Zimmer Nexel Total Elbow Surgical Technique 97 8401 002 00

2014-06-20

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Zimmer
Nexel™
Total Elbow
®

Surgical Technique

Zimmer Nexel™ Total Elbow Surgical Technique
®

Table of Contents

PAGE

Indications / Contraindications............................. 1
Pre-Operative Considerations................................ 2
Surgical Technique Summary................................. 3

SECTION

Surgical Preparation and Exposure

Humeral Preparation

Ulnar Preparation

Trial Reduction

Component Implantation

Final Assembly

7. Closure

Postoperative Management

Poly Revision

10. Component Removal

Zimmer Nexel™ Total Elbow Surgical Technique
®

Device Description
This device is a total elbow prosthesis designed for use with
bone cement. It is available in sizes 4, 5 and 6, in left and
right configurations. The Ulnar and Humeral Components are
manufactured from Tivanium® (Ti-6Al-4V) alloy. The Ulnar
Component has a porous coating of Ti-6Al-4V plasma spray and
is curved to facilitate implantation. The Humeral Component
has a porous coating of Ti-6Al-4V plasma spray and has an
anterior flange to accommodate a bone graft. The Axle-Pin and
Humeral Screws are manufactured from Zimaloy® (Co-Cr-Mo)
alloy. Vitamin E highly cross-linked ultra-high molecular weight
polyethylene (Vivacit-E®) bearings prevent metal-to-metal
articulating contact.
Note: Size 4, 5 and 6 are numerical relative descriptions of the
available girths of the Implant stems. 4,5 and 6 do not imply or
equate to a dimension. 4 does not equal 4 mm, and so on.
Ulnar Bearing

Ulnar Eye
Humeral Screws

Axle-Pin

Plasma Spray

Ulnar Component

Ulnar Bearing
Humeral
Component

Humeral Bearing

Plasma Spray

Anterior Flange

Zimmer Nexel™ Total Elbow Surgical Technique
®

Indications / Contraindications
INDICATIONS

CONTRAINDICATIONS

Indications for use include:

Use of the Zimmer® Nexel™ Total Elbow is
contraindicated in patients with:

• Elbow joint destruction which significantly compromises the
activities of daily living
• Post-traumatic lesions or bone loss contributing to elbow
instability
• Ankylosed joints, especially in cases of bilateral ankylosis
from causes other than active sepsis
• Advanced rheumatoid, post-traumatic, or degenerative
arthritis with incapacitating pain
• Instability or loss of motion when the degree of joint or soft
tissue damage precludes reliable osteosynthesis
• Acute comminuted articular fracture of the elbow joint
surfaces that precludes less radical procedures, including
13-C3 fractures of the distal humerus

• Currently active, or history of repeated, local infection at
the surgical site
• Paralysis or dysfunctional neuropathy involving the elbow
joint
• Significant ipsilateral hand dysfunction
• Excessive scarring of the skin or soft tissue that could
prevent adequate soft tissue coverage
• Daily activities that would subject the device to significant
stress (i.e., heavy labor, torsional stress, and/or
competitive sports)

• Revision arthroplasty

Relative contraindications include:

Caution: This device is intended for cemented use only

• Distant foci of infection (e.g. genitourinary, pulmonary, skin
[chronic lesions or ulcerations], or other sites). In cases of
distant infection, the foci of infection should be treated
prior to, during and after surgery.
• Ancient prior sepsis

Zimmer Nexel™ Total Elbow Surgical Technique
®

Pre-Operative Considerations
• For those inexperienced in the technique of elbow
arthroplasty, training with a cadaver specimen(s) is
recommended to appreciate the soft tissue implications of
the technique.

Axis of Flexion

M L

• Be aware of existing shoulder pathology; assess shoulder
stiffness, avoid forceful rotation.
• Avoid overlapping cement mantles and/or interference
between shoulder and elbow humeral stems, and/or a short
cement gap between shoulder and elbow humeral stems as
these are known fracture risks.
• Understand if a revision length stem is to be used and
assess/accommodate for the amount of anterior bowing of
the humerus on the lateral pre-operative radiographs.

Fig. 0.0
Posterior View

• To address flexion contracture, consider counter sinking the
Humeral Component to the extent that does not produce a
fracture of the medial condyle.
• For proper orientation of the humeral component,
understand the humeral osseous landmarks establishing
the axis of flexion of the elbow. Medially, the landmark is a
point at the anterior/inferior aspect of the medial condyle.
Laterally, the landmark is the center of the capitellum
(Fig. 0.0-0.2).

Axis of Flexion

L M

Fig. 0.1
Anterior View

Center of Rotation

2
Fig. 0.2
Lateral View

Zimmer Nexel™ Total Elbow Surgical Technique
®

Surgical Technique Summary

Dashed line denotes
top of Implant

Axis of
Flexion

A
Fig. 2.1

Use saw or ronguers to remove trochlea and
access humeral canal.

Fig. 2.3

Use Humeral Awl Reamer to open canal and
confirm readiness for Rasps.

Fig. 2.4

Sequentially Rasp the canal; solid line needs
to align with the axis of flexion.

Fig. 2.13
Do not start drill
until pin in hole.
Fully seat
Trephine
Stabilizer

1
Fig. 2.7

Score the bone, and create rounded humeral
cut by using the Trephine saw.

Fig. 2.11

Secure the Humeral Cut Guide by inserting
the Pin, then make vertical cuts using
oscillating saw.

Fig. 2.12

Create notch
with rongeur

Anterior View

Fully seat the Trephine Stabilizer until the marking
aligns with the axis of Flexion (notch anterior
humerus), and finish the Trephine cut.

Flat of the Olecranon

3
Fig. 2.14

Assess Humeral bone preparation with
Provisional.

Fig. 3.5

Prepare the distal ulna using Flexible Reamers,
Solid followed by Cannulated, until marking
aligns with chosen length Implant.

Fig. 3.7

Prepare the proximal ulna using sequential
Rasps, until hole feature on Rasp aligns
with axis of flexion.

Zimmer Nexel™ Total Elbow Surgical Technique
®

Surgical Technique Summary
Fig. 3.11

Fig. 3.9

After using the Ulnar Bearing Clearance
Template to confirm adequate clearance for
Implant, assess the ulnar preparation using
the Ulnar Provisional.

Fig. 5.2

Use Ulnar Stem Inserter to fully seat implant.

Fig. 6.1

After the scrub nurse has loaded the Ulnar
Bearing Assembly Tool (UBAT) with Bearings/
Axle-Pin, attach the assembly to Ulnar
Implant in situ.

Fig. 4.1

Reduce joint and perform a trial range of
motion.

Fig. 5.4

Retrograde fill the humeral canal with cement.

Fig. 6.4

Partially reduce the joint with hand pressure,
then fully reduce it using the Articulation
Inserter. (Alternate: Ulnar Bearing Tamp is
used with the triceps-on exposure.)

Fig. 5.1

Retrograde fill the ulnar canal with cement.

Fig. 5.5

Insert bone graft under the anterior flange
and use the Humeral Stem Inserter to fully
seat the Implant.

Fig. 6.6

Bearings will be flush with top of Implant
when fully seated, and Humeral Screws will
thread in easily using Elbow Torque Driver.

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

Ulnar Crest

1. Surgical Preparation and Exposure
1.1 Patient Preparation

Ulnar Nerve

• Position the patient.
· Position patient in supine with a sandbag under
the scapula.

Fig. 1.1

· Place the arm across the chest.

Incision just lateral to medial epicondyle.

• Place a rolled towel under elbow.
TECHNIQUE TIP

1.2

A more midline positioned incision decreases the need for
elevating an extensive flap.

Flexor carpi
ulnaris m.

Medial epicondyle

1.2 Incision
• Make a straight incision approximately 15cm in length.
· Center incision over the elbow joint just lateral to the
medial epicondyle and just medial to the tip of the
olecranon (Fig. 1.1).

Fig. 1.2
Translocate ulnar nerve to subcutaneous tissue.

1.3 Ulnar Nerve Protection

Motor branch
of ulnar m.

• Isolate the ulnar nerve.

Sharpey’s fibers

· Identify the medial aspect of the triceps mechanism.
· Use ocular magnification and a bipolar cautery
as necessary.
• Mobilize the ulnar nerve to the first motor branch.
• Very carefully translocate the nerve anteriorly into the
subcutaneous tissue (Fig. 1.2).
Note: Carefully protect the nerve throughout the remainder of
the procedure.

Fig. 1.3
Remove triceps from the proximal ulna.

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

™

1.4 The Bryan/Morrey Approach*
The Bryan/Morrey approach is recommended for new and
inexperienced users of the Nexel Total Elbow System. This
approach employs a meticulous repair of the triceps that is
detailed at the end of this surgical technique. Once experience
is gained, other exposures (e.g., Triceps-On/Sparing) can be
employed at the surgeon’s discretion.
• Release the triceps (Fig. 1.3 previous page).
· Make an incision over the medial aspect of the ulna.
· Elevate the ulnar periosteum along with the forearm fascia.
• Expose distal humerus, proximal ulna and radial head
(Fig 1.4)

Fig. 1.4
Transpose the extensor mechanism laterally.

· Retract the medial aspect of the triceps along with the
posterior capsule.
· Remove the triceps from the proximal ulna by releasing the
Sharpey’s fibers from their insertion
· Further reflect the extensor mechanism laterally including
the anconeus.
· Transpose the entire extensor mechanism (triceps, ulnar
periosteum, and anconeus) as a single soft-tissue sleeve
laterally.
• Expose and dislocate the joint.

Fig. 1.5
Release medial and lateral collateral ligaments.

· Release the medial and lateral collateral ligaments from
their humeral attachment (Fig. 1.5).

Released MCL

· Flex the elbow to disarticulate the ulna from the humerus
(Fig. 1.6).

Released LCL

Ulnar nerve

· Externally rotate the forearm to allow further flexion
and separation of the articulation.
· Release the anterior capsule and contracted soft tissue
from the distal humerus (Fig. 1.7).

Triceps

Fig. 1.6
TECHNIQUE TIP

1.4

Flex elbow to disarticulate ulna from humerus.

A complete release of the soft tissues from the medial aspect of the
distal humerus protects the medial epicondyle from fracture during
flexion and manipulation of the forearm. Elbows with severe arthritis,
post-traumatic surgery, and/or extensive soft-tissue contractures
should undergo releases of the capsule and extensor/flexor origins
to facilitate motion and soft tissue balance.

Fig. 1.7
* Morrey, Bernard F., The Elbow and its Disorders. 4th. Philadelphia, PA:
Saunders Elsevier, 2009.

Release anterior capsule from distal humerus.

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

2. Humeral Preparation
Note: Be aware that instruments labeled size “5/6” can be
used for a size 5 or 6 implant; likewise, instruments labeled
size “4/5” can be used for a size 4 or 5 implant.

2.1 Trochlear Resection
• Resect the central portion of the trochlea (Fig. 2.1).
· Use a saw or a rongeur as appropriate.
· Retain resected bone for the anterior bone graft
(Section 5.1).

TECHNIQUE TIP

Fig. 2.1
Use oscillating saw to remove trochlea.
Bur

2.1

The bone graft can be harvested at this time by first making a
center cut, followed by additional medial or lateral cuts.

2.2 Humeral Canal Exposure

Base of
olecranon fossa

• Identify and expose the humeral canal (Fig. 2.2).
· Use a bur or rongeur at the proximal base of the
olecranon fossa.

Fig. 2.2
Use bur to expose humeral canal.

2.3 Humeral Canal Reaming
• Use the Humeral Awl Reamer to open the humeral canal
(Fig. 2.3).
Note: The Humeral Awl Reamer should be centered and
fit through the previously resected middle portion of the
trochlear cut, otherwise remove more bone until it fits; this
ensures clearance for the width of the Humeral Rasp.

Ensure proper width.
Check for bony
interferences.

Fig. 2.3
Use Humeral Awl Reamer to open canal.

Instruments

Humeral Awl
Reamer
00-8401-060-00

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

SCRUB NURSE

™

Rasp Connections
A. The Rasps attach to the T-Handle by pushing and twisting
them together. An audible click will be heard.

Fig. A
Connect Rasps to T-Handle.

2.4 Humeral Canal Rasping
• Use the Pilot Humeral Rasp to initiate canal preparation.
· Gently impact the Rasp until the solid etched line is
coincident with the axis of flexion (Fig. 2.4).

Dashed line denotes
top of Implant

• Progressively rasp until the desired size and fit is achieved
(see table).
· Place the Internal/External Alignment Rod
perpendicularly through the Rasp to assist with
determination of axial alignment (Fig. 2.5).

Fig. 2.4

• Do not remove the final Humeral Rasp or the T-Handle.

T-Handle removed for clarity

Implant Length (mm)

100

150

4-100

4-150

n/a

5-100

5-150

6-100

6-150

200

Fig. 2.5

Note: While rasping, keep the flat posterior side of the Humeral
Rasp approximately parallel to the plane formed by the
posterior cortices of the medial and lateral columns at the level
of the roof of the olecranon fossa (Fig. 2.6). If these landmarks
are not available, use the relatively flat posterior surface of the
distal humeral shaft to approximate this plane.

Use Internal/External Alignment Rod to assess axial
alignment.
Plane formed by medial and lateral columns

2.1

Flexible Cannulated Reamers are available if difficulty is encountered
during rasping. (Sizes 8-12 mm located in the Revision Case.)

Fig. 2.6

Rasp

Cross-section A-A with Internal/External Alignment Rod
inserted through Rasp.

Instruments

Humeral
Pilot Rasp
00-8401-064-00

Sequentially Rasp the canal; solid line needs to align with
the axis of flexion.

Final Rasp by Implant Size/Length
Implant
Size

TECHNIQUE TIP

Axis of Flexion

Humeral
Rasp
00-8401-065-15

T-Handle
00-8401-002-00

Internal/External
Alignment Rod
00-8401-061-00

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

2.5 Initial Trephine Cut
• Identify the position of the rounded humeral cut.
· Use the appropriate size-matched Trephine based
on the final Rasp. (Size 5-100 Rasp and 5/6 Trephine
shown for example - Fig. 2.7).
· Insert the pilot pin into the Rasp and carefully advance
the Trephine’s pilot pin until the depth stop is reached
(Fig. 2.7).

Pilot Pin

· Score the posterior surface of the distal humerus (Fig.
2.8). This provides a reference for the final preparation.

Size 5/6 Trephine

Fig. 2.7
Note: Irrigation should be employed during cutting to reduce
heat generation.

Advance until Trephine reaches depth stop.

Note: The Size 4 Trephine has a slightly different pilot
pin diameter than the Size 5/6 to prevent mismatch from
occurring between the Trephine and Humeral Rasps.

Fig. 2.8
View of bone after initial Trephine cut.

Instruments

Humeral
Rasp
00-8401-065-10

Trephine
00-8401-075-00

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

™

2.6 Trochlear Excision
• Excise the remaining trochlea using the Humeral Cut Guide.
Choose closest peg
option that allows full
seating of cut guide.

· Attach the size-matched Humeral Cut Guide to the
Humeral Rasp (Fig. 2.9).
· Stabilize the Humeral Cut Guide with the Humeral
Bearing Driver Pin if desired (Fig. 2.10).
· Use an oscillating or reciprocating saw through the
Humeral Cut Guide slots (Fig. 2.11).
Note: Assess the preliminary humeral preparation. If it is
determined that the Humeral Component needs to be inserted
further proximally, the T-Handle/Rasp can be impacted to the
desired depth and steps 2.4–2.6 are repeated as necessary.

Fig. 2.9
Attach the Humeral Cut Guide to the Rasp.

Fig. 2.10
Insert the Pin to secure the Guide in place.
Do not impact
Cut Guide.

Oscillating saw fits
inside the closedended slots.
Blade thickness =
.050 in. (1.27mm)

Fig. 2.11
Secure the Humeral Cut Guide by inserting the Pin, then
make vertical cuts using oscillating saw.
Instruments

Humeral
Rasp
00-8401-065-10

Humeral Bearing
Driver Pin
00-8401-079-00

Humeral
Cut Guide
00-8401-005-00

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

2.7 Final Trephine Cut
• Complete the rounded humeral cut.
· Insert the Trephine Stabilizer into the humeral canal.

· Notch the coronoid fossa (anterior cortex) with a bur
or rongeur to achieve proper depth of insertion of the
Trephine Stabilizer (Fig. 2.12).

Fully seat Trephine
Stabilizer

· Insert the Trephine’s pilot pin into the Trephine
Stabilizer and drill while gently advancing the Trephine
to its depth stop (Fig. 2.13).

1
TECHNIQUE TIP

Anterior View

Fig. 2.12

2.2

Similar to the Humeral Rasps, the Trephine Stabilizer has etch lines
on its posterior side indicating the axis of flexion (solid line), and the
distal “top” of the Humeral Component (dashed line).

Create notch with
rongeur

Notch anterior cortex to allow Stabilizer to fully seat.

2.8 Humeral Canal Assessment

Do not start drill
until pin in hole.

• Insert the appropriate size-matched Humeral Provisional
into the humeral canal.
· Ensure the Humeral Provisional is fully seated. If
necessary, use a mallet to lightly tap Provisional to
final depth.
· The distal aspect of the Humeral Provisional should
not sit proud relative to the distal aspect of the lateral
humeral condyle.

Fig. 2.13
Finish the Trephine cut using Stabilizer.

• Use a rongeurs to trim any excess condylar bone distal to
the Provisional (Fig. 2.14).

Trim any bone
as necessary to
be flush with
Provisional.

• Remove the Humeral Provisional. Use the Humeral Bearing
Driver Pin to assist as needed (Fig. 2.14).

Humeral Bearing Driver
Pin can be inserted
here to assist with
removal of Provisional.

Fig. 2.14
Assess Humeral bone preparation with Provisional.

Instruments

Humeral
Provisional
00-8401-045-10

Trephine
00-8401-075-00

Trephine
Stabilizer
00-8401-012-05

Humeral Bearing
Driver Pin
00-8401-079-00

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

™

3. Ulnar Preparation
Note: Be aware that instruments labeled size “5/6” can be
used for a size 5 or 6 implant; likewise, instruments labeled size
“4/5” can be used for a size 4 or 5 implant.
Note: Excessive resection of the olecranon compromises the
re-attachment of the triceps mechanism and weakens the
olecranon process. Inadequate resection tilts the intramedullary
Rasp causing malalignment of the Ulnar Component and risks
perforation of the dorsal ulnar cortex.

Fig. 3.1
Remove tip of olecranon.

3.1 Ulnar Canal Exposure
• Remove the tip of the olecranon using an oscillating saw
(Fig. 3.1).
• Use a high-speed bur to open the medullary canal at the
base of the coronoid (Fig. 3.2).

Fig. 3.2

bur

Enter ulnar canal with bur.

3.2 Ulnar Canal Reaming
• “Notch” the olecranon.
· Notch the olecranon using a bur or rongeur (Fig. 3.3).
· The notch should be aligned and deep enough such that
in-line access to the ulnar canal can be achieved with the
Reamers/Rasps.
• Open the canal using the Ulnar Awl Reamer (Fig. 3.4).

Fig. 3.3
Create notch with rongeur.

· Place fingers along the exposed shaft of the ulna to
help identify the location of the ulnar shaft distal to the
coronoid to prevent violation of the cortices distally.

Ulnar Awl Reamer

Fig. 3.4
Enter ulnar canal with Ulnar Awl Reamer.
Instruments

Ulnar Awl
Reamer
31-8106-168-00

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

Note: Flexible Reamers must be used for ulnar canal
preparation. They are used to expand the canal prior to
rasping and fully prepare the distal portion of the canal for
implantation. They must be used progressively beginning with
the smallest 4.5mm Flexible Solid Reamer. DO NOT skip sizes,
or attempt to begin with larger cutting head sizes.

• Progressively ream the ulnar canal until the desired size is
achieved (see table).
· Start with the Flexible Solid Reamers.

Fig. 3.5

- Ream to the depth marking (75, 90 or 115 mm)
based on the desired Implant length (Fig. 3.5).

Ream canal with Flexible Reamers to depth mark.

· Continue reaming with Flexible Cannulated Reamers as
necessary depending on chosen implant size.
Solid Reamer

- Use with Sterile Ball Tip Guide Wire 2.4 x 70 to avoid
cortical penetration as necessary depending on
chosen implant size.

75mm 90mm 115mm

Cannulated Reamer

Ulnar Reaming
Size Ulnar Component
Final Flexible Reamer (mm)

4.5

6.5

7.0

Ball at end of
Guide Wire

Fig. 3.6
Note: Flexible Cannulated Reamers do not have depth
markings and can be marked with a surgical marker (Fig. 3.6).

Instruments

Flexible Solid
Reamer
00-8401-070-05

Flexible Cannulated
Reamer
00-8401-072-01

Ball Tip
Guidewire
47-2255-008-00

Mark Cannulated reamers with surgical marker.

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

™

Flat of the Olecranon

3.3 Ulnar Canal Rasping
Note: Keep the flat posterior surface of the Rasp parallel to the
relatively flat surface of the posterior aspect of the olecranon in
both the coronal and sagittal planes (Fig. 3.7 & 3.8).

• Continue ulnar canal preparation with the Pilot Ulnar Rasp.
· Gently impact the T-Handle until the “eye” of the Rasp
is concentric with the projected center of the sigmoid
notch in the sagittal plane (Fig. 3.7).
• Progressively rasp until the desired size or fit is achieved.
• Do not remove the final Rasp or T-Handle.

“Eye” of the Rasp matches the
diameter of the Ulnar Component.

Fig. 3.7
Rasp canal until the “eye” is concentric with center of sigmoid notch.
Flat of the Olecranon

T-Handle
removed
for clarity

Fig. 3.8
Rasp is parallel to flat of the olecranon.

Instruments

Ulnar Rasp
Pilot
00-8401-033-01

T-Handle
00-8401-002-00

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

3.4 Sigmoid Notch Preparation
• Ensure adequate clearance exists around the sigmoid notch
to allow articulation.

Ulnar Clearance
Template

T-Handle

· Place the Ulnar Clearance Template through the Ulnar
Rasp (Fig. 3.9).
· Score the bone surface by rotating the Template around
the sigmoid notch, while supporting Rasp/T-Handle.
· Withdraw the Template and remove the remaining bone
within the scoring and any other osseous impingements
with a bur.
· Repeat on the opposite side.
• Reinsert the Template on each side of the Rasp to confirm
adequate bone has been removed and to achieve
impingement-free device articulation.

Rasp

Fig. 3.9
Use Ulnar Clearance Template to confirm sufficient bone
removal.

3.5 Ulnar Canal Assessment
Warning: Do not cement the Ulnar Provisional
• Assess ulnar canal depth of preparation.
· Insert the appropriate size/length Ulnar Provisional into
the Ulnar canal.
· If necessary, use a mallet to lightly impact the Ulnar
Provisional to final depth.

Fig. 3.10
Insert Ulnar Provisional to assess ulnar bone preparation.

· Confirm that the center of the Ulnar Provisional is
concentric with the projected center of the greater
sigmoid notch (Fig. 3.10).
• Assess proper rotation of Ulnar Provisional.
· Use the Humeral Bearing Driver Pin to confirm rotational
and varus/valgus alignment (Fig. 3.11).

Fig. 3.11
Use Pin to assess alignment.

Instruments

Ulnar Clearance
Template
00-8401-039-00

Ulnar
Provisional
00-8401-015-07

Humeral Bearing
Driver Pin
00-8401-079-00

T-Handle
00-8401-002-00

Ulnar Rasp
00-8401-034-01

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

™

4. Trial Reduction
4.1 Link Provisionals
• Connect the Provisionals and reduce the joint.
· Re-insert the appropriate Humeral Provisional.
· Slide the Ulnar Provisional into the Humeral Provisional
(Fig. 4.1).
Fig. 4.1

4.2 Evaluate Range of Motion

Reduce the joint.

• Perform a trial range of motion.
· Remove any osseous impingements. This could include
all or portions of the radial head and coronoid process.
· Perform any additional soft tissue releases as needed.
• Remove Provisionals
· Use the Humeral Bearing Driver Pin to aid in Ulnar and
Humeral Provisional removal as needed.
Note: Provisionals will provide varus/valgus and internal/
external rotation laxity at the coupling similar to the
final Implants.
Note: Causes for incomplete restoration of elbow extension
include: inadequate depth of insertion of the Humeral
Component, inadequate depth of insertion of the Ulnar
Component, unresolved angular deformity, inadequate release
of anterior, medial or lateral soft-tissue contracture and
posterior bone impingement. Assess these factors prior to final
component implantation.

Instruments

Humeral
Provisional
00-8401-045-10

Ulnar
Provisional
00-8401-015-07

Humeral Bearing
Driver Pin
00-8401-079-00

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

5. Component Implantation
5.1 Prepare the bone graft
• Fashion a bone graft from the excised trochlea or
radial head.
• If no bone from the elbow is available (in most revision
cases) use either a bone graft from the radial head if still
present, or the iliac crest or an allograft.

5.2 Prepare Canals for Cementing
• Prepare the humeral and ulnar canals for cementing.
· Use copious irrigation to clean both medullary canals,
then dry.
· Insert Cement Restrictors as needed.

TECHNIQUE TIP

5.2

The use of high viscosity cement is difficult in smaller diameter
cement nozzles used in elbow replacement. Be sure to inject the
cement when still in the viscous state.

5.3 Cement Ulnar Component
• Inject cement into the ulnar canal.
· Cut the Cement Nozzle to the length of the Ulnar
Component.
- Leave approximately 1 cm of the proximal canal free
of cement to avoid excessive backflow (Fig. 5.1).

Instruments

Cement Restrictor
with Nozzle
32-8105-038-00

Fig. 5.1
Retrograde fill canal with cement.

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

™

• Insert the Ulnar Component into the canal.
• Fully seat and align the Ulnar Component (Fig. 5.2).
· Use the Ulnar Stem Inserter to protect the articular
surface of the Ulnar Component from damage during
insertion.
· Ensure the implant is perpendicular with the flat plane of
the olecranon.
· Center the Ulnar eye on the projected center of the
greater sigmoid notch (Fig. 5.3).
• Remove excess cement from around the Ulnar Component.
· Use the plastic Quik-Use® Curette to avoid scratching the
Implant.
Note: Excess/loose cement can lead to third-body wear of
the articulation.

Fig. 5.2
Use Ulnar Stem Inserter to fully seat Implant.

Note: DO NOT install the Axle-Pin and Ulnar Bearings until after
the Ulnar Component has been placed properly in the canal, all
bone cement has been removed from the exposed articulation
area, and the cement has fully cured. Only use the Ulnar Stem
Inserter to seat the Ulnar Implant.

Fig. 5.3
Implant eye is concentric with the projected center of
sigmoid notch.

Instruments

Ulnar Stem
Inserter
00-8401-028-00

Quik-Use
Curette
00-5049-053-00

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

SCRUB NURSE
Install the Humeral Bearing
A. Place the appropriate-sized Humeral Bearing into the
Humeral Component using the Humeral Bearing Placement
Tool.
· The Humeral Bearing will not be fully seated
at this stage.

Peg

· Only the “pilot cylinder” of the peg feature should be
inserted into the hole in the base of the yoke of the
Humeral Component.
· See last figure for proper orientation of the Humeral
Bearing.

Pilot Cylinder

Peg

Fig. A

Place Humeral Bearing using Humeral Placement Tool.

B. Position the Humeral Bearing Driver against articulation
surface of the Humeral Bearing and insert the Humeral
Bearing Driver Pin simultaneously through the Humeral
Implant and the slots in the shaft of the Driver.

· The handle of Humeral Bearing Driver should be parallel
to flat posterior face of Humeral Component.
· Turn the T-Handle 90 degrees clockwise.
Collar

· Resistance will be felt, but no audible click will occur.
C. The Humeral Bearing will be fully seated when there are
no visual gaps when viewing from the posterior and the
anterior sides of the Humeral yoke.

1
Fig. B
Position Driver, slide collar into Humeral slots, insert pin,
turn Driver handle.

No gaps

Fig. C

No Gaps should be present when bearing is fully seated.

Humeral
Bearing Driver
00-8401-078-00

Humeral Bearing
Placement Tool
00-8401-082-00

Humeral Bearing
Driver Pin
00-8401-079-00

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

™

5.4 Cement Humeral Component
• Inject cement into the humeral canal.
· Cut the Cement Nozzle to the length of the
Humeral Component.
· Leave approximately 1 cm of the distal canal free of
cement to avoid excessive backflow (Fig. 5.4).

Cement
nozzle

• Implant the Humeral Component into the humeral canal.
· Before fully seated, wedge a bone graft between the
flange of the Humeral Component and the anterior distal
humeral cortex (Fig. 5.5).
· Carefully impact the Humeral Component with the
appropriate size-matched Humeral Stem Inserter to fully
seat the Component (Figs. 5.5-5.6).

Fig. 5.4
Retrograde fill canal with cement.

• Clear any excess bone cement with the plastic Quik-Use
Curette.

Insert bone graft

• Allow cement to fully cure.

Fig. 5.5
Insert bone graft and fully seat the Humeral Component
using Humeral Stem Inserter.

Bone graft

Fig. 5.6
Cross-section view.

Instruments

Humeral
Stem Inserter
00-8401-058-05

Quik-Use
Curette
00-5049-053-00

Cement Restrictor
with Nozzle
32-8105-038-00

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

SCRUB NURSE
Install the Humeral Bearing
A. Load an Ulnar Bearing into one side of the Ulnar Bearing
Assembly Tool (UBAT).
B. Load the Axle-Pin into the opposite jaw of the tool
maintaining a finger-hold on the Axle-Pin.
C. Squeeze the handles.
· Stop when hard resistance is felt – no audible click will
be heard.

Fig. A
Lock bearings into spring loaded part of UBAT.

D. Load the second Ulnar Bearing.
· DO NOT squeeze the second Bearing onto the Axle-Pin.
· Carefully hand the pre-loaded instrument to the surgeon
after the Ulnar Component has been cemented and
cleared of any debris.

Fig. B
Maintain finger-hold on Axle-Pin.

Fig. C
Squeeze UBAT to press Axle-Pin into Bearing.

Do not squeeze.

21
Fig. D
Load second Ulnar Bearing.

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

™

6. Final Assembly
6.1 Ulnar Bearing Assembly
• Attach the Bearing/Axle-Pin assembly to the Ulnar
Component.
· Carefully place the Axle-Pin through the eye of the
Ulnar Component in-situ (Fig. 6.1).
· Squeeze the handles of the pre-loaded Ulnar Bearing
Assembly Tool (UBAT) until hard resistance is felt.
No audible click will be heard (Fig. 6.2).

Fig. 6.1
Use UBAT to place Bearings.

Note: Bearings/Axle-Pin assembly is designed to be loose
fitting to the Ulnar eye.
Note: Use caution to avoid contact between the Axle-Pin and
the Ulnar Component to avoid scratching the Implant.

6.2 Elbow Reduction
• Begin to reduce the joint.

Fig. 6.2
Use UBAT to attach bearings.

· Align the Axle-Pin and the tabs of the Ulnar Bearings to
the slots in the Humeral Component (Fig. 6.3).
· Partially reduce the joint by applying hand pressure to -
the forearm to drive the Axle-Pin and Bearings into the
Humeral Implant.

Fig. 6.3
Align Bearing tabs and partially reduce joint.

Instruments

Ulnar Bearing
Assembly Tool
00-8401-081-00

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

Feet fit into Bearing
tab pockets.

• Finish reduction of joint.
· To complete reduction of the joint, apply the Articulation
Inserter.
- Top of the Articulation Inserter fits into the Ulnar
Bearing tab pockets.
- Bottom of the Articulation Inserter fits into the
proximal posterior hole in the Humeral Component
(Fig. 6.4 & 6.5).

Fig. 6.4

· Squeeze the instrument until resistance is felt and
Bearings are fully seated. No audible click will be heard.

Insert Peg in hole of Humeral Component and feet into the
Bearing pockets.

- The Ulnar Bearings should appear flush with the
curved distal surfaces of the Humeral Component
(Fig. 6.6).

TECHNIQUE TIP

Align Bearing
tabs with slots in
Humeral Implant

6.5

The Ulnar Bearing Tamp is an alternate tool available to assist with
alignment and insertion of the articulation, if access is unachievable
with the Articulation Inserter (Fig. 6.7).

Fig. 6.5
Use Articulation Inserter to squeeze together implants.

Bearings should
be flush with top
of implant

Fig. 6.6
Bearings will be flush with top of implant when fully seated.
Gently push or tap
Bearing tabs on each
side of the olecranon.

Fig. 6.7

Use Ulnar Bearing Tamp to press bearings in place if needed.
Instruments

Articulation
Inserter
00-8401-019-00

Ulnar
Bearing Tamp
00-8401-018-00

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

™

SCRUB NURSE
Remove and discard
plastic tubing

Screw Loading
A. Load Humeral Screw
· Use the flexible plastic tubing to grasp the Humeral Screw.
· Thread Humeral Screw into the black-etched side of a Screw Holder.
· Remove and discard the tubing.
· Repeat with second Screw and second Screw Holder.

Fig. A
Use Elbow Torque Driver to insert screws.

6.3 Humeral Screw Insertion

Load Humeral Screw into Humeral Screw Holder.

Note: Proper application of torque to install the Humeral Screws
is required for a successful prosthesis; only use the tools
provided in the instrument set to apply torque.
Note: If Bearings are not flush with the Humeral Component,
difficulty might be encountered during Humeral Screw inser
tion. Ensure Bearings are fully seated prior to inserting Screws
(see section 6.2, Fig. 6.6).

Elbow
Torque Driver

Screw
Holder

Note: Never reuse any Humeral Screw after it has been installed
to its prescribed torque, even if during same surgery. The Elbow
Torque Driver is designed for single-surgery.

Fig. 6.8

• Insert the screws.

Use Elbow Torque Driver to insert screws.

· Place the loaded Humeral Screw Holder against the
posterior face of the Humeral Component and drive the
Screw free of the Screw Holder; repeat on the other side.
• Sequentially tighten the Screws to the prescribed torque.

Tighten until “Click” is heard.

· Lightly snug each Screw before final torquing either one.
· Drive each Screw to the final torque with the Elbow
Torque Driver until an audible “click” is heard (Fig. 6.9).
· Dispose of Elbow Torque Driver when finished.

6.4 Final Range of Motion
• Perform a final range of motion.
· Remove any impinging bone and address any soft tissue
contractures.

Lightly snug each Screw then achieve final torque “click.”

Instruments

Humeral
Screw Holder
00-8401-084-00

Fig. 6.9

Elbow
Torque Driver
00-8401-080-00

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

7. Closure
• Repair the triceps.
· Place cruciate and transverse drill holes in the proximal
ulna (Fig. 7.1).
• Perform cruciate repair of the triceps.
· Reposition triceps.
· Return triceps to a position that is slightly overcorrected from its anatomic position.
· Pull the sleeve medially about 2 cm.
• Begin to suture and first locking stitch.
· Start suture medially and directed laterally through the
drill hole to capture the lateral triceps tendon with a
locking stitch (Fig 7.2).

Fig. 7.1
Drill holes in proximal ulna.

· Use a #5 nonresorbable suture.
• Second locking stitch.
· The suture is brought to the midline of the triceps and
a second locking stitch is placed slightly more proximal
and in the triceps tendon’s midline.
• Third locking stitch.
· The third locking stitch aligns with the medial tunnel
in the olecranon and the suture is drawn through the
tunnel emerging on the lateral aspect of the reflected
mechanism.
· It is brought through the sleeve of tissue from lateral to
medial.

Fig. 7.2
Capture triceps tendon with locking stitch.

• Transverse Repair.
· Start to suture medial to lateral through the olecranon
(Fig. 7.3).
· After piercing the lateral sleeve of tissue, it is brought
to the midportion of the triceps tendon and a locking
stitch is placed slightly proximal to the attachment after
which it again pierces the medial aspect of the margin
of the triceps.
- Use #5 nonresorbable suture.
- Tie sutures with the elbow in approximately 45
degrees of flexion.

Fig. 7.3
Suture medial to lateral through the olecranon.

SECTION

Zimmer Nexel Total Elbow Surgical Technique
®

™

• Complete the closure in a routine fashion.
· Stabilize the ulnar nerve in the anterior subcutaneous
pocket.
· Obtain hemostasis with bipolar cautery.
· Close the wound in layers.
· Insert a drain, if desired.
• Finish closure.
· Apply a compressive dressing, use an anterior splint
with the elbow in full extension and elevate the arm.

8. Postoperative Management
• Remove the drain, if used, the next day.
• Remove the compressive dressing on the first or second
day after surgery.
• Instruct the patient on activities of daily living.
· Typically, no formal physical therapy is required.
· Avoid strengthening exercises.
· Allow elbow flexion and extension as tolerated.
• If greater than 45 degree flexion contracture was present
before surgery, use a static extension brace at night for 4-8
weeks.
• The patient must avoid forcible extension for 6-8 weeks.
• Lifting limitations
· The patient must not lift more than one pound (~0.5
kg) during the first three post-operative months; and,
thereafter, not more than five pounds (~2.25 kg) with
the operated arm.

SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

9. Poly Revision
9.1 Unlink Implant
• Remove both Humeral Screws using the Elbow Torque
Driver (Fig. 9.1).
• Hyperflex the forearm to create a separation between
Implants.
• Apply the tip of the Articulation Extractor between the
Ulnar eye and the Humeral Bearing (Fig. 9.2.); Lever the
Articulation Extractor to separate the articulation (Fig. 9.2.).

9.2 Remove Bearings

Fig. 9.1
Remove the screws with the Elbow Torque Driver.

Push Articulation
Extractor handle down.

• Remove Ulnar Bearings.
· Firmly grasp the Axle-Pin with a rongeur and pull it
through the opposite Bearing to release the Ulnar
Bearings. A second rongeur can be used to secure the
opposing Ulnar Bearing (Fig. 9.3).
Fig. 9.2
Use Articulation Extractor to separate the implants.

Pull Axle-Pin

Fig. 9.3
Remove Ulnar Bearings using rongeurs.

Instruments

Articulation
Extractor
00-8401-092-00

SECTION

Zimmer Nexel Total Elbow Surgical Technique
™

• Remove Humeral Bearing.

Rongeur

· Use a rongeur to remove the Humeral Bearing by
grasping the Bearing and rocking the rongeur fore or aft
(Fig 9.4).
- Confirm no fragments of the Bearing remain in the
Implant.

9.3 Replace Bearings
• Place the appropriate size-matched Humeral Bearing
into the Humeral Component using the Humeral Bearing
Placement Tool (Fig. 9.5).

Fig. 9.4
Remove the Humeral Bearing using rongeurs.

· The Humeral Bearing will not be fully seated at this
stage.
· Only the “pilot cylinder” of the peg feature should be
inserted into the hole in the base of the yoke of the
Humeral Component.

Peg

• Position the Humeral Bearing Driver against the articulation
surface of the Humeral Bearing.
• Carefully impact the Humeral Bearing Driver with a mallet to
seat the Humeral Bearing (Fig. 9.6).
· Confirm there are no gaps between the Humeral Bearing
and the Humeral Component.

Pilot Cylinder

Fig. 9.5
Use Humeral Bearing Placement Tool to place bearing.

• Finish the procedure using the primary technique starting
at Section 6: Final Assembly.

No gaps when
fully seated

Sliding collar drops into
slots of Humeral Component
to stabilize tool

Fig. 9.6
Position Driver, slide collar into Humeral slots, tap Driver to
fully seat Bearing.

Instruments

Humeral
Bearing Driver
00-8401-078-00

Humeral Bearing
Placement Tool
00-8401-082-00

10
SECTION

Zimmer Nexel™ Total Elbow Surgical Technique
®

hammer
Implant
Extractor
Hook

SCRUB NURSE
Slide Hammer Assembly

shaft

A. Assemble Slide Hammer
nut

· Place the Hammer on the shaft and lock in place by
threading the nut onto the shaft.

Fig. A

· Thread the Implant Extractor Hook on the end of the shaft.

Assemble the Slide Hammer

10. Component Removal
TECHNIQUE TIP

6.5

If the Ulnar Component is well fixed, remove the cement from around
the Implant as extensively as possible before attempting extraction.

Fig. 10.1
Extract Ulnar Implant.

10.1 Ulnar Component Removal
• Place the Implant Extractor Hook through the Ulnar eye (Fig.
10.1).
• Remove the Ulnar Component with the Slide Hammer.

10.2 Humeral Component Removal
Note: If the Humeral Component is well fixed, remove the
cement from around the implant as extensively as possible
before attempting extraction.

Fig. 10.2
Attach Humeral Extractor Plate.

• Attach the size-matched Humeral Extractor Plate.
· Insert the Humeral Extractor Screws through the
openings in the Humeral Extractor Plate and into the
Humeral Implant threaded holes (Fig. 10.2).
· Lightly tighten the Screws using the Small Hex
Screwdriver – no audible click will be heard.
• Place the Implant Extractor Hook under the Humeral
Extractor Plate (Fig. 10.3).
• Remove the Humeral Component with the Slide Hammer.

Fig. 10.3
Extract Humeral Implant.

Instruments

Humeral
Extractor Plate
00-8401-059-05

Humeral Extractor
Screws
00-8401-093-00

Small Hex
Screw Driver
00-4812-035-00

Extractor
Hook
00-8401-029-00

Slide
Hammer
00-8401-009-00

Zimmer Nexel™ Total Elbow Surgical Technique
®

This documentation is intended exclusively for physicians and is not intended for laypersons.
Information on the products and procedures contained in this document is of a general nature
and does not represent and does not constitute medical advice or recommendations. Because
this information does not purport to constitute any diagnostic or therapeutic statement with
regard to any individual medical case, each patient must be examined and advised individually,
and this document does not replace the need for such examination and/or advice in whole or
in part. Please refer to the package inserts for important product information, including, but not
limited to, contraindications, warnings, precautions, and adverse effects.

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

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

Source Exif Data:

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Author                          : Zimmer, Inc.
Create Date                     : 2013:07:09 08:40:44-04:00
Date Released                   : 07/2013
ID                              : 97-8401-002-00
Keywords                        : Zimmer, Nexel, Total, Elbow, Surgical, Technique
Modify Date                     : 2013:07:26 13:32:11-04:00
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History Instance ID             : xmp.iid:FEE68957CC2068118083C1A60E2E75D3, xmp.iid:FFE68957CC2068118083C1A60E2E75D3, xmp.iid:2E045B85842168118083C1A60E2E75D3, xmp.iid:1774B88A862168118083C1A60E2E75D3, xmp.iid:DD8CE19E9A2168118083C1A60E2E75D3, xmp.iid:CB4A3F8A9E2168118083C1A60E2E75D3, xmp.iid:CC808DDFA12168118083C1A60E2E75D3, xmp.iid:90B3C2AAA22168118083C1A60E2E75D3, xmp.iid:B283B426A42168118083C1A60E2E75D3, xmp.iid:94D6E6B1A42168118083C1A60E2E75D3, xmp.iid:E4EFB25FA52168118083C1A60E2E75D3, xmp.iid:F23F8B71A52168118083C1A60E2E75D3, xmp.iid:4E6185DDA52168118083C1A60E2E75D3, xmp.iid:4F6185DDA52168118083C1A60E2E75D3, xmp.iid:74CE5BCAA62168118083C1A60E2E75D3, xmp.iid:953FAC29A72168118083C1A60E2E75D3, xmp.iid:48C96F75A72168118083C1A60E2E75D3, xmp.iid:75FACDE6A72168118083C1A60E2E75D3, xmp.iid:F8A1B408A82168118083C1A60E2E75D3, xmp.iid:ADDEEB62A82168118083C1A60E2E75D3, xmp.iid:E42E0B43AA2168118083C1A60E2E75D3, xmp.iid:2F9234522E2268118083C1A60E2E75D3, xmp.iid:C09C07CA432268118083C1A60E2E75D3, xmp.iid:C19C07CA432268118083C1A60E2E75D3, xmp.iid:C29C07CA432268118083C1A60E2E75D3, xmp.iid:10F6674B4C2268118083C1A60E2E75D3, xmp.iid:D0C6F092562268118083C1A60E2E75D3, xmp.iid:BD46F4EF562268118083C1A60E2E75D3, xmp.iid:1C1081D3572268118083C1A60E2E75D3, xmp.iid:2C4A8A03582268118083C1A60E2E75D3, xmp.iid:8F827D6F582268118083C1A60E2E75D3, xmp.iid:910ED813592268118083C1A60E2E75D3, xmp.iid:DCC2D444592268118083C1A60E2E75D3, xmp.iid:DDC2D444592268118083C1A60E2E75D3, xmp.iid:8FC7EB125A2268118083C1A60E2E75D3, xmp.iid:E2FAC4425B2268118083C1A60E2E75D3, xmp.iid:F99F24715B2268118083C1A60E2E75D3, xmp.iid:4AE2A7265C2268118083C1A60E2E75D3, xmp.iid:7A2E0F4F5C2268118083C1A60E2E75D3, xmp.iid:00443E595C2268118083C1A60E2E75D3, xmp.iid:85C7CFBF5C2268118083C1A60E2E75D3, xmp.iid:86C7CFBF5C2268118083C1A60E2E75D3, xmp.iid:E05DC7A95E2268118083C1A60E2E75D3, xmp.iid:E3B113FC5E2268118083C1A60E2E75D3, xmp.iid:E4B113FC5E2268118083C1A60E2E75D3, xmp.iid:E5B113FC5E2268118083C1A60E2E75D3, xmp.iid:3E9AC0DA5F2268118083C1A60E2E75D3, xmp.iid:8AE7D84B602268118083C1A60E2E75D3, xmp.iid:D0668C9B602268118083C1A60E2E75D3, xmp.iid:041A0324612268118083C1A60E2E75D3, xmp.iid:350D773A612268118083C1A60E2E75D3, xmp.iid:360D773A612268118083C1A60E2E75D3, xmp.iid:37834719622268118083C1A60E2E75D3, xmp.iid:34D39871622268118083C1A60E2E75D3, xmp.iid:2AA2E0AF622268118083C1A60E2E75D3, xmp.iid:D3C422D5622268118083C1A60E2E75D3, xmp.iid:1ECC65F5622268118083C1A60E2E75D3, xmp.iid:1FCC65F5622268118083C1A60E2E75D3, xmp.iid:4CD19C19632268118083C1A60E2E75D3, xmp.iid:757A899C632268118083C1A60E2E75D3, xmp.iid:7D8F6CE9632268118083C1A60E2E75D3, xmp.iid:C70D36F0632268118083C1A60E2E75D3, xmp.iid:EE452416652268118083C1A60E2E75D3, xmp.iid:649A701F652268118083C1A60E2E75D3, xmp.iid:FEA640F7652268118083C1A60E2E75D3, xmp.iid:100FCB30662268118083C1A60E2E75D3, xmp.iid:EC0D17740720681180839D015032F7E7, xmp.iid:A77FADA931206811808390D7C1BF7653, xmp.iid:4594805633206811808390D7C1BF7653, xmp.iid:D0827FF634206811808390D7C1BF7653, xmp.iid:2B483A7A3A206811808390D7C1BF7653, xmp.iid:157D6F2C3B206811808390D7C1BF7653, xmp.iid:127E94393F206811808390D7C1BF7653, xmp.iid:1A3BBBCE40206811808390D7C1BF7653, xmp.iid:6C5208C644206811808390D7C1BF7653, xmp.iid:38A7E7605C226811808390D7C1BF7653, xmp.iid:2E4052B2212068118083F3E4080E2DC9, xmp.iid:19DD3565222068118083F3E4080E2DC9, xmp.iid:09F0691B2C2068118083F3E4080E2DC9, xmp.iid:B078C9A82D2068118083F3E4080E2DC9, xmp.iid:D6AC7B5B2E2068118083F3E4080E2DC9, xmp.iid:B1EC10D32E2068118083F3E4080E2DC9, xmp.iid:932BF4422F2068118083F3E4080E2DC9, xmp.iid:C0A8D45D2F2068118083F3E4080E2DC9, xmp.iid:498A56D2392068118083F3E4080E2DC9, xmp.iid:A4A220354E2068118083F3E4080E2DC9, xmp.iid:94A20E884E2068118083F3E4080E2DC9, xmp.iid:F73756CF4E2068118083F3E4080E2DC9, xmp.iid:4E5BF9794F2068118083F3E4080E2DC9, xmp.iid:D076D0C24F2068118083F3E4080E2DC9, xmp.iid:4978D1B4502068118083F3E4080E2DC9, xmp.iid:4A78D1B4502068118083F3E4080E2DC9, xmp.iid:7C74F018532068118083F3E4080E2DC9, xmp.iid:23288547532068118083F3E4080E2DC9, xmp.iid:289B1485892368118083ADAD1352839F, xmp.iid:3D6BB1A6892368118083ADAD1352839F, xmp.iid:7619A81D922368118083ADAD1352839F, xmp.iid:49754988D22368118083ADAD1352839F, xmp.iid:98831D76FE2368118083ADAD1352839F, xmp.iid:43561EF5252068118083E0ABBEABD51C, xmp.iid:A427D3FC252068118083E0ABBEABD51C, xmp.iid:86AE75D6262068118083E0ABBEABD51C, xmp.iid:5126EB5A292068118083E0ABBEABD51C, xmp.iid:123B7D092A2068118083E0ABBEABD51C, xmp.iid:9AEFAA552A2068118083E0ABBEABD51C, xmp.iid:83C815632A2068118083E0ABBEABD51C, xmp.iid:D82BA0EB2A2068118083E0ABBEABD51C, xmp.iid:B02D75AC2B2068118083E0ABBEABD51C, xmp.iid:3776F02B2D2068118083E0ABBEABD51C, xmp.iid:008D0C5F2E2068118083E0ABBEABD51C, xmp.iid:A53E35882E2068118083E0ABBEABD51C, xmp.iid:8D7F98D42F2068118083E0ABBEABD51C, xmp.iid:3E391EFF452068118083E0ABBEABD51C, xmp.iid:C71F08C12E2068118083E59F823400E2, xmp.iid:B0E0B771322068118083E59F823400E2, xmp.iid:E697AF10392068118083E59F823400E2, xmp.iid:8DA44698392068118083E59F823400E2, xmp.iid:5BF654C5392068118083E59F823400E2, xmp.iid:B61A78DD3D2068118083E59F823400E2, xmp.iid:F874D0103F2068118083E59F823400E2, xmp.iid:959E476C412068118083E59F823400E2, xmp.iid:7BA65F10432068118083E59F823400E2, xmp.iid:F6BF134F432068118083E59F823400E2, xmp.iid:C280C6D2442068118083E59F823400E2, xmp.iid:9325A089452068118083E59F823400E2, xmp.iid:9425A089452068118083E59F823400E2, xmp.iid:74740153472068118083E59F823400E2, xmp.iid:8EE169C7482068118083E59F823400E2, xmp.iid:C8B42C434C2068118083E59F823400E2, xmp.iid:C65A797D4F2068118083E59F823400E2, xmp.iid:10059BB32B2068118083E0A9D12EE885, xmp.iid:9C2BEB5D2F2068118083E0A9D12EE885, xmp.iid:1439A1E0302068118083E0A9D12EE885, xmp.iid:29305138BE2068118083E0A9D12EE885, xmp.iid:B05E1700C02068118083E0A9D12EE885, xmp.iid:535BC28FC02068118083E0A9D12EE885, xmp.iid:1A045D85C32068118083E0A9D12EE885, xmp.iid:C2C6C61AC52068118083E0A9D12EE885, xmp.iid:FB2F7E2CC62068118083E0A9D12EE885, xmp.iid:E4745F7EC72068118083E0A9D12EE885, xmp.iid:9DF147D10C2068118083F5A43574B5D3, xmp.iid:20C07D3A102068118083F5A43574B5D3, xmp.iid:72F92216D12068118083F5A43574B5D3, xmp.iid:036D7175D12068118083F5A43574B5D3, xmp.iid:0DEB8F8DD52068118083F5A43574B5D3, xmp.iid:9AA57AA8D62068118083F5A43574B5D3, xmp.iid:AA8CE9BCD72068118083F5A43574B5D3, xmp.iid:B33E6EDDD82068118083F5A43574B5D3, xmp.iid:8A3CDDE9D92068118083F5A43574B5D3, xmp.iid:CED5916ADA2068118083F5A43574B5D3, xmp.iid:F40320EBDB2068118083F5A43574B5D3, xmp.iid:AE03B300DE2068118083F5A43574B5D3, xmp.iid:243237CCDE2068118083F5A43574B5D3, xmp.iid:DEF02DA3DF2068118083F5A43574B5D3, xmp.iid:23146866E32068118083F5A43574B5D3, xmp.iid:90709E42E92068118083F5A43574B5D3, xmp.iid:1414FA5DEC2068118083F5A43574B5D3, xmp.iid:9B401084ED2068118083F5A43574B5D3, xmp.iid:355B3D39EE2068118083F5A43574B5D3, xmp.iid:6EA22D96EE2068118083F5A43574B5D3, xmp.iid:38DD43EAEE2068118083F5A43574B5D3, xmp.iid:CCA11C74072068118083DB65D57A5B9E, xmp.iid:0DF9D6CC072068118083DB65D57A5B9E, xmp.iid:0EF9D6CC072068118083DB65D57A5B9E, xmp.iid:344D394A082068118083DB65D57A5B9E, xmp.iid:354D394A082068118083DB65D57A5B9E, xmp.iid:364D394A082068118083DB65D57A5B9E, xmp.iid:374D394A082068118083DB65D57A5B9E, xmp.iid:384D394A082068118083DB65D57A5B9E, xmp.iid:8DD58029252068118083B0D9BF481FDB, xmp.iid:6776DBA32B2068118083B0D9BF481FDB, xmp.iid:FFD4FEA32C2068118083B0D9BF481FDB, xmp.iid:DD37286D2D2068118083B0D9BF481FDB, xmp.iid:740E3AFF2D2068118083B0D9BF481FDB, xmp.iid:58D52174072068118083CBF2E9B73B40, xmp.iid:9765CAEF102068118083CBF2E9B73B40, xmp.iid:4A229ACD132068118083CBF2E9B73B40, xmp.iid:26B8F648152068118083CBF2E9B73B40, xmp.iid:27B8F648152068118083CBF2E9B73B40, xmp.iid:DB42E751B12068118C14AA25AAEBAAF4, xmp.iid:335099BA402168118C14AA25AAEBAAF4, xmp.iid:727B43B5482168118C14AA25AAEBAAF4, xmp.iid:AC0603DF492168118C14AA25AAEBAAF4, xmp.iid:F0CD616F4A2168118C14AA25AAEBAAF4, xmp.iid:A6CCE265592168118C14AA25AAEBAAF4, xmp.iid:91893C056A2168118C14AA25AAEBAAF4, xmp.iid:4B05D3BC0B2268118C14AA25AAEBAAF4, xmp.iid:406A3174072068118083BF747438A459, xmp.iid:079A8D3A092068118083BF747438A459, xmp.iid:089A8D3A092068118083BF747438A459, xmp.iid:099A8D3A092068118083BF747438A459, xmp.iid:0A9A8D3A092068118083BF747438A459, xmp.iid:33C9C5C6112068118083BF747438A459, xmp.iid:7F1AE703142068118083BF747438A459, xmp.iid:02B72D5E142068118083BF747438A459, xmp.iid:03B72D5E142068118083BF747438A459, xmp.iid:3F96B480672068118083EA598798502C, xmp.iid:79F18E4F682068118083EA598798502C, xmp.iid:62A2C35F682068118083EA598798502C, xmp.iid:DD917F95682068118083EA598798502C, xmp.iid:C65D3301692068118083EA598798502C, xmp.iid:B48F2C2C692068118083EA598798502C, xmp.iid:BFB4EF49692068118083EA598798502C, xmp.iid:BDDE2F5E6B2068118083EA598798502C, xmp.iid:C69D51516D2068118083EA598798502C, xmp.iid:D464CD656D2068118083EA598798502C, xmp.iid:76F849D26D2068118083EA598798502C, xmp.iid:E5F04287732068118083EA598798502C, xmp.iid:D55883A9732068118083EA598798502C, xmp.iid:BE272C97772068118083EA598798502C, xmp.iid:B48C57DE782068118083EA598798502C, xmp.iid:84AF2749792068118083EA598798502C, xmp.iid:C75D960C7B2068118083EA598798502C, xmp.iid:051A43B77F2068118083EA598798502C, xmp.iid:59DA0F3D232068118083C5649354386A, xmp.iid:14B916CD232068118083C5649354386A, xmp.iid:1B10FCE5252068118083C5649354386A, xmp.iid:5D07EE78262068118083C5649354386A, xmp.iid:05DC8D79272068118083C5649354386A, xmp.iid:10AB33F7272068118083C5649354386A, xmp.iid:6E8AE5352B2068118083C5649354386A, xmp.iid:53882F3F2C2068118083C5649354386A, xmp.iid:BC12185E2C2068118083C5649354386A, xmp.iid:8923813E2D2068118083C5649354386A, xmp.iid:30F7F2DD2D2068118083C5649354386A, xmp.iid:E124C7A72E2068118083C5649354386A, xmp.iid:70BEE5FB2E2068118083C5649354386A, xmp.iid:71BEE5FB2E2068118083C5649354386A, xmp.iid:C7CD6D692F2068118083C5649354386A, xmp.iid:CDA16A43B22068118083EA598798502C, xmp.iid:875DB10EB42068118083EA598798502C, xmp.iid:56DC8E40B42068118083EA598798502C, xmp.iid:DB2C2A74072068118C14E0BC7364F84F, xmp.iid:401C34C0072068118C14E0BC7364F84F, xmp.iid:6C3E0BDE092068118C14E0BC7364F84F, xmp.iid:7D9EC5020A2068118C14E0BC7364F84F, xmp.iid:7E9EC5020A2068118C14E0BC7364F84F, xmp.iid:C813F4C60B2068118C14E0BC7364F84F, xmp.iid:09BCC0120F2068118C14E0BC7364F84F, xmp.iid:4D19034B172068118C14E0BC7364F84F, xmp.iid:F64C7C6C182068118C14E0BC7364F84F, xmp.iid:1254AED91A2068118C14E0BC7364F84F, xmp.iid:2542A76C162068118A6D9746EE8D7B11, xmp.iid:CF811E28172068118A6D9746EE8D7B11, xmp.iid:83A52331172068118A6D9746EE8D7B11, xmp.iid:84A52331172068118A6D9746EE8D7B11, xmp.iid:97F1C762172068118A6D9746EE8D7B11, xmp.iid:53ACCE6E172068118A6D9746EE8D7B11, xmp.iid:2C46B798172068118A6D9746EE8D7B11, xmp.iid:C9B4DAD5172068118A6D9746EE8D7B11, xmp.iid:EEB20B25182068118A6D9746EE8D7B11, xmp.iid:8F5B0CA4182068118A6D9746EE8D7B11, xmp.iid:CF0F35C0182068118A6D9746EE8D7B11, 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History When                    : 2011:02:28 15:34:31-05:00, 2011:02:28 15:34:31-05:00, 2011:03:01 13:33-05:00, 2011:03:01 13:47:28-05:00, 2011:03:01 16:11:12-05:00, 2011:03:01 16:39:16-05:00, 2011:03:01 17:03:08-05:00, 2011:03:01 17:08:49-05:00, 2011:03:01 17:19:26-05:00, 2011:03:01 17:23:20-05:00, 2011:03:01 17:28:11-05:00, 2011:03:01 17:28:41-05:00, 2011:03:01 17:31:42-05:00, 2011:03:01 17:32:21-05:00, 2011:03:01 17:38:19-05:00, 2011:03:01 17:40:59-05:00, 2011:03:01 17:43:07-05:00, 2011:03:01 17:46:17-05:00, 2011:03:01 17:47:14-05:00, 2011:03:01 17:49:45-05:00, 2011:03:01 18:03:10-05:00, 2011:03:02 09:48:33-05:00, 2011:03:02 12:22:14-05:00, 2011:03:02 13:14:04-05:00, 2011:03:02 13:21:41-05:00, 2011:03:02 13:23:07-05:00, 2011:03:02 14:36:42-05:00, 2011:03:02 14:39:18-05:00, 2011:03:02 14:45:40-05:00, 2011:03:02 14:47:01-05:00, 2011:03:02 14:50:02-05:00, 2011:03:02 14:54:37-05:00, 2011:03:02 14:56-05:00, 2011:03:02 14:56:28-05:00, 2011:03:02 15:01:45-05:00, 2011:03:02 15:10:15-05:00, 2011:03:02 15:11:33-05:00, 2011:03:02 15:16:37-05:00, 2011:03:02 15:17:45-05:00, 2011:03:02 15:18:02-05:00, 2011:03:02 15:20:54-05:00, 2011:03:02 15:21:22-05:00, 2011:03:02 15:34:37-05:00, 2011:03:02 15:36:55-05:00, 2011:03:02 15:37:48-05:00, 2011:03:02 15:39:56-05:00, 2011:03:02 15:43:09-05:00, 2011:03:02 15:46:18-05:00, 2011:03:02 15:48:32-05:00, 2011:03:02 15:52:21-05:00, 2011:03:02 15:52:59-05:00, 2011:03:02 15:54:16-05:00, 2011:03:02 15:59:12-05:00, 2011:03:02 16:01:41-05:00, 2011:03:02 16:03:25-05:00, 2011:03:02 16:04:28-05:00, 2011:03:02 16:05:22-05:00, 2011:03:02 16:05:44-05:00, 2011:03:02 16:06:22-05:00, 2011:03:02 16:10:02-05:00, 2011:03:02 16:12:11-05:00, 2011:03:02 16:12:23-05:00, 2011:03:02 16:20:36-05:00, 2011:03:02 16:20:51-05:00, 2011:03:02 16:26:53-05:00, 2011:03:02 16:28:30-05:00, 2011:03:03 10:04:24-05:00, 2011:03:11 14:33:48-05:00, 2011:03:11 14:45:47-05:00, 2011:03:11 14:57:25-05:00, 2011:03:11 15:36:54-05:00, 2011:03:11 15:41:53-05:00, 2011:03:11 16:10:53-05:00, 2011:03:11 16:22:13-05:00, 2011:03:11 16:50:36-05:00, 2011:03:14 09:44:50-04:00, 2011:03:14 15:20:49-04:00, 2011:03:14 15:25:49-04:00, 2011:03:14 16:35:21-04:00, 2011:03:14 16:46:27-04:00, 2011:03:14 16:51:27-04:00, 2011:03:14 16:54:48-04:00, 2011:03:14 16:57:56-04:00, 2011:03:14 16:58:41-04:00, 2011:03:15 09:13:11-04:00, 2011:03:15 11:39:07-04:00, 2011:03:15 11:41:26-04:00, 2011:03:15 11:43:26-04:00, 2011:03:15 11:48:12-04:00, 2011:03:15 11:50:14-04:00, 2011:03:15 11:57-04:00, 2011:03:15 11:57:40-04:00, 2011:03:15 12:14:07-04:00, 2011:03:15 12:15:26-04:00, 2011:03:21 10:43:18-04:00, 2011:03:21 10:44:14-04:00, 2011:03:21 11:44:50-04:00, 2011:03:22 10:43:19-04:00, 2011:03:22 15:57:46-04:00, 2011:03:23 15:58:41-04:00, 2011:03:23 15:58:54-04:00, 2011:03:23 16:04:59-04:00, 2011:03:23 16:23-04:00, 2011:03:23 16:27:53-04:00, 2011:03:23 16:30:01-04:00, 2011:03:23 16:30:24-04:00, 2011:03:23 16:34:13-04:00, 2011:03:23 16:39:36-04:00, 2011:03:23 16:50:20-04:00, 2011:03:23 16:58:55-04:00, 2011:03:23 17:00:04-04:00, 2011:03:23 17:09:22-04:00, 2011:03:24 09:21:27-04:00, 2011:03:28 13:54:02-04:00, 2011:03:28 14:20:27-04:00, 2011:03:28 15:07:51-04:00, 2011:03:28 15:11:38-04:00, 2011:03:28 15:12:54-04:00, 2011:03:28 15:42:12-04:00, 2011:03:28 15:50:48-04:00, 2011:03:28 16:07:40-04:00, 2011:03:28 16:19:25-04:00, 2011:03:28 16:21:10-04:00, 2011:03:28 16:32:01-04:00, 2011:03:28 16:37:08-04:00, 2011:03:28 16:38:33-04:00, 2011:03:28 16:49:55-04:00, 2011:03:28 17:00:20-04:00, 2011:03:28 17:25:16-04:00, 2011:03:28 17:48:22-04:00, 2011:03:29 14:18:49-04:00, 2011:03:29 14:45:03-04:00, 2011:03:29 14:55:52-04:00, 2011:03:30 07:47:42-04:00, 2011:03:30 08:00:26-04:00, 2011:03:30 08:04:27-04:00, 2011:03:30 08:25:39-04:00, 2011:03:30 08:36:59-04:00, 2011:03:30 08:44:38-04:00, 2011:03:30 08:54:05-04:00, 2011:03:30 16:02:08-04:00, 2011:03:30 16:26:33-04:00, 2011:03:31 15:27:10-04:00, 2011:03:31 15:29:50-04:00, 2011:03:31 15:59:09-04:00, 2011:03:31 16:07:04-04:00, 2011:03:31 16:14:47-04:00, 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2013:07:08 13:56:22-04:00, 2013:07:09 08:39:59-04:00
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Doc Change Count                : 21969
Format                          : application/pdf
Title                           : Zimmer Nexel Total Elbow Surgical Technique 97-8401-002-00
Description                     : Zimmer Nexel Total Elbow Surgical Technique
Creator                         : Zimmer, Inc.
Subject                         : Zimmer Nexel Total Elbow Surgical Technique
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Date 0020 Released              : 0.00347739692001987
Id                              : 97-8401-002-00
Page Count                      : 36
Warning                         : [Minor] Ignored duplicate Info dictionary

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Zimmer Nexel Total Elbow Surgical Technique 97 8401 002 00

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