Download MAXLOCK EXTREME

MAXLOCK EXTREME
™
™
Lateral TTC Plate
SURGIC A L T ECHNIQUE
Contents
Overview
2
Exposure3
Surgical Technique
4
Implants and Instruments
10–11
Proper surgical procedures and techniques are the responsibility of the medical professional. The following guidelines are furnished for
information purposes only. Each surgeon must evaluate the appropriateness of the procedures based on his or her personal medical
training and experience. Prior to use of the system, the surgeon should refer to the product package insert for complete warnings,
precautions, indications, contraindications and adverse effects. Package inserts are also available by contacting Wright Medical.
Please contact your local Wright representative for product availability.
Advantages
Inferior Eyelet
The plate’s distal contour wraps plantarly and accommodates a 7.0 mm compression screw that is
directed across both joints to provide outstanding compression and multiplanar stability
Anatomic Design
Contours to the lateral aspect of the TTC joints for minimal bone sculpting and a low
profile fit
Targeting Jig
Construct specific instrumentation designed for the simple and reproducible placement of
two percutaneus 7.0 mm cannulated MaxTorque™ Screws
Overview
A tibiotalocalcaneal (TTC) arthrodesis is one which includes the ankle and the subtalar joint.
Generally, even substantial coronal and sagittal plane deformities can be corrected with a TTC arthrodesis
alone. The indications for a TTC arthrodesis are arthritis with or without associated deformity of the ankle
and subtalar joint, avascular necrosis of the talus, rheumatologic arthritis and deformity, and Charcot
neuroarthropathy. The TTC arthrodesis should not be used as an alternative to an isolated ankle arthrodesis
if arthritis and deformity is limited to the tibiotalar joint. The technique described below applies to both the
tibiotalocalcaneal and a tibiocalcaneal (TC) arthrodesis where a partial or total talectomy is necessary.
2
Surgical Approach
A lateral transfibular approach to the ankle and hindfoot is used for the arthrodesis and correction of
deformity. This approach is particularly useful in the setting of severe deformity in either the sagittal or coronal
plane or both.
Exposure
The incision is made vertically, directly over the fibula, extending down distally over the sinus tarsi toward the
inferior aspect of the calcaneus. The sural nerve must be identified and then retracted inferiorly and posteriorly
with the peroneal tendons. It may be necessary to retract the nerve and tendons anteriorly depending on the
soft tissue, scarring and deformity. In some cases it is acceptable to cut the peroneal tendons, particularly where
they are already torn, a common finding with a chronic varus hindfoot
and ankle deformity.
With the peroneal tendons retracted, the calcaneofibular and anterior talofibular ligaments are cut exposing
the entire distal fibula. A fibulectomy is now performed. It is ideal to use the fibula for bone graft, and this can
be morcellized following an osteotomy with a saw. Alternatively, a small acetabular reamer can be utilized prior
to the fibulectomy to harvest the distal fibula. The reamer is applied with pressure to the fibula, and is used
to completely denude and decorticate the bone leaving only a shell of the inner cortex behind and yielding
copious cancellous graft.
For application of the plate, it is necessary to remove 8-10 cm of the distal fibula. If the reamer was utilized prior
to creating the fibular osteotomy, the remaining fibula is cut more proximally with a saw and discarded.
The lateral aspect of the calcaneus must partially be exposed in order to visualize the plantar lateral margin of
the calcaneus for apposition of the plate. The approach for preparation of the joint surfaces depends on the
need for preservation of the anatomy and the presence of deformity. If there is minimal deformity present,
then it is preferable to use a chisel to thoroughly denude the ankle and subtalar joints. One must be careful not
to remove excess bone laterally from either joint since this will tilt the arthrodesis into valgus. If deformity is
present, the joint surfaces can be prepared by making flat cuts with a saw.
A wide fan shaped saw blade is used while protecting the soft tissue on the posterior and anterior ankle
with malleable retractors. The saw is oriented perpendicular to the tibial shaft and the cut, is conducted in
order to remove approximately 2 mm in the center of the joint increasing to about 5 mm anteriorly and
7 mm posteriorly (depending on the presence of osteophytes in the anterior and posterior ankle). Then while
holding the ankle in neutral dorsiflexion and 5-7 degrees of valgus, a parallel flat cuts are made on the dome of
the talus removing approximately 5 mm of bone.
Depending on the ability to obtain a plantigrade foot and a neutral position of the ankle, the medial malleolus
may be cut obliquely through a separate incision on the medial ankle. This cut is made obliquely so that it exits
at the level of the tibial plafond. This osteotomy will permit easy translation of the talus under the tibia in any
direction to facilitate deformity correction.
Once the foot is in a neutral position under the tibia, the neutral position should be verified under fluoroscopy
and provisionally maintained by two crossing guide wires. The lateral flare of the distal tibia will require
ostectomy with a chisel or osteotome to allow the plate to sit flush on the bone surface.
3
Surgical
Technique
Special Note: The Lateral TTC Plate Caddy is
intended to be used in conjunction with both
the MAXLOCK™ EXTREME™ System and the
MaxTorque™ System. Ensure all sets are available
for use at the time of surgery.
Step 1
After the appropriate joint preparation has been
achieved, position the plate over the lateral aspect of
the TTC joint complex. Insert the plate deep with
respect to the peroneal tendons (the tendons can be
excised if torn) in order to avoid compromising either
skin closure or ultimate peroneal function. Once the
desired position is achieved, the plate can be
provisionally fixed by a combination of k-wires and
olive wires. Generally, placing Olive Wires in slotted
holes over the tibia and in one of the calcaneal screw
holes will be sufficient to secure the plate and ensure
good bony apposition. Place olive wires in the most
proximal portion of the slotted holes. This will allow
for compression in subsequent steps.
Standard TTC Plate
Note: In order for the plate to lie flush on the
calcaneus, talus and tibia, it may be necessary to
shave down prominent ridges and osteophytes
particularly along the distal metaphysis of the
tibia. Re-apply the plate and re-contour with
a saw until the plate lies flush with the lateral
bone surfaces.
Note: If needed, the TTC Distal Plates are
available for smaller anatomy. The TTC Distal
Plates have a modified distal geometry and hole
positions to accommodate additional patient
populations or reduced talar body height.
Step 2
4
Attach the Primary Targeting Guide to the plate.
The threaded insert in the targeting guide will
thread into the central hole over the talus as shown.
The distal portion of the guide will sit outside the
incision and wrap under the inferior aspect of the
calcaneus. This guide will facilitate the insertion of a
MAXTORQUE™ 7.0 mm screw from the calcaneus into
the tibia.
Distal TTC Plate
Step 3
Assemble the Guide Wire Insert into the distal
head of the Targeting Guide as shown. The
Insert is orientation specific and will not fit
into the Targeting Guide if it is not oriented
correctly.
Step 4
Insert the 2.3 mm Guide Wire from the
MAXTORQUE™ set through one of the holes
in the Guide Wire Insert. This guide wire will
be utilized for the placement of a 7.0 mm
MaxTorque cannulated compression screw that
spans both the subtalar and ankle joints. The
Guide Wire Insert has three options labeled
#1, #2 and #3 with graduations of 5°. The
appropriate option will depend on the height
of the talus. The intended trajectory is such that
the wire exits the medial tibia just superior to
the medial malleolus. Select the angle that best
captures the distal medial tibia and confirm
under fluoroscopy. Note the selected hole
number as this will determine the available
options for subsequent “homerun” screw
placement.
5
Step 5
Following fluoroscopic verification of the Guide
Wire position, remove the Guide Wire Insert by
pulling it over the guide wire.
Step 6
Use the provided depth gauge to determine the
appropriate length for the cannulated screw.
Ensure the depth gauge is fully seated against
the bone when taking the reading. Consider the
amount of compression to be generated when
selecting a screw length. A shorter screw than
indicated by the depth gauge may be required.
Step 7
Use the 4.7 mm cannulated drill bit to perforate
the calcaneus, talus and the cortical edge of the
distal tibia.
Step 8
Using the MAXTORQUE™ 7.0 Driver, insert the
desired length 7.0 mm short thread screw to
compress across both the ankle and the subtalar
joints. The olive wires within the slotted holes
in the tibia may remain in place to ensure good
apposition of the plate is maintained during
compression. All other provisional fixation
should be removed prior to final tightening to
ensure maximum compression is achieved.
6
Optional Secondary 7.0 mm Screw Insertion (steps 9–13)
The Secondary Targeting Guide can be used if a second 7.0 mm
“homerun” compression screw is desired. This guide will allow
placement of a 7.0 mm “homerun” screw through the center of the
calcaneus into the anterior aspect of the distal tibia and will prevent
collision with the primary screw. The guide is designed to introduce the
guide wire into either the posterior calcaneus or anterior aspect of the
distal tibia, depending on surgeon preference.
Step 9
Insert the Secondary Targeting Guide through
the hole corresponding to the operative side
in the Primary Targeting Guide. Adjust the
shaft to the desired position and fix in place
by tightening the Hexalobe Lock Nut using the
MAXTORQUE™ 7.0 mm Driver.
Step 10
The Secondary Targeting Guide provides three
hole options labeled #1,#2, and #3 for the
position of the secondary 7.0 mm screw. To
ensure no collision, use an equal or lesser hole
number than was previously used
for the primary 7.0 mm screw in Step 4. For
example, if the #2 hole was used in Step 4,
the holes labeled 1 or 2 may be used for the
positioning of the secondary 7.0 mm screw.
Insert a 2.3 mm k-wire through the desired
guide hole as the desired exit point in just
superior to the anterior flare of the distal tibia.
Drive the wire across both joints and confirm
under fluoroscopy.
7
Step 11
Following fluoroscopic verification of the
position of the guide wire, remove the entire
targeting guide assembly.
Step 12
Measure using the provided depth gauge and
insert the desired length 7.0 mm short
thread screw.
Note: The depth gauge reading corresponds to
the working length of the screw (from distal tip
to underneath the screw head).
Step 13
Use the 4.7 mm cannulated drill bit to perforate
the calcaneus, talus and the anterior cortical
edge of the distal tibia.
Step 14
Use the MAXTORQUE™ 7.0 driver to insert the
desired length 7.0 mm short thread screw.
The remaining plate screw holes may be filled
with either MAXLOCK™ EXTREME™ 3.5 mm
Fixed-Angle Locking Screws, 3.5 mm NonLocking Screws or 4.0 mm Non-Locking Screws
as desired based on the need for stability and
fixation.
Note: Screw holes that line the main body of
the plate lie on the same plane and have the
potential for interference with the primary
7.0 mm screw. In addition, the posterior talar
screw holes lies on the same plane as the
secondary 7.0 mm screw. For this reason, if
adjuvant fixation is needed, these holes should
be drilled and filled with caution to avoid
damage to installed hardware.
Step 15
To drill for locking screws, use either the fixed
drill guide or the Keyway Drill Guide. The fixed
drill guide threads into the locking hole to
provide the proper angle for drilling. To use the
Keyway Drill Guide, align the lobes on the tip of
8
the guide with the lobes in the threaded hole
and press into the plate while drilling to ensure
proper alignment.
Step 16
Using the 2.4 mm drill bit drill to the desired
depth. Take care to not move the plate after
drilling for a fixed angle locking screw in order
to maintain the proper pilot hole alignment and
prevent locking screw cross-threading.
Lateral View of Final Construct
Posterior View of Final Construct
Step 17
Measure using the provided depth gauge and
insert the appropriate length screw using the
HEXSTAR™ driver.
Step 18
If desired, non-locking screws may be placed
in the slots or any threaded hole. Use the 2.7
mm drill bit and 2.7 mm drill guide to prepare
a pilot hole for a 4.0 mm non-locking screw.
Measure with the provided depth gauge and
insert an appropriate length screw using the
HEXSTAR™ driver.
9
Ordering
Information
IMPLANTS
Plates
Description
Part #
Right Lateral Plate
ANK-002-TTCR
Left Lateral Plate
ANK-002-TTCL
Right Lateral Distal Plate
ANK-002-TTCR-D
Left Lateral Distal Plate
ANK-002-TTCL-D
Screws
10
Description
Part #
ø7.0 mm Screw
MSD-010-70-XXX
ø3.5 mm Fixed-Angle Locking Screw
MFT-021-35-XX
ø3.5 mm Non-Locking Screw
MFT-011-35-XX
ø4.0 mm Non-Locking Screw
MFT-011-40-XX
INSTRUMENTS
Description
Part #
ø2.3 mm Guide Wire
CSS-040-23
ø2.3 mm Threaded Guide Wire
CSS-040-23-T
ø1.1 mm K-Wire
MFT-040-11-SS
Threaded Olive Wire – XL
MFT-040T-XL
ø4.7 mm Drill Bit
CSS-072-47
ø4.7 mm Square Drill Bit
CSS-072-47-SQ
ø2.4 mm Drill Bit
MFT-072-24
ø2.7 mm Drill Bit
MFT-072-27
Lateral Targeting Guide
ANK-167
Lateral K-Wire Guide Insert
ANK-167-01
Lateral Secondary Targeting Guide
ANK-167-02
Lateral Primary Targeting Guide
ANK-067-03
Lateral Primary Targeting Guide Healobe™
Lock Nut
ANK-067-04
ø2.3 mm Drill Bit Sleeve
(available by request)
ANK-051
11
1023 Cherry Road
Memphis, TN 38117
800 238 7117
901 867 9971
www.wright.com
10801 Nesbitt Avenue South
Bloomington, MN 55437
888 867 6437
952 426 7600
www.tornier-us.com
™Trademarks and ®Registered marks of Wright Medical Group N.V. or its affiliates.
©2016 Wright Medical Group N.V. or its affiliates. All Rights Reserved.
ANK 801-002 Rev B ECN 160495 13-Apr-2016