The ITST Intramedullary Nail System is
designed to treat unstable,comminuted,proximal fractures
of the femur,specifically,the
Intertrochanteric and Subtrochanteric regions,thereby combining many of the
features of an intramedullary nail and hip screw system. The implant supports
the anatomic reduction and internal fixation of the femoral head and neck and
provides anti-rotational stability for many difficult fracture situations.
The ITST Intramedullary Nail System
features a sliding or non-sliding Lag Screw,to help allow for neck fracture
settlement,while preventing fragment impaction. System includes options for
dynamic and static distal locking.
Manufactured from high strength stainless
steel alloy(22-13-5),the ITST intramedullary nail implants are available in a
wide range of diameters,as well as short and long lengths to accommodate total
joint prostheses. Most femoral neck-shaft angles measure 130˚.The ITST Lag
Screw was designed to mimic this angle for use in the majority of patients.In
cases where appropriate, a 6.5mm Anti-Rotation Screw is available for use in
combination with the 11mm Lag Screw to help stabilize fracture fragments.
The ITST Intramedullary Nail is indicated
for use in a variety of femoral fractures, such as:
with Bone Loss
WARNING:The surgeon should beaware that the
use of the system in osteoporotic bone, nonanatomic reductions, or improper
placement of the nail-screw construct could increase the risk of failure or cut
out of the implant.
fractures involving the knee joint
canal obliterated by a previous fracture or tumor
having grossly abnormal,excessive bow(i.e.,curvature deformity)
The implant is contraindicated for use in
medial neck fractures. This implant may not provide the required/desired
stability when used to treat some femoral neck fractures types.
Overt systemic infection is an absolute
contraindication.For patients that exhibit any of the following,systemic
infection must be ruled out to minimize the potential hematogenous spread to
the implant site:
local inflammation signs
destruction or bone absorption apparent on roentgenograms
sedimentation rate or Creactive protein unexplained by other diseases
White Blood Cells (WBS) and/or marked shift in WBC differential
of this device is contraindicated in patients with active infection at sites
such as the genitourinary tract, pulmonary system,skin, or other sites because
hematogenous spread may occur. The foci of infection must be treated and the infection
resolved prior to surgery. Routine prophylactic antibiotic treatment
immediately before, during, and after surgery may be especially useful for
The ITST Femoral Fixation System implants
are designed to place the Lag Screw at 130˚,with15˚ of anteversion on the long
nails, to accommodate the most common anatomic femoral neck angle,while
minimizing inventory requirements.A/P and lateral C-arm images should be
obtained prior to the surgical procedure.
NOTE:The suitability of this implant for
the patient should be determined by templating prior to surgery using X-rays of
the affected femur.
An A/P preoperative X-ray should be taken
of the contralateral hip or of the affected limb once an anatomic reduction has
X-rays taken at a 36-inch distance from the
source result in 10-15 percent magnification of the bone .An Ossimeter,which
takes this magnification into account, should be used to help determine the
actual nail length and diameter to be used. The angle of the intersection of
the femoral shaft axis and femoral neck axis should be observed. The ITST
Templates reflect a 15 percent magnification of actual size.
The patient may be placed in either the
supine (free legged or traction)or lateral (traction) position.
LEGGED - Place the patient supine on a radiolucent table (Fig.1).The table should
not have a central pole or metal sidebars . Place the patient's buttock next to
the edge of the table with a radiolucent bump (not a bean bag) under the
buttock. The eccentric position and elevated buttock improves starting site
posi-tion and reduces drape encroachment. Furthermore,the elevated buttock
enhances fluoroscopic lateral viewing of the femoral head and neck. The
ipsilateral upper trunk and extremity should angle towards the contralateral
shoulder. The ipsilateral
arm should be placed above the chest on an
arm holder or on a pillow with stockinet. This upper extremity placement
improves starting point entry and unencumbered implant insertion.
TRACTION ON FRACTURE
TABLE - Place the patient supine on the
fracture table (Fig.2).Pad all areas of potential pressure. Flex and abduct the
non-injured leg onto a well padded leg holder .Or , place the non-injured leg
into a scissor type position.
Position the buttock of the injured leg as
close to the edge of the table as possible.Some tables will allow for an
eccentric peroneal post connection to the table. Make sure the peroneal post is
padded and wide in order to dissipate the pressure on the groin area.
Place the injured leg into skeletal
traction (distal femoral or proximal tibial)or boot-traction.The ipsilateral
arm should be placed above the chest on an arm holder or on a pillow with
(3)LATERAL TRACTION ON FRACTURE
TABLE-Use the radiolucent table with a
radiolucent peroneal post. Place the traction boots on the patient during anesthesia
induction. Turn the patient in a lateral position,with the operative leg over
the over the top of the peroneal post. Attach the boots to the table with
straight traction applied through the boots.
If heavy traction is necessary, a pin is
placed in the distal femur and the knee is flexed, applying traction through
the pin.Flex and adduct the operative leg. Straighten the non-operative leg in
line with the body. Rotate the patella
slightly inwards towards the floor, to help prevent an external rotation
deformity. Bring the C-arm in perpendicular to the long axis of the femur. When
moving proximally and distally, the entire
C-arm is moved, to stay perpendicular to the long axis,To visualize the
proximal femur and the head, rotate the C-arm 15˚ over the top and tilted
Patient Positioning for Standard Technique
The patient should be placed in either the supine or lateral decubitus position
on the table. The sacral rest and perineal post should be well padded. In
multiple trauma patients,the supine position may be used for easier access to
the patient's airway, as well as to facilitate the treatment of other injuries.
The supine position also facilitates fracture reduction and rotational
alignment of the femur.
It is critical to reduce the fracture
before beginning the surgical procedure. An anatomic reduction or a slight
valgus reduction of the femoral head and neck,should be seen in the A/P
film.Occasionally, a slight sag of the fracture
may be seen on the lateral view. This should be taken into consideration
during the surgical procedure.
Occasionally, flexion of the injured limb
will facilitate sagittal reduction. As a rule of thumb, intertrochanteric
fractures are locked into position with internal rotation of the leg. The patella
should point towards the ceiling.
For Pertrochanteric or Subtrochaneric
fractures(especially with involvement of the lesser trochanter)the fracture is
reduced with the leg in external rotation. Oblique roll over or roll back
fluoroscopic views can assist visualization of proper rotation. This is most
important when considering the starting point of the Steinman pins or the
steinman pins or cannulated awlinto the femur.
NOTE: It is essential to obtain excellent
A/P and lateral images of the femoral head and neck prior to beginning the
surgery regardless of which patient position is used.
The use of image intensification or other
x-ray imaging is required. The image intensifier should be sterile-draped and
may be positioned form the contralateral or ipsilateral side of the operating
Confirm visualization of the hip as well as
the shaft of the femur using image intensification before prepping and draping.
Bend the patient's torso away from the affected extremity to improve access to
the greater trochanter. If access to the greater trochanter is still
inadequate,adduct the affected leg. However, to achieve proper alignment of the
fracture, this adducted position must be corrected prior to insertion of the
Prep and Drape
The prep includes the ipsilateral axilla,
trunk,buttock, hip, thigh(circumferentially),and knee. The drape should extend
up to the axilla with U-shaped drapes. The free trunk and buttock skin improves
nail insertion and diminishes guide entrapment on the drapes. Furthermore,the
free area increases the freedom for percutaneous insertion and incision
closure. The drape should extend past the knee to allow for distal interlock
Prep and Drape for Standard Technique
Prep and drape similar to the MIS technique,
although it is only necessary to drape proximally to the distal portion of the
thoracic cavity for the standard technique, not all the way to the axilla. If
the patient is obese, Prep and drape to the axilla and use a more proximal
Fracture Site Reduction After Prep and
An attempt at fracture site reduction
should be performed initially to facilitate the starting site placement,
central reaming, and nail-screw insertion, The rotation and alignment should
have been performed before the prep and drape. In fractures with varus
alignment despite traction, placement of the patient in a lateral position of
the percutaneous reduction instruments can help assist the reduction. A spike
pusher or tenaculum clamp can be inserted through a 25 to 30mm incision to
realign the a 25 to 30mm incision to realign the proximal fragment. The classic
flexion, abduction, and external rotation of the proximal fragment requires
reduction at this the time.A spike pusher or tenaculum clamp in an anterior to
posterior direction will help accomplish the reduction.
Starting Point and Steinman Pin lnsertion
and Incision Using Long Cannulated Awl
Palpate the line of the femur starting at
the greater trochanter. Continue this line of insertion proximally until
reaching the level approximating the iliac crest (more proximal with obese
Using a sterile marking pen, mark the line
of intersection between these two lines; this corresponds to the insertion
site. Insert the 3.2mm terminally threaded Steinman pin through the soft
tissues.The correct atarting point on the Ap view is the medial half of the
greater trochanter. The correct starting point on the lateral view corresponds
to the central half of the femoral neck. An optional cannula can also be used to
help guide the pin into the correct position. The cannula is inserted through a
25mm incision at the levet of the iliac crest. The cannula can also be used to
protect tissues while reaming.
Use a # 15 blade to create an incision
centered around the Steinman pin. The incision needs to be only 15mm-20mm in
Starting Point and Incision for Standard
Begin the skin incision 1cm proximal to the
tip of the greater trochanter, and extend it proximally for about 5cm in a
longitudinal direction. Continue the incision down through the subcutaneous
tissues and split the fascia lata.
Creating the Entry Portal
Insert the terminally threaded Steinman pin
through the greater trochanter down to the level of the lesser trochanter(about
8cm). Ream using the 8mm trochanteric reamer (for comminuted fracture lines
extending into or around the insertion site)followed by the 17mm trochanteric
reamer (initially for fractures without fracture lines extending into the
starting site)followed by the 17mm trochanteric reamer (initially for fractures
without fracture lines extending into the starting site). The reamers can be
inserted freely through the soft tissues or through the cannula. The entry
portal should be in line with the planned nail insertion and should line up
with the femoral canal on the AP and lateral views (not aiming to the medial or
A cannulated awl can be used instead of a
guide wire to create the entry portal. Place the tip of the awl in the selected
starting point (tonfirm using bi-planer fluoroscopy).Advance the awl through
the greater trochanter into the canal in line with the planned nail insertion
Guide Wire Placement
On the back table, attach the 3.0mm
Bulb-tipped Guide Wire to the Wire Grip T-Handle,and tighten(Fig.5). The tip of
the Guide Wire may be bent to approximately 20˚,to facilitate passage across
the fracture site or into the central aspect of the distal femur.
NOTE:If using a cannulated awl, the 3.0mm
Bulb-Tipped Guide Wire may be passed directly through the cannulated awl
without the 45˚bend(Fig.6).
Insert the Guide Wire through the entry
hole and manipulate it down the proximal femur across the fracture site. At the
fracture site, manipulate the Guide Wire under C-arm control across the
fracture site . If reduction of the abducted and flexed hip is difficult, place
pressure on the proximal fragment, either with the hand or directly with a
reduction rod or other instrument. An alternative technique is to reduce the
fracture using the Reduction Instruments shown in Figure 7 .
The reduction finger can also be used to
assist in reduction if the surgeon creates an initial oblique starting portal.
Once in the distal canal, pass the wire to the distal epiphyseal scar. Gently
tap the guide wire into the dense distal bone, so that the wire will not
retract with reamer removal.
The surgeon determines the proper nail
length using the Nail Length Gauge. Slide the gauge over the guide wire until
the tip rests along the proximal aspect of the greater trochanter(Fig.8).
The ITST MIS Cannula can be inserted into
the incision to protect the soft tissue while reaming.
Thread the Centering Bushing into the Cannula
and place the Cannula firmly against the bone. Remove Centering Bushing. Ream
the femoral canal sequentially in 0.5mm increments using the Long Pressure
Sentinel®Intramedullary Reaming System(Fig.9).Ream until cortical
chatter is experienced. Based on bone quality and curvature of radius, nail
diameter is 1-22mm less than the last reamer used.
Over-reaming the canal by one or two
millimeters may facilitate preparation of the bone to accommodate the implant.
The trochanteric region should be reamed to 17mm using the Trochanteric Reamer
for all patients to accommodate the implant and avoid separation or widening of
known or unknown fracture lines(Fig.10).Use caution in advancing the Taper
Reamer. An alternative to sequentially ream with a Pressure Sentinel
Intramedullary Reamer to 17mm diameter.
Ream to the level of the lesser
trochanter(or about 8cm depth), to accommodate the implant by advancing the
Taper reamer into the proximal canal opening until the reamer flutes are sunk
to the level of the lesser trochanter(Fig.11).Confirm position using the C-arm.
Replace the Bulb-Tipped Guide wire with the
Smooth Guide Wire through the Exchange Tube.
NOTE: Reaming amounts will depend on the
quality of the bone present, the minimum diameter of the femoral shaft, and the
amount of femoral curvature present.
Attach the blue Modular Targeting Arm to
the Barrel using the Connecting Bolt.Tighten the Connecting Bolt by
hand(Fig.12).Twist the Targeting Arm Nut on to the end of the Blue Targeting
Guide in preparation for lag screw insertion(Fig.13).The Nut should not be
tightened at this point.
Slide the ITST Locking Bolt through the
barrel (Fig.14). Approximate the nail to the external "keys"on the
NOTE: The Guide is universal and it is
critical that the nail be properly aligned with the Guide for a Left or Right
implant. Line up the keys of the Guide with the keyways of the nail so that
they fit snugly(Fig.15).
Place the T-Handled Locking Bolt Inserter
into the guide barrel(Fig.16)
Toggle and rotate the Inserter slightly
until it seats into the teeth of the Locking Bolt. The etched arrow at the
proximal rim of the nail should be exactly aligned with the arrow on the distal
rim of the Targeting Guide (Fig.17).Using downward pressure on the Locking Bolt
Inserter, thread the Locking Bolt into the threads of the proximal end of the
nail until secured. Completely tighten.
NOTE: Prior to inserting the implant,
insert the two sets of Drill and Screw Bushings into the appropriate holes in
the targeting Guide. Slide a drill or guide pin through the Bushings, and
through the screw holes in the implant to assess correct instrument assembly
Monitor the progression of the nail down
the canal using a C-arm.
A percutaneous 3.2mm Threaded Guide Pin may
be placed along the anterior axis of the femoral neck paralleling the femoral
neck on the AP and lateral views to mark the correct anteversion.
Align the Targeting Guide parallel(on the
lateral view)to the percutaneous pin to assure that accurate implant
anteversion has been achieved. Check the final position of the implant using
C-arm. If the nail fails to progress easily down the canal, remove it, and use
a smaller nail, or over-ream the canal in 0.5mm increments untiy the implant
passes more easily down the femoral canal. The surgeon should also check the
status of the nail in the distal femur. If the nail is too long, a shorter nail
should be used to avoid distal femoral cortical or articular penetration.If the
curvature of the femur does not accommodate the nail, using a shorter or
smaller nail will assist nail placement.
NOTE: If nail insertion can not be achieved
by hand, thread the Small or Long Threaded Driver on the Barrel (Fig.19).Insert
the nail into the canal using a series of gentle impactions, if necessary, on
the Threaded Driver until the nail is seated at the desired depth.
The ITST Nail accommodates both an 11mm Lag
Screw and a 6.5mm Anti-Rotation Screw.
The Anti-Rotation Screw may be utilized in the case of certain fractures, where
the bone stock and femoral neck/head bone stock is able to accommodate it. If
only one screw is used, it must be the 11mm Lag Screw.
NOTE: The 6.5mm Anti-Rotation Screw may be
used to enhance fracture stability if the femoral
neck is able to accommodate it; however, it
should not be used if there is any concern that the femoral head or neck neck
bone will not accommodate it.
WARNING: Failure to appropriately consider
femoral head/neck bone mass and quality could result in implant cut-out.
Remember the goal of lag screw placement is
perfect placement into the central position of the femoral head on the AP and
Lag Screw Positioning
The projected path of the Lag Screw into
the Femoral Head should be assessed using the C-arm(Fig.20).This may be
verified using the Screw Position Outrigger and the 3.2mm Threaded Guide Pin.
Assemble the Outrigger into the Modular Targeting Arm and place a Threaded Guide
Pin into the Anteversion Verification Hole
in the barrel(Fig.21). Verify under C-arm that the Guide Pin appears in the
center of the femoral neck in a superior/lateral view.
This will help prevent any parallax error.
The outer aspect of the windowed arm of the Outrigger,which lies directly over
the femoral neck, represents the superior and inferior position of the Lag and
If the nail anteversion requires
adjustment, move the nail up or down in the canal by hand or by gently
impacting the Threaded Driver until the position of the nail with the C-arm.
Adjusting nail depth may be useful in accommodating various femoral neck
NOTE: If the C-arm is off axis, the
alignment of the Outrigger may not accurately predict the position of Lag and
Anti-Rotation Screws. In the event this occurs, adjust the position of the
C-arm until it is on axis.
Nail may be inserted by hand, If insertion can not be achieved by hand, please
see note on page 10.Insert nail (assembled with targeting guide)into the
Lag Screw Preaparation
NOTE: The 6.5mm Anti-Rotation Screw may be
used to enhance fracture stability if the femoral neck is able to accommodate
Remove the 3.2mm Guide Wire. Assemble the
Lag Screw Pin Bushing and Lag Screw Bushing together and place the assembly
into the inferior screw hole in the Targeting Arm (Fig.23).Assemble the 3.2mm
Arm Pin Bushing, the 5.0mm Drill Bushing and the 8.0mm Screw Bushing and insert
the assembly into the superior screw hole in the Targeting Arm(Fig.24). When
both bushings are inserted, the 8.0mm Drill Bushing will slide freely in the
Targeting Arm. Make small incisions in the soft tissue and through the
iliotibial band, down to the lateral cortex of the femur. Be certain that the
bushings are firmly seated on the bone. Do not force the bushings or impact.
Insert a 3.2mm Threaded Guide Pin into the
inferior set of bushings. Drill the Guide Pin to the level of the subchondral
bone of the femoral head, without penetrating the femoral head cortex(Fig.25).
Insert a Guide Pin into the superior set of bushings. The Screw Inserter
Adapter may be used with this Guide Pin to prevent impingement on the adjacent
Guide Pin during insertion (Fig.26). Drill the Guide Pin to the level of the
subchondral bone of the femoral head, without penetrating the femoral head
cortex. Assess the position of the Guide Pins using C-arm in the A/P and
NOTE: Ideally each Guide Pin should be
situated well inside the femoral neck to allow adequate room for screw
placement without contacting the cortical wall, If there is not sufficient
cortical wall surrounding the Guide Pins on examination with the C-arm, the
nail may be repositioned and implanted using only the Lag Screw.
Remove the Lag Screw Pin Bushing. Slide the
Cannulated Depth Gauge over the lag screw Guide Pin,(i. e. the inferior of the
two guide pins), until the gauge contacts the lateral aspect of the
femur(Fig.27).Assess that the Gauge is seated against the bone using the C-arm.
Read and record the length of the guide pin from the calibrated depth gauge.
NOTE: This measurement designates the
correct length of the Lag Screw to be implanted(Fig.28).
Slide the Stop Assembly onto the ITST Lag
Screw Reamer, keeping the gold portion of the Stop Assembly toward the cutting
end of the reamer(Fig.29).Move the Stop Assembly along the incremented lengths
listed on the reamer. Align the threaded end of the Stop Assembly with the notch
denoting the appropriate length.
When the Stop Assembly is fully seated, the
arrow on the Stop Assembly will indicate the appropriate depth level.
This"length"corresponds to the measurement obtained from the guide
Place the ITST Lag Screw Reamer over the
Guide Pin and seat it against the femoral cortex. Under power, advance the
reamer until the Stop Assembly stops against the Lag Screw
Bushing(Fig.31).Monitor progress of the reamer using the C-arm. Remove the
(If necessary), assemble the Lag Screw Tap
by locking the Stop Assembly at the level of the apporpriate measurement, in
the same fashion as the Lag Screw Reamer. Place the Lag Screw Tap over the
Guide Pin and through the Lag Screw Bushing. Advance the tap until the Stop
Assembly stops against the collar of the Lag Screw Bushing(Fig.32).Confirm Tap
position with the C-arm.
Lag Screw Insertion With ITST Compression
If not using the ITST Compression Device,
proceed to page 16.
Thread the Compressor onto the Lag Screw
Compression Device T-Handle. Insert Compression Retainer through the Lag Screw
Compression Device T-Handle(Fig.33)and thread into the appropriate Lag Screw
until it is securely fastened to the Lag Screw Compression Device T-Handle.
Pass the Lag Screw compression Device assembly through the Lag Screw Bushing
and over the Guide Pin (Fig.34).Thread Lag Screw to within 5mm of the
subchondral bone, monitoring the Lag Screw advancement with the C-arm.
If planning to use a Nail Cap which
prevents rotation or limits sliding, rotate the Lag Screw Compression Device
T-Handle(Fig.35).such that one of the four etched lines is in line with the
vertical slot on the Targeting Guide.
After inserting the Lag Screw to the
appropriate depth, confirm Lag Screw position using the C-arm.To begin
compression of the C-arm. To begin compression of the femoral neck, advance the
Compressor clockwise against the Lag Screw Bushing (Fig.36). The surgeon
continues to advance the Compressor while monitoring femoral neck compression
using the C-arm, until the desired fracture reduction is achieved.
After reduction, unthread the Compression
Retainer from the Lag Screw. After removing the compression Retainer, the Lag Screw
Compression Device Assembly can be removed. Remove the Superior Guide Pin and
Bushings if used. If using ITST Global Long Nail, remove Targeting Guide using
the Pin Wrench and Locking Bolt Extractor.
Standard Lag Screw Insertion (Optional)
Thread the Inserter Link (Fig.37)into the
Lag Screw until securely fastened. Slide the Lag Screw Inserter Shaft over the
Insert this assembly over the Guide Pin.
Thread the Lag Screw to within 5mm of the Subchondral bone. Rotate the Inserter
Shaft (Fig.39)and align one of the four etch lines on the Inserter Shaft with
the vertical slot on the Targeting Guide(Fig.48).Check the Lag Screw position
using the C-arm. Leave the Inserter Link attached to the Lag Screw.
Remove the 3.2mm Pin Bushing. Slide the
Cannulated Depth Gauge over the Guide Pin, until the Gauge contacts the lateral
aspect of the femur. Confirm the position of the Depth Gauge using the C-arm.
Read the depth of the guide pin from the Cannulated Depth Gauge. The Anti-Rotation
Screw length should be 15mm to 20mm shorter than the depth gauge
measurement.This will provide the proper screw placement to help minimize
femoral neck cutout2(Fig.40). Remove the Guide Pin. Under C-arm
control, drill into the femur with the 5.0mm Drill until the correct
calibration on the drill is level with the outer collar of the Drill Bushing.
Remove the 5.0mm Drill Bushing and Drill.
Insert the Anti-Rotation Screw using the 5.0mm T-Handle Screwdriver through the
8mm Screw Bushing and into the femoral head until seated. Placement of the
screw should be monitored using the C-arm.
Distal Screw Fixation-180mm/Short Nails
With the Proximal Targeting Guide still in
place, retighten the Locking Bolt if necessary. Assemble the appropriate Drill
Bushing(see Table 1)into the 8.0mm Screw Bushing, and place the nested bushings
through one of the distal targeting holes in the ITST Modular Targeting
Guide(Fig.41).Make a small incision through the skin and fascia lata. Spread
the soft tissue down to the bone. Advance the bushing until it contacts the
lateral femoral cortex. Advance the appropriate size Drill through the bushings
until both cortices of bone have been penetrated.
NOTE: If using the Calibrated 3.7mm or
5.0mm Drill, read calibrations from end of bushing to determine screw length.
Remove the Drill and Drill Bushing, and
insert the ITST Screw Depth Gauge through the 8.0mm Screw Bushing until the
gauge captures the far cortex of bone(Fig. 42, 43).
Read the measurement for the screw from the
end of the depth gauge.
NOTE: Choose a screw length that is at
least 2.5mm longer than the depth measured, to ensure that bicortical screw
fixation is attined.
If the bone quality is good, it may be
necessary to tap the channel using the 4.5mm Tap(Fig.44).
Place the appropriate length Cortical Screw
onto the 3.5mm T-Handle Hex Screwdriver and insert the screw into the bone
through the 8.0mm Screw Bushing, until it is flush against the lateral cortex
of the femur (Fig.45).Confirm the position of the screw in the A/P and lateral
views with the C-arm.
Place the second distal locking screw in
the same fashion as the first.
Distal Screw Fixation-Long Nails-Freehand
The distal locking screws may be inserted
with a freehand technique using the Freehand Targeting Device (Fig.46). Insert
a 3.7mm Drill (Color Code: Blue)for a 4.5mm screw, or insert a 5.0 mm
Drill(Color Code: Green)for 5.5mm screw into the Freehand Targeting Device.
Finger tighten the set screw.
Choose the appropriate locking hole based
on the need for dynamization. The superior locking hole on the ITST Nail is
used for static locking, while the distal locking hole is used for dynamic
locking. If static locking is preferred, but there is a potential need for
later dynamization, insert screws in both locking holes. The locking screw in
the static hole can then be removed to achieve dynamization later.
For success with this technique, proper
placement of the lateral X-ray beam is critical. Position the C-arm so that the
locking hole of the nail appears perfectly round on the monitor(Fig.47＆48).
this is achieved, bring the tip of the 3.7mm Drill to the skin and use the
C-arm to center it over the hole. Make a lateral stab wound opposite the
appropriate locking hole, and dissect down to the bone. Bring the tip of the
3.7mm Drill to the bone and center it over the locking hole using the C-arm.
Align the 3.7mm Drill with the axis of the X-ary beam(Fig.49).Before dilling
through the medial cortex,check the A/P and lateral C-arm image to assure that
the drill is in the hole in the nail. Drill through the medial cortex
Remove the Drill and insert the Distal
Screw Depth Gauge(Fig.52).The length of the screw is determined by reading it
directly off the Distal Screw Depth Gauge.
NOTE: Select an appropriate length screw to
ensure adequate engagement of the medial cortex.
Insert the appropriate size M/DN®Screw
using the Distal Screwdriver (Fig.53).
If desired, insert the second screw in the
second locking hole of the nail in an identical manner. Check the position of
both screws with the C-arm in the A/P and lateral planes(Fig.54).
Bushings are available that can be used
with the Freehand Targeting Device. A separate radiolucent Bushing Insert is
available to aid in targeting.
Remove the ITST barrel Targeting Arm,
Threaded Driver and Locking Bolt using the Locking Bolt Extractor(Fig.55).Take
care to leave the Lag Screw Inserter Link in place for final Nail Cap seating.
Insert the appropriate Nail Cap: Neutral
Nail Cap(Fig.56). Sliding Nail Cap(Fig.57).or Locking Nail Cap(Fig.58)with the
Nail Cap Inserter(Fig.59,60).
Tighten until fully seated. If using a
Sliding or Locking Cap, slide the Lag Screw Inserter Shaft over the Insert Link
and into the Lag Screw (Fig.59). Slowly rotate the Lag Screw Inserter and Nail
Cap Inserter until the Nail Cap flange can be felt seating into one of the four
lag screw shaft grooves(Fig.60).
Closure and Postoperative Care
Close the proximal wound and apply a soft
Postoperative range of motion exercises and
weight bearing should be individually determined by the surgeon based on
patient age, fracture pattern, and surgeon evaluation.
In order to extract the nail, remove any
existing distal screws with the 3.5mm T-Handle Hex Screwdriver. Remove the Nail
Cap with the 5.0mm T-Handle Screwdriver. Make a small incision in the area of
the existing proximal incision to expose the ends of the Lag Screw and
Anti-Rotation Screw. Clear any bony ingrowth away from the Lag Screw hex, and
thread the Retaining Shaft into the Lag Screw. Slide the Lag Screw Inserter
into the Lag Screw, and tighten the Extraction knob. Remove the lag screw,
turning counter clockwise, with a slight backward pulling motion(Fig.62). Once
the Lag Screw has been removed, use the 5.0mm T-Handled Hexdriver to remove the
Attach the Extractor Bolt into the nail
(Fig.63).Screw the Slaphammer onto the Extractor Bolt and remove the nail.