V Alloy

47-2494-160-11 Retrograde Short Femoral Nail 11.5mm X

16cm Universal Ti-6Al-4V Alloy

47-2494-200-11 Retrograde Short Femoral Nail 11.5 mm X

20cm Universal Ti-6Al-4V Alloy

47-2494-240-11 Retrograde Short Femoral Nail 11.5 mm X

24cm Universal Ti-6Al-4V Alloy

47-2494-160-13 Retrograde Short Femoral Nail 13mm X

16cm Universal Ti-6Al-4V Alloy

47-2494-200-13 Retrograde Short Femoral Nail 13mm X

20cm Universal Ti-6Al-4V Alloy

47-2494-240-13 Retrograde Short Femoral Nail 13mm X

24cm Universal Ti-6Al-4V Alloy

Short Nails

Part Number Description

47-2494-280-10 Retrograde Femoral Nail 10mm X 28cm

Universal Ti-6Al-4V Alloy

47-2494-300-10 Retrograde Femoral Nail 10mm X 30cm

Universal Ti-6Al-4V Alloy

47-2494-320-10 Retrograde Femoral Nail 10mm X 32cm

Universal Ti-6Al-4V Alloy

47-2494-340-10 Retrograde Femoral Nail 10mm X 34cm

Universal Ti-6Al-4V Alloy

47-2494-360-10 Retrograde Femoral Nail 10mm X 36cm

Universal Ti-6Al-4V Alloy

47-2494-380-10 Retrograde Femoral Nail 10mm X 38cm

Universal Ti-6Al-4V Alloy

47-2494-400-10 Retrograde Femoral Nail 10mm X 40cm

Universal Ti-6Al-4V Alloy

47-2494-420-10 Retrograde Femoral Nail 10mm X 42cm

Universal Ti-6Al-4V Alloy

47-2494-440-10 Retrograde Femoral Nail 10mm X 44cm

Universal Ti-6Al-4V Alloy

47-2494-280-11 Retrograde Femoral Nail 11.5 mm X 28cm

Universal Ti-6Al-4V Alloy

Long Nails

47-2494-300-11 Retrograde Femoral Nail 11.5 mm X 30cm

Universal Ti-6Al-4V Alloy

47-2494-320-11 Retrograde Femoral Nail 11.5 mm X 32cm

Universal Ti-6Al-4V Alloy

47-2494-340-11 Retrograde Femoral Nail 11.5 mm X 34cm

Universal Ti-6Al-4V Alloy

47-2494-360-11 Retrograde Femoral Nail 11.5 mm X 36cm

Universal Ti-6Al-4V Alloy

47-2494-380-11 Retrograde Femoral Nail 11.5 mm X 38cm

Universal Ti-6Al-4V Alloy

47-2494-400-11 Retrograde Femoral Nail 11.5 mm X 40cm

Universal Ti-6Al-4V Alloy

47-2494-420-11 Retrograde Femoral Nail 11.5 mm X 42cm

Universal Ti-6Al-4V Alloy

47-2494-440-11 Retrograde Femoral Nail 11.5 mm X 44cm

Universal Ti-6Al-4V Alloy

47-2494-280-13 Retrograde Femoral Nail 13mm X 28cm

Universal Ti-6Al-4V Alloy

47-2494-300-13 Retrograde Femoral Nail 13mm X 30cm

Universal Ti-6Al-4V Alloy

47-2494-320-13 Retrograde Femoral Nail 13mm X 32cm

Universal Ti-6Al-4V Alloy

47-2494-340-13 Retrograde Femoral Nail 13mm X 34cm

Universal Ti-6Al-4V Alloy

47-2494-360-13 Retrograde Femoral Nail 13mm X 36cm

Universal Ti-6Al-4V Alloy

47-2494-380-13 Retrograde Femoral Nail 13mm X 38cm

Universal Ti-6Al-4V Alloy

47-2494-400-13 Retrograde Femoral Nail 13mm X 40cm

Universal Ti-6Al-4V Alloy

47-2494-420-13 Retrograde Femoral Nail 13mm X 42cm

Universal Ti-6Al-4V Alloy

47-2494-440-13 Retrograde Femoral Nail 13mm X 44cm

Universal Ti-6Al-4V Alloy

Part Number Description

47-2484-030-60 6.0mm Cancellous Screw 30mm Length