Zimmer Natural Nail System Tibia Surgical Technique

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Zimmer®

Natural Nail®

System

Tibial Nail

Surgical

Suprapatella Technique

Zimmer® Natural Nail® System - Tibial (Suprapatella) 1

Zimmer Natural Nail

System Tibial Nail

Surgical Technique

(Suprapatella)

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

Reaming 6

Nail Assembly and Insertion 6

Proximal Screw Placement 9

Distal Targeting – Freehand Technique 11

Finalize Implant Placement 13

Postoperative Care 13

Nail Extraction 13

Tibial Nail Details 14

Case Examples 15

Product Information 16

Zimmer® Natural Nail® System - Tibial (Suprapatella)

2

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 Tibial Nail is designed to help treat

various fractures of the tibia. 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 proximal

body to allow surgeons to address

different fracture types. The proximal slot

allows for compression or dynamization

across a fracture.

A choice of lengths and diameters

is available to match the individual

anatomy of the patient.

Implant Overview

Nail Diameters: 8.3, 9.3, 10, 11, 12mm

Nail Lengths: 24 to 44cm in 2cm

increments

Proximal Screw Diameter: 5.0mm

Proximal Screw Lengths: 20 to 60mm

in 2.5mm increments, 65 to 100mm in

5mm increments

Distal Screw Diameter: 4.0mm for 8.3mm

diameter nails

5.0mm for 9.3mm and larger diameter

nails

Distal Screw Lengths: 20 to 60mm in

2.5mm increments, 65 to 100mm in

5mm increments

Materials: Ti-6Al-4V alloy

Precision instrumentation is provided

to help implant the nail. Many of the

instruments and implants feature

color coding to help the surgical team

use the system, easily and efficiently.

Certain universal instruments are not

color coded. The color coding system is

referenced in the technique. A wall chart

(97-2495-003-00) is also available to

help explain the color coding system.

The technique is written to explain use

of the SUPRAPATELLA TARGETING GUIDE

which should be used when the knee is

in extension.

Indications

The Zimmer Natural Nail System is

intended for temporary fracture fixation

and stabilization of the bone.

Indications for the tibial nails include the

following:

• 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

• Periprosthetic fractures

• Pseudoarthrosis, non-union, mal-

union and delayed union

• Surgically created defects such as

osteotomies

When this device is implanted using a

Suprapatella surgical approach, all of

the above indications apply with the

exception of Periprosthetic 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 and

if the Suprapatella surgical approach is

not being used for implantation. When

treating a periprosthetic fracture, the

nail should be positioned so that it does

not come in contact with the in situ

device.

Zimmer® Natural Nail® System - Tibial (Suprapatella) 3

Surgical Technique

Preoperative Planning

Preoperative planning is recommended

before beginning the surgical procedure.

A/P and Lateral x-rays of the injured tibia

should be taken preoperatively and

evaluated for length, canal size and

implant suitability. A/P and Lateral x-rays

of the contralateral uninjured tibia can

also be taken preoperatively to provide

insight into the characteristics of the pre-

injured tibia.

Patient Positioning

The patient should be positioned in the

supine position. The positioning should

allow the knee of the injured leg to be

placed in at least 10°-20° of flexion. Use

e.g. blankets, custom foam devices or

sterile bumps to support this position.

The use

of a fracture table can be beneficial

to help

reduce fractures as well as to

facilitate intraoperative imaging with a

C-arm. The C-arm should be placed to allow

for imaging of the tibia in both planes

along the entire length of the bone.

Drape the patient appropriately to allow the

surgeon to work from the knee to the foot.

Reduction

It is critical to achieve anatomic

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,

ball spike pushers and Steinman pins,

femoral distractors or external fixation

systems.

Starting Point Location

The starting point for the nail is located

on the shelf of the tibia, just medial to the

Lateral Intracondylar Eminence (Fig. 1).

Avoid an excessively medial start point

to minimize potential for intra-articular

damage. With the knee in full extension,

make a 2cm longitudinal skin incision

either starting at the pole of the patella

or starting 1cm superior (corresponds

to one finger breadth) to the pole of the

patella.

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Fig. 1

Zimmer® Natural Nail® System - Tibial (Suprapatella)

4

Fig. 5

Fig. 6

The deep incision, also longitudinal,

splits the quadriceps tendon in its

midsubstance, just above its insertion

into the patella and enters the knee joint

through the suprapatellar pouch.

Blunt dissection can be used to loosen

the patella in the suprapatellar pouch,

allowing the patella to lift off. Displace

the patella anteriorly.

Assemble the ENTRY CANNULA with the

corresponding blue ENTRY CANNULA

HANDLE (Fig. 2). Orient the laser mark

on the handle to any laser mark on the

cannula.

Insert the CANNULATED TROCAR into the

handle assembly. Push down on and lock

the inner instruments to make sure that

everything is properly put together (Fig. 3).

NOTE: Inspect the ENTRY CANNULA as it

may become damaged, bend or chipped

with excessive prior reaming and

insertion of any other instruments. Any

flaws in the tube can lead to damage of

the surrounding tendons and tissues.

CAUTION: Do not use ENTRY CANNULA

without trocar properly assembled

or directly with the STARTING POINT

MODIFIER attached.

Insert the handle assembly through the

incision into the knee joint so that it

glides between the articular surface of

the patella and the trochlea of the distal

femur and rests securely in this groove,

while the patella is displaced anteriorly.

When the CANNULATED TROCAR reaches

the surface of the tibia stop pushing

down the handle assembly.

NOTE: The knee must remain in

extension or slightly flexed once the

handle assembly has been inserted.

Pin Insertion

Place the 3.0mm PIN through the

CANNULATED TROCAR and advance to

the anterior surface of the tibia (Fig. 4).

Slight adjustment of the knee flexion

(between 10°-20°) will provide the ideal

radiographic location for the starting

point and insertion of the PIN into the

tibia.

Use the C-arm to visualize the pin’s

position from A/P and Lateral views. The

PIN should be inserted at the identified

point heading slightly posterior into the

medullary canal.

Drive the pin through the starting point

into the center of the medullary canal.

Adjustments to the PIN location can be

Fig. 3

Fig. 2

Fig. 4

made by replacing the CANNULATED

TROCAR by the STARTING POINT

MODIFIER (Fig. 5). Rotate it to place a

second PIN while the first PIN remains

in place. Distance between the two

pins is 4mm. After correct placement

of the second PIN the initial PIN and

the STARTING POINT MODIFIER can be

removed.

Once the ENTRY CANNULA is in place

and the PIN position is verified, the

CANNULATED TROCAR can be removed

from the surgical field (Fig. 6). If needed,

a standard suction device can be

attached to the ENTRY CANNULA.

Place the 8mm ENTRY REAMER over

the PIN, through the ENTRY CANNULA

and down to the bone (Fig. 7). Using

fluoroscopy, ream an entry portal into

the proximal tibia to the metadiaphyseal

flare. The PIN and the ENTRY REAMER

should not reach the posterior cortex.

Zimmer® Natural Nail® System - Tibial (Suprapatella) 5

Fig. 9

Fig. 8

Fig. 7

Remove the ENTRY REAMER.

Alternatively, a STRAIGHT AWL or a 12mm

ENTRY REAMER can be used to find the

entry

point and create the entry portal (Fig. 8).

NOTE: Do not use the STRAIGHT AWL

with power. Always attach the MODULAR

HANDLE to perform the opening of the

IM canal.

Only nails up to 12mm may be used

with this technique. If an 8mm entry

reamer was used for proximal reaming,

then use the 12.0mm ENTRY REAMER to

finish preparing the proximal tibia for

the proximal portion of the nail (sizes

8-11mm). If the bone is especially

dense, it may be necessary to over-ream

the proximal tibia by 0.5 to 1.0mm to

accommodate the proximal portion of

the nail. The groove in the reamer flutes

indicates the final position of the top of

the nail. In addition, the c-arm should

be used to visualize the depth of the

reamer in the proximal tibia. Care should

be taken to keep the reamer in line with

the shaft of the tibia to avoid reaming

through the cortex of the tibia.

Remove the pin.

Place a 3.0mm x 100cm BALL TIP GUIDE

WIRE or TEAR DROP GUIDE WIRE through

the ENTRY CANNULA into the medullary

canal all the way into the distal tibia. To

aid in manipulation, bend the tip of the

GUIDE WIRE at about a 100 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.

Fluoroscopy can assist you in guiding

the GUIDE WIRE past the fracture site. If

you plan to ream the canal of the tibia,

the GUIDE WIRE should be centered and

embedded in the distal tibia at the level

of the distal epiphyseal scar using the

GUIDE WIRE GRIPPER and a MALLET (Fig.

9). Care should be taken not to drive the

wire through the ankle joint.

Assemble the two piece NAIL LENGTH

GAUGE. 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 entry point (confirm position

using fluoroscopy)( Fig. 10).

The proximal end of the GUIDE WIRE

indicates the

length of the wire in the

canal (Fig. 11).

When determining nail

length, consideration should be taken as

to how deep the nail will be inserted into

the tibia based upon the desired location

of the proximal screws. A RULER is also

included in the set which can be used to

radiographically determine nail length.

If a 70cm GUIDE WIRE is used, measure

the length of the canal by sliding only the

half of the NAIL LENGTH GAUGE that is

etched with length measurements to the

level of the entry point. The proximal end

of the 70cm GUIDE WIRE will indicate the

length of the wire that is in the canal.

Fig. 10

Fig. 11

Zimmer® Natural Nail® System - Tibial (Suprapatella)

6

Fig. 13

Reaming

Attach a standard suction device to the

ENTRY CANNULA to remove reaming

debris from the knee joint.

Insert the reamer over the GUIDE WIRE

through the ENTRY CANNULA. 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.

NOTE: If the reamer head gets stuck in

the IM canal or interferes with the ENTRY

CANNULA, tilt the ENTRY CANNULA

HANDLE to a anterior-inferior position

to re-align the reamer head and ENTRY

CANNULA (Fig. 12).

The GUIDE WIRE PUSHER can help

prevent the GUIDE WIRE from coming out

of the tibia during reaming. When cortical

chatter occurs, stop reaming. Choose a

nail that is 1.0 – 1.5mm smaller than the

last reamer used. The proximal diameter

of nails equal to or smaller than 11mm

in diameter is 11mm. For nails 11mm

and larger in diameter, the diameter of

the nail is constant. If a nail smaller than

11mm is to be used, be sure to ream the

proximal portion of the bone to 11.5mm

to accommodate the proximal portion of

the nail.

NOTE: The ENTRY CANNULA allows

reamers up to 13.5mm to go through.

Do not use a larger reamer. Therefore

nails with a diameter of 13mm or 14mm

can’t be utilized with the suprapatella

instrumentation.

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.

Nail Assembly and Insertion

The color code for the tibial nail is

YELLOW. Ti-6Al-4V alloy nails, the

SUPRAPATELLAR TARGETING GUIDE and

the CONNECTING BOLT all have yellow

colors and the word YELLOW etched on

them. Place the appropriate CONNECTING

BOLT (Suprapatella) through the barrel

of the LONG TARGETING GUIDE HANDLE.

Begin threading the CONNECTING BOLT

(by hand or using the CONNECTING BOLT

INSERTER) into the proximal portion of

the nail. Orient the nail so that the distal

portion of the nail angles anterior, the

same direction as the TARGETING GUIDE

HANDLE (Fig. 13).

Fig. 12

Zimmer® Natural Nail® System - Tibial (Suprapatella) 7

Fig. 14

Fig. 15

Slots in the top of the nail will match

tabs on the TARGETING GUIDE HANDLE to

help orient the nail correctly. Completely

tighten the CONNECTING BOLT to secure

the nail to the guide (Fig. 14). The arrow

on the nail will line up with the arrow on

the barrel of the guide when the nail is

correctly aligned.

Attach the TARGETING MODULE to the

TARGETING GUIDE HANDLE. Use a screw

cannula, drill sleeve and drill bit to verify

that the holes in the guide target the

holes in the nail. Remove the TARGETING

MODULE BEFORE inserting the nail.

Insert the NAIL over the GUIDE WIRE with

the arm of the guide facing anterior.

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 (Fig. 15).

NOTE: Before inserting the nail, the

ENTRY CANNULA has to be removed as

the nail will not pass through it.

Zimmer® Natural Nail® System - Tibial (Suprapatella)

8

Fig. 16

Fig. 17

INSTRUMENT TYPE COLOR CODE

Screw Cannula Orange/Orange

Trocar Orange/Orange

4.3mm Drill Sleeve Orange/Orange & Red

4.3mm Drill Bit Orange/Orange & Red

Depth Gauge Orange

Screwdriver

Orange/Orange

If the nail does not pass down the canal

easily, attach the IMPACTION HEAD to

the TARGETING GUIDE HANDLE. Using the

MALLET, impact gently on the IMPACTION

HEAD (Fig. 16). Do not impact when the

MODULE is attached to the IMPACTION

HEAD. Verify that the CONNECTING BOLT

is tight while impacting. Do not impact

on any other portion of the TARGETING

GUIDE HANDLE or MODULE 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. Place the top of

the nail in line with or below the surface

of the tibia, depending on its position

relative to the expected screw location.

Care should be taken to not pry on the

handle as this may cause damage to the

instrumentation.

Remove the GUIDE WIRE from the nail

using the GUIDE WIRE GRIPPER (Fig. 17).

If possible, remove the GUIDE WIRE

before fully seating the nail, if desired.

Zimmer® Natural Nail® System - Tibial (Suprapatella) 9

Retighten the CONNECTING BOLT to

the nail.

Attach the TARGETING MODULE to the

TARGETING GUIDE HANDLE (Fig. 18).

Select the screw holes that will be used

in the nail. Insert HOLE INDICATORS in

the holes in the TARGETING MODULE that

will NOT be used.

Fig. 18

Fig. 19

Fig. 20

*Under certain conditions, especially in patients with thin cortical bone,

Partially Threaded Screws from 20mm to 32.5mm in length may form a

Fixed Angle construct with the nail.

INSTRUMENT TYPE COLOR CODE

Screw Cannula Orange/Orange

Trocar Orange/Orange

4.3mm Drill Sleeve Orange/Orange & Red

4.3mm Drill Bit Orange/Orange & Red

Depth Gauge Orange

Screwdriver

Orange/Orange

Proximal Screw Placement

All of the screw holes in the tibial nail

allow for standard locking or fixed angle

locking. To achieve standard locking,

choose a PARTIALLY THREADED SCREW.

To achieve a fixed angle construct,

choose a FIXED ANGLE SCREW.

Instruments that are specific to the

tibia nail are marked in YELLOW. The

instruments needed to place screws

through the proximal portion of the nail

are color coded ORANGE/ORANGE. These

instruments are placed through holes in

the targeting guide which are color coded

ORANGE. The chart below details the

color coded instruments that are used to

target and place screws.

Slide the TROCAR into the SCREW

CANNULA. Slide the SCREW CANNULA

through one of the selected holes in the

TARGETING MODULE. Dissect through

the tissue down to the bone to make a

path for the SCREW CANNULA (Fig. 19).

Advance the SCREW CANNULA until the

tip of the TROCAR is against the bone

(Fig. 20).

Zimmer® Natural Nail® System - Tibial (Suprapatella)

10

Fig. 22

Fig. 21

Fig. 22

Fig. 23

Remove the TROCAR. Insert the 4.3mm

DRILL SLEEVE through the CANNULA

down to the bone. Place the 4.3mm

DRILL BIT through the DRILL SLEEVE.

Before the DRILL BIT contacts the bone,

start the drill. Advance the spinning

DRILL BIT through the bone bicortically.

Use fluoroscopy to verify the appropriate

location of the DRILL BIT in the bone.

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 SCREW CANNULA (Fig. 21).

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.

(Alternatively, the DRILL BIT and DRILL

SLEEVE can be removed and the SCREW

DEPTH GAUGE used to measure the

length of screw.)

Remove the DRILL BIT and DRILL SLEEVE.

Place the appropriate length 5.0mm

screw (color coded RED) through the

SCREW CANNULA into the bone (Fig. 22).

Using the screwdriver, advance the screw

to achieve bicortical purchase (the screw

head should sit on the near cortex of the

bone). The screws are self tapping so

tapping should not be necessary (Fig.

23).

If using the CAPTURED SCREWDRIVER,

place the appropriate screw on the

3.5mm HEX and tighten the screw to the

CAPTURED SCREWDRIVER by turning the

knob next to the handle clockwise.

CAUTION: If using the CAPTURED

SCREWDRIVER, do not torque the

CAPTURED SCREWDRIVER beyond the

calibration line next to the handle.

CAUTION: Do not drive the screws into

the bone under power, as damage to the

bone, screws and nail could result.

Note: Do not overtighten the screws.

Repeat this technique to place

additional proximal screws as necessary.

Zimmer® Natural Nail® System - Tibial (Suprapatella) 11

Fig. 24

Fig. 25

Distal Targeting – Freehand

Technique

8.3mm nails utilize a 4.0mm screw

(3.3mm drill bit) distally. These items are

color coded WHITE.

9.3mm and larger diameter nails use a

5.0mm screw (4.3mm drill bit) distally.

These items are color coded RED.

NOTE: There is no color indication on the

screw itself. Screw packaging and the

screw case contain color coding to help

identify the screw size.

Insert the appropriate diameter

FREEHAND DRILL BIT into the DISTAL

TARGETING WAND. Finger tighten the SET

SCREW. Position the C-arm in order to get

a lateral view of the distal tibia. 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 (Fig. 24).

Make a stab incision 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 center

of the hole. While keeping the tip of the

drill bit against the bone, move the other

end of the drill bit into other positions

and take additional fluoroscopic images

to verify the position of the tip in the

center of the hole. Align the drill bit with

the C-arm beam. Tap the drill bit into the

bone using the MALLET.

Loosen the SET SCREW and remove the

DISTAL TARGETING WAND, leaving the

DRILL BIT in place. Slide the FREEHAND

TISSUE PROTECTION SLEEVE over the

DRILL BIT (Fig. 25).

Zimmer® Natural Nail® System - Tibial (Suprapatella)

12

Fig. 27

Fig. 26

Attach the DRILL to the 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 (Fig. 26).

Alternatively, the appropriate length

of screw can be measured using the

numbered etch on the DRILL BIT closest

to the end of the FREEHAND TISSUE

PROTECTION SLEEVE when the DRILL

BIT is in the bone and the SLEEVE is

touching the bone (Fig. 27). Insert the

appropriate length screw using the

screwdriver.

If using the CAPTURED SCREWDRIVER,

place the appropriate screw on the

3.5mm HEX and tighten the screw to the

CAPTURED SCREWDRIVER by turning the

knob next to the handle clockwise.

CAUTION: If using the CAPTURED

SCREWDRIVER, do not torque the

CAPTURED SCREWDRIVER beyond the

calibration line next to the handle.

CAUTION: Do not drive the screws into

the bone under power, as damage to the

bone, screws and nail could result.

NOTE: Do not overtighten the screws.

Repeat these steps to insert additional

distal screws.

Zimmer® Natural Nail® System - Tibial (Suprapatella) 13

Fig. 29

Fig. 28

Fig. 30

Finalize Implant Placement

Observe the depth of the nail in proximal

tibia. Ridges in the targeting guide barrel

indicate depths of 5, 10 and 15mm.

Disconnect the TARGETING MODULE

from the TARGETING GUIDE HANDLE and

set aside. Place a 2.0MM PIN through

the guide against the proximal screws.

Loosen and remove the CONNECTING

BOLT from the nail (Fig. 28). Remove the

TARGETING GUIDE HANDLE and set aside.

Assemble the ENTRY CANNULA with the

blue ENTRY CANNULA HANDLE and slide

over 2.0MM PIN.

Choose the appropriate height TIBIAL

NAIL CAP. Secure the selected NAIL CAP

to the NAIL CAP INSERTER using the NAIL

CAP RETAINING SHAFT (Fig. 29). Slide the

TIBIAL NAIL CAP over the 2.0MM PIN and

tighten to the nail (Fig. 30). Using the

C-arm, verify that the cap is completely

seated to the top of the nail.

Disengage the NAIL CAP INSERTER from

the TIBIAL 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

Because of the potential for damage

to intra-articular structures, use a

standard parapatellar incision for any

nail extractions. Do not extract the nail

via a suprapatellar approach. Before

attempting to remove any screws or nail

caps, clean any bone from the hex of the

screw or cap.

Use the C-arm to locate any distal screws.

Remove the screws using a 3.5mm hex

screwdriver. Remove the nail cap (if one

was inserted) with the CONNECTING BOLT

INSERTER or another Zimmer 5.0mm hex

screwdriver. Expose the proximal screws

and use a 3.5mm hex screwdriver to

remove them.

NOTE: Use the specific captured

screwdriver.

To remove the nail, slide a 2.0mm

Guide 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.

Zimmer® Natural Nail® System - Tibial (Suprapatella)

14

Tibial Nail Details

Oblique Screw, descends with joint line (12 to 17mm from top)

Oblique Screw, ascending (20 to 25mm from top)

Dynamization slot (28 to 44mm from top)

Transverse Screw (49 to 54mm from top)

Anterior bevel

at top of nail

Posterior bevel on tip

25 to 30mm from tip

2° anterior bow

60mm proximal

body length

10° Herzog curve

Tri-flute shape (10mm and up)

15 to 20mm from tip

5 to 10mm from tip

11mm proximal body diameter for 8.3, 9.3, 10 and 11mm nails. The

proximal body diameter for 12mm nails is consistent with shaft diameter

8.3, 9.3, 10, 11, 12mm

Shaft Diameters 4.0mm (Distal Holes of 8.3mm Nails Only)

7mm Diameter Head

3.9mm Head Height

3.4mm Minor Diameter

3.3mm Drill

1.8mm Tip Length

5.0mm

8mm Diameter Head

3.9mm Head Height

4.3mm Minor Diameter

4.3mm Drill

2.2mm Tip Length

Zimmer® Natural Nail® System - Tibial (Suprapatella) 15

Pre-Op Post-Op

Pre-Op Post-Op

Case Examples

Zimmer® Natural Nail® System - Tibial (Suprapatella)

16

Item Number Product Description

47-2495-240-08 Tibia Nail 8.3mm X 24cm Ti-6AL-4V Alloy

47-2495-260-08 Tibia Nail 8.3mm X 26cm Ti-6AL-4V Alloy

47-2495-280-08 Tibia Nail 8.3mm X 28cm Ti-6AL-4V Alloy

47-2495-300-08 Tibia Nail 8.3mm X 30cm Ti-6AL-4V Alloy

47-2495-320-08 Tibia Nail 8.3mm X 32cm Ti-6AL-4V Alloy

47-2495-340-08 Tibia Nail 8.3mm X 34cm Ti-6AL-4V Alloy

47-2495-360-08 Tibia Nail 8.3mm X 36cm Ti-6AL-4V Alloy

47-2495-380-08 Tibia Nail 8.3mm X 38cm Ti-6AL-4V Alloy

47-2495-400-08 Tibia Nail 8.3mm X 40cm Ti-6AL-4V Alloy

47-2495-420-08 Tibia Nail 8.3mm X 42cm Ti-6AL-4V Alloy

47-2495-440-08 Tibia Nail 8.3mm X 44cm Ti-6AL-4V Alloy

47-2495-240-09 Tibia Nail 9.3mm X 24cm Ti-6AL-4V Alloy

47-2495-260-09 Tibia Nail 9.3mm X 26cm Ti-6AL-4V Alloy

47-2495-280-09 Tibia Nail 9.3mm X 28cm Ti-6AL-4V Alloy

47-2495-300-09 Tibia Nail 9.3mm X 30cm Ti-6AL-4V Alloy

47-2495-320-09 Tibia Nail 9.3mm X 32cm Ti-6AL-4V Alloy

47-2495-340-09 Tibia Nail 9.3mm X 34cm Ti-6AL-4V Alloy

47-2495-360-09 Tibia Nail 9.3mm X 36cm Ti-6AL-4V Alloy

47-2495-380-09 Tibia Nail 9.3mm X 38cm Ti-6AL-4V Alloy

47-2495-400-09 Tibia Nail 9.3mm X 40cm Ti-6AL-4V Alloy

47-2495-420-09 Tibia Nail 9.3mm X 42cm Ti-6AL-4V Alloy

47-2495-440-09 Tibia Nail 9.3mm X 44cm Ti-6AL-4V Alloy

47-2495-240-10 Tibia Nail 10mm X 24cm Ti-6AL-4V Alloy

47-2495-260-10 Tibia Nail 10mm X 26cm Ti-6AL-4V Alloy

47-2495-280-10 Tibia Nail 10mm X 28cm Ti-6AL-4V Alloy

47-2495-300-10 Tibia Nail 10mm X 30cm Ti-6AL-4V Alloy

47-2495-320-10 Tibia Nail 10mm X 32cm Ti-6AL-4V Alloy

47-2495-340-10 Tibia Nail 10mm X 34cm Ti-6AL-4V Alloy

Product Information

47-2495-360-10 Tibia Nail 10mm X 36cm Ti-6AL-4V Alloy

47-2495-380-10 Tibia Nail 10mm X 38cm Ti-6AL-4V Alloy

47-2495-400-10 Tibia Nail 10mm X 40cm Ti-6AL-4V Alloy

47-2495-420-10 Tibia Nail 10mm X 42cm Ti-6AL-4V Alloy

47-2495-440-10 Tibia Nail 10mm X 44cm Ti-6AL-4V Alloy

47-2495-240-11 Tibia Nail 11mm X 24cm Ti-6AL-4V Alloy

47-2495-260-11 Tibia Nail 11mm X 26cm Ti-6AL-4V Alloy

47-2495-280-11 Tibia Nail 11mm X 28cm Ti-6AL-4V Alloy

47-2495-300-11 Tibia Nail 11mm X 30cm Ti-6AL-4V Alloy

47-2495-320-11 Tibia Nail 11mm X 32cm Ti-6AL-4V Alloy

47-2495-340-11 Tibia Nail 11mm X 34cm Ti-6AL-4V Alloy

47-2495-360-11 Tibia Nail 11mm X 36cm Ti-6AL-4V Alloy

47-2495-380-11 Tibia Nail 11mm X 38cm Ti-6AL-4V Alloy

47-2495-400-11 Tibia Nail 11mm X 40cm Ti-6AL-4V Alloy

47-2495-420-11 Tibia Nail 11mm X 42cm Ti-6AL-4V Alloy

47-2495-440-11 Tibia Nail 11mm X 44cm Ti-6AL-4V Alloy

47-2495-240-12 Tibia Nail 12mm X 24cm Ti-6AL-4V Alloy

47-2495-260-12 Tibia Nail 12mm X 26cm Ti-6AL-4V Alloy

47-2495-280-12 Tibia Nail 12mm X 28cm Ti-6AL-4V Alloy

47-2495-300-12 Tibia Nail 12mm X 30cm Ti-6AL-4V Alloy

47-2495-320-12 Tibia Nail 12mm X 32cm Ti-6AL-4V Alloy

47-2495-340-12 Tibia Nail 12mm X 34cm Ti-6AL-4V Alloy

47-2495-360-12 Tibia Nail 12mm X 36cm Ti-6AL-4V Alloy

47-2495-380-12 Tibia Nail 12mm X 38cm Ti-6AL-4V Alloy

47-2495-400-12 Tibia Nail 12mm X 40cm Ti-6AL-4V Alloy

47-2495-420-12 Tibia Nail 12mm X 42cm Ti-6AL-4V Alloy

47-2495-440-12 Tibia Nail 12mm X 44cm Ti-6AL-4V Alloy

Tibial Nails

Zimmer® Natural Nail® System - Tibial (Suprapatella) 17

Item Number Product Description

47-2483-020-40 4.0mm Cortical Screw 20mm Length

47-2483-022-40 4.0mm Cortical Screw 22.5mm Length

47-2483-025-40 4.0mm Cortical Screw 25mm Length

47-2483-027-40 4.0mm Cortical Screw 27.5mm Length

47-2483-030-40 4.0mm Cortical Screw 30mm Length

47-2483-032-40 4.0mm Cortical Screw 32.5mm Length

47-2483-035-40 4.0mm Cortical Screw 35mm Length

47-2483-037-40 4.0mm Cortical Screw 37.5mm Length

47-2483-040-40 4.0mm Cortical Screw 40mm Length

47-2483-042-40 4.0mm Cortical Screw 42.5mm Length

47-2483-045-40 4.0mm Cortical Screw 45mm Length

47-2483-047-40 4.0mm Cortical Screw 47.5mm Length

47-2483-050-40 4.0mm Cortical Screw 50mm Length

47-2483-052-40 4.0mm Cortical Screw 52.5mm Length

47-2483-055-40 4.0mm Cortical Screw 55mm Length

47-2483-057-40 4.0mm Cortical Screw 57.5mm Length

47-2483-060-40 4.0mm Cortical Screw 60mm Length

47-2483-065-40 4.0mm Cortical Screw 65mm Length

47-2483-070-40 4.0mm Cortical Screw 70mm Length

47-2483-075-40 4.0mm Cortical Screw 75mm Length

47-2483-080-40 4.0mm Cortical Screw 80mm Length

47-2483-085-40 4.0mm Cortical Screw 85mm Length

47-2483-090-40 4.0mm Cortical Screw 90mm Length

47-2483-095-40 4.0mm Cortical Screw 95mm Length

47-2483-100-40 4.0mm Cortical Screw 100mm Length

4.0mm Screws (Partially Threaded)

(for distal screw holes on nails 8.3mm nail)

Item Number Product Description

47-2484-020-40 4.0mm Cortical Screw 20mm Length

47-2484-022-40 4.0mm Cortical Screw 22.5mm Length

47-2484-025-40 4.0mm Cortical Screw 25mm Length

47-2484-027-40 4.0mm Cortical Screw 27.5mm Length

47-2484-030-40 4.0mm Cortical Screw 30mm Length

47-2484-032-40 4.0mm Cortical Screw 32.5mm Length

47-2484-035-40 4.0mm Cortical Screw 35mm Length

47-2484-037-40 4.0mm Cortical Screw 37.5mm Length

47-2484-040-40 4.0mm Cortical Screw 40mm Length

47-2484-042-40 4.0mm Cortical Screw 42.5mm Length

47-2484-045-40 4.0mm Cortical Screw 45mm Length

47-2484-047-40 4.0mm Cortical Screw 47.5mm Length

47-2484-050-40 4.0mm Cortical Screw 50mm Length

47-2484-052-40 4.0mm Cortical Screw 52.5mm Length

47-2484-055-40 4.0mm Cortical Screw 55mm Length

47-2484-057-40 4.0mm Cortical Screw 57.5mm Length

47-2484-060-40 4.0mm Cortical Screw 60mm Length

47-2484-065-40 4.0mm Cortical Screw 65mm Length

47-2484-070-40 4.0mm Cortical Screw 70mm Length

47-2484-075-40 4.0mm Cortical Screw 75mm Length

47-2484-080-40 4.0mm Cortical Screw 80mm Length

47-2484-085-40 4.0mm Cortical Screw 85mm Length

47-2484-090-40 4.0mm Cortical Screw 90mm Length

47-2484-095-40 4.0mm Cortical Screw 95mm Length

47-2484-100-40 4.0mm Cortical Screw 100mm Length

Fixed Angle (Fully Threaded)

All Screws have a 3.5mm Hex Head

Zimmer® Natural Nail® System - Tibial (Suprapatella)

18

Item Number Product Description

47-2483-020-50 5.0mm Cortical Screw 20mm Length

47-2483-022-50 5.0mm Cortical Screw 22.5mm Length

47-2483-025-50 5.0mm Cortical Screw 25mm Length

47-2483-027-50 5.0mm Cortical Screw 27.5mm Length

47-2483-030-50 5.0mm Cortical Screw 30mm Length

47-2483-032-50 5.0mm Cortical Screw 32.5mm Length

47-2483-035-50 5.0mm Cortical Screw 35mm Length

47-2483-037-50 5.0mm Cortical Screw 37.5mm Length

47-2483-040-50 5.0mm Cortical Screw 40mm Length

47-2483-042-50 5.0mm Cortical Screw 42.5mm Length

47-2483-045-50 5.0mm Cortical Screw 45mm Length

47-2483-047-50 5.0mm Cortical Screw 47.5mm Length

47-2483-050-50 5.0mm Cortical Screw 50mm Length

47-2483-052-50 5.0mm Cortical Screw 52.5mm Length

47-2483-055-50 5.0mm Cortical Screw 55mm Length

47-2483-057-50 5.0mm Cortical Screw 57.5mm Length

47-2483-060-50 5.0mm Cortical Screw 60mm Length

47-2483-065-50 5.0mm Cortical Screw 65mm Length

47-2483-070-50 5.0mm Cortical Screw 70mm Length

47-2483-075-50 5.0mm Cortical Screw 75mm Length

47-2483-080-50 5.0mm Cortical Screw 80mm Length

47-2483-085-50 5.0mm Cortical Screw 85mm Length

47-2483-090-50 5.0mm Cortical Screw 90mm Length

47-2483-095-50 5.0mm Cortical Screw 95mm Length

47-2483-100-50 5.0mm Cortical Screw 100mm Length

5.0mm Screws (Partially Threaded)

(for all proximal screw holes and distal screw holes on nails 9.3mm

and larger)

47-2484-020-50 5.0mm Cortical Screw 20mm Length

47-2484-022-50 5.0mm Cortical Screw 22.5mm Length

47-2484-025-50 5.0mm Cortical Screw 25mm Length

47-2484-027-50 5.0mm Cortical Screw 27.5mm Length

47-2484-030-50 5.0mm Cortical Screw 30mm Length

47-2484-032-50 5.0mm Cortical Screw 32.5mm Length

47-2484-035-50 5.0mm Cortical Screw 35mm Length

47-2484-037-50 5.0mm Cortical Screw 37.5mm Length

47-2484-040-50 5.0mm Cortical Screw 40mm Length

47-2484-042-50 5.0mm Cortical Screw 42.5mm Length

47-2484-045-50 5.0mm Cortical Screw 45mm Length

47-2484-047-50 5.0mm Cortical Screw 47.5mm Length

47-2484-050-50 5.0mm Cortical Screw 50mm Length

47-2484-052-50 5.0mm Cortical Screw 52.5mm Length

47-2484-055-50 5.0mm Cortical Screw 55mm Length

47-2484-057-50 5.0mm Cortical Screw 57.5mm Length

47-2484-060-50 5.0mm Cortical Screw 60mm Length

47-2484-065-50 5.0mm Cortical Screw 65mm Length

47-2484-070-50 5.0mm Cortical Screw 70mm Length

47-2484-075-50 5.0mm Cortical Screw 75mm Length

47-2484-080-50 5.0mm Cortical Screw 80mm Length

47-2484-085-50 5.0mm Cortical Screw 85mm Length

47-2484-090-50 5.0mm Cortical Screw 90mm Length

47-2484-095-50 5.0mm Cortical Screw 95mm Length

47-2484-100-50 5.0mm Cortical Screw 100mm Length

Fixed Angle (Fully Threaded)

Item Number Product Description

Item Number Product Description

47-2487-005-00 Tibial Nail Cap 0mm Height

47-2487-005-05 Tibial Nail Cap 5mm Height

47-2487-005-10 Tibial Nail Cap 10mm Height

47-2487-005-15 Tibial Nail Cap 15mm Height

Nail Caps

Zimmer® Natural Nail® System - Tibial (Suprapatella) 19

Item Number Product Description

02.00020.049 Ratchet Wrench 11mm

00-2237-008-00 Skin Protector

00-2490-000-14 Connecting Knob

00-2490-000-30 Nail Diameter Gauge

00-2490-000-33 Ruler

00-2490-000-34 Nail Length Gauge

00-2490-000-41 Hole Indicator

00-2490-005-01 Small Tibial Connecting Bolt

00-2490-005-05 Tibial Module

00-2490-005-10 Tibial Targeting Guide Small Handle

00-2490-005-49 Tibial Axial Compression Device

00-2490-010-01 Short Cannulated Awl

00-2490-010-02 7mm Diameter Awl - Angled Tip

00-2490-012-00 Guide Wire Gripper

00-2490-014-80 Entry Reamer 8mm

00-2490-017-00 Guide Wire Pusher

00-2490-031-00 Connecting Bolt Inserter

00-2490-031-05 11mm Hex/ Pin Wrench

00-2490-032-00 Impaction Head

00-2490-032-01 Slotted Mallet

00-2490-033-00 Slap Hammer Adapter

00-2490-035-50 Modular Screwdriver 3.5mm Hex

00-2490-035-62 Short 3.5mm Hex Screwdriver - Captured

00-2490-035-72 Freehand 3.5mm Hex Screwdriver -

Captured

Instruments

KT-2490-005-00 – SMALL Tibia Nail Instrument Set

00-2490-035-75 Freehand Modular 3.5mm Hex Screwdriver

00-2490-046-20 2.0mm Pin

00-2490-012-30 3.0mm Threaded Pin

00-2490-046-32 Guide Pin Inserter / Extractor

00-2490-050-00 Modular Handle AO

00-2490-050-02 Modular T-Handle

00-2490-051-80 Screw Cannula 8.0mm

00-2490-052-80 Screw Trocar 8.0mm

00-2490-053-43 Tibial Drill Sleeve 4.3mm

00-2490-054-43 Calibrated Drill 4.3mm Tibial

00-2490-065-80 Short Screw Depth Gauge 8.0mm

00-2490-070-00 Freehand Targeting Wand

00-2490-070-01 Targeting Wand Set Screw

00-2490-072-33 3.3mm Freehand Targeting Drill

00-2490-072-43 4.3mm Freehand Targeting Drill

00-2490-073-00 Freehand Targeting Depth Gauge

00-2490-074-00 Freehand Tissue Protection Sleeve

00-2490-080-00 Nail Cap Inserter

00-2490-080-03 Nail Cap Retaining Shaft

00-2490-090-00 Cannulated Extraction Adapter 5/16”

00-5900-099-00 Case Lid

Zimmer® Natural Nail® System - Tibial (Suprapatella)

20

Item Number Product Description

02.00020.049 Ratchet Wrench 11mm

00-2237-008-00 Skin Protector

00-2490-000-14 Connecting Knob

00-2490-000-30 Nail Diameter Gauge

00-2490-000-33 Ruler

00-2490-000-34 Nail Length Gauge

00-2490-000-41 Hole Indicator

00-2490-005-05 Tibial Module

00-2490-005-07 Tall Tibial Connecting Bolt

00-2490-005-13 Tibia Targeting Guide Tall Handle

00-2490-005-49 Tibial Axial Compression Device

00-2490-010-01 Short Cannulated Awl

00-2490-010-02 7mm Diameter Awl - Angled Tip

00-2490-012-00 Guide Wire Gripper

00-2490-014-80 Entry Reamer 8mm

00-2490-017-00 Guide Wire Pusher

00-2490-031-00 Connecting Bolt Inserter

00-2490-031-05 11mm Hex / Pin Wrench

00-2490-032-00 Impaction Head

00-2490-032-01 Slotted Mallet

00-2490-033-00 Slap Hammer Adapter

00-2490-035-50 Modular Screwdriver 3.5mm Hex

00-2490-035-62 Short 3.5mm Hex Screwdriver - Captured

00-2490-035-72 Freehand 3.5mm Hex Screwdriver -

Captured

00-2490-035-75 Freehand Modular 3.5mm Hex Screwdriver

00-2490-046-20 2.0mm Pin

00-2490-012-30 3.0mm Threaded Pin

00-2490-046-32 Guide Pin Inserter / Extractor

00-2490-050-00 Modular Handle AO

00-2490-050-02 Modular T-Handle

KT-2490-005-01 – TALL Tibia Nail Instrument Set 00-2490-051-80 Screw Cannula 8.0mm

00-2490-052-80 Screw Trocar 8.0mm

00-2490-053-43 Tibial Drill Sleeve 4.3mm

00-2490-054-43 Calibrated Drill 4.3mm Tibial

00-2490-065-80 Short Screw Depth Gauge 8.0mm

00-2490-070-00 Freehand Targeting Wand

00-2490-070-01 Targeting Wand Set Screw

00-2490-072-33 3.3mm Freehand Targeting Drill

00-2490-072-43 4.3mm Freehand Targeting Drill

00-2490-073-00 Freehand Targeting Depth Gauge

00-2490-074-00 Freehand Tissue Protection Sleeve

00-2490-080-00 Nail Cap Inserter

00-2490-080-03 Nail Cap Retaining Shaft

00-2490-090-00 Cannulated Extraction Adapter 5/16”

00-5900-099-00 Case Lid

KT-2490-005-10 Suprapatellar Add-on Instrument Set

Item Number Product Description

00-2490-005-21 Long Tibial Connecting Bolt

00-2490-005-20 Long Tibial Targeting Guide Handle

00-2490-010-06 Modular Straight Awl, cannulated

00-2490-013-05 Long Tibial Entry Cannula, Locking

00-2490-013-06 Starting Point Modifier, Locking

00-2490-051-20 Cannulated Trocar, Locking

00-2490-013-07 Long Tibial Entry Cannula Handle

00-5900-099-00 Case Lid

Zimmer® Natural Nail® System - Tibial (Suprapatella) 21

Item Number Product Description

00-2490-020-30 3.0mm Self Drilling Reduction Pin

00-2490-020-50 5.0mm Self Drilling Reduction Pin

00-2490-021-00 Ball Spike Pusher

00-2490-022-01 Bone Clamp

00-2490-022-02 Verbrugge Clamp

00-2490-022-03 Reduction Tong

00-2490-025-24 Bone Hook Small - 24mm

00-2490-025-34 Bone Hook Large - 34mm

00-2490-026-00 Reduction Rod

00-2490-050-00 Modular T-Handle AO

00-2490-060-50 Reduction Base and Tray

00-5900-099-00 Case Lid

KT-2490-020-00 – Reduction Instrument Set

Item Number Product Description

47-2490-097-00 3.0mm x 100cm Tear Drop Guide Wire

(Sterile)

47-2490-097-01 2.4mm x 100cm Tear Drop Guide Wire

(Sterile)

47-2490-098-00 3.0mm x 70cm Tear Drop Guide Wire

(Sterile)

47-2490-098-01 2.4mm x 70cm Tear Drop Guide Wire

(Sterile)

Tear Drop Guide Wire (available separately)

Surgical Technique Lit. No. 97-2495-009-00

Wall Chart Lit. No. 97-2495-003-00

X-ray Templates Lit. No. 97-2495-050-00

Optional Instruments

Item Number Product Description

00-2490-014-12 Entry Reamer 12mm

Item Number Product Description

00-2490-075-50 Tibial Case 1 of 2 – Stainless Steel

and Aluminum

00-2490-079-50 Tibial Case 2 of 2 – Stainless Steel

and Aluminum

00-2490-075-00 Tibial Case 1 of 2 – Stainless Steel

00-2490-079-00 Tibial Case 2 of 2 – Stainless Steel

00-2490-075-20 Suprapatella Tibia Instrument Add-on Case

Instrument Cases (Select both “Stainless Steel” or

both “Stainless Steel and Aluminum” Cases)

Zimmer® Natural Nail® System - Tibial (Suprapatella)

22

Zimmer® Natural Nail® System - Tibial (Suprapatella) 23

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

97-2495-009-00 Rev. 3 6-26-15 Printed in USA ©2015 Zimmer, Inc.

DISCLAIMER:

This documentation is intended exclusively for physicians and is not intended for laypersons. Information on the products and

procedures contained in this document is of a general nature and does not represent and does not constitute medical advice or

recommendations. Because this information does not purport to constitute any diagnostic or therapeutic statement with regard

to any individual medical case, each patient must be examined and advised individually, and this document does not replace

the need for such examination and/or advise in whole or in part.

Please refer to the package inserts for important product information, including, but not limited to, indications,

contraindications, warnings, precautions, and adverse effects.

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

FAi DRAFT July 20, 2015 3:25 PM