Expert ALFN. Adolescent Lateral Femoral Nail.
Expert ALFN. Adolescent Lateral FemoralNail.Surgical TechniqueEXPERTNailing SystemThis publication is not intended fordistribution in the USA.Instruments and implantsapproved by the AO Foundation.
Image intensifier controlThis description alone does not provide sufficient background for direct useof DePuy Synthes products. Instruction by a surgeon experienced in handlingthese products is highly recommended.Processing, Reprocessing, Care and MaintenanceFor general guidelines, function control and dismantling of m ulti-partinstruments, as well as processing guidelines for i mplants, please contact yourlocal sales representative or refer are-maintenanceFor general information about reprocessing, care and maintenance of Synthesreusable devices, instrument trays and cases, as well as processing of Synthesnon-sterile implants, please consult the Important Information leaflet(SE 023827) or refer are-maintenance
Table of ContentsIntroductionSurgical TechniqueProduct InformationExpert ALFN 2AO Principles 4Indications and Contraindications 5Clinical Cases 6Preoperative Planning 10Opening the Femur 13Inserting the Nail 18Locking Options 24Proximal Locking – Standard 26Proximal Locking – Recon (Optional) 31Distal Locking 36End Cap Insertion 42Implant Removal 44Implants 50Instruments 54 Comparison Table 65 Handling Information 67Set List Modular Cases Vario Cases 696973Optional: Angular Stable Locking System (ASLS) 77MRI Information Expert ALFNSurgical TechniqueDePuy Synthes791
Expert ALFNAdolescent Lateral Femoral Nail SystemNail features–– Design accommodates a lateral entry site throughthe greater trochanter–– Anatomic nail design based on a femoral canal study*–– Titanium cannulated nail for reamed or unreamed techniques–– Lengths from 240 mm to 400 mm, in 20 mm increments–– Designed for use in patients where Titanium Elastic Nailsare not large enough and the Expert Lateral F emoral Nailfor adults is too large–– 8.2 mm, 9.0 mm, and 10.0 mm diameter nails with11.0 mm diameter proximal endsEnd caps–– Prevent ingrowth of tissue and facilitate nail extraction–– Self-retaining, T40 Stardrive recess for easy pickupand insertion of the end cap–– Cannulated for insertion over a guide wire–– 0 mm end cap sits flush with the nail–– 5 mm, 10 mm, and 15 mm end caps extend nail height ifthe nail is overinserted* Ehmke L, Polzin B, Roth C, Bottlang M (2006) Femoral Nailing Throughthe Trochanter: The Reamer Pathway Indicates A Helical Shape. Journalof Orthopedic Trauma Vol. 20 (Number 10): 668–6742DePuy Synthes Expert ALFN Surgical TechniqueImproved instrumentation–– Easy-to-use instrumentation facilitates the surgical procedure–– Ball-tip reaming rod can be removed through the nail andthe insertion instruments, eliminating the need for an exchange tube–– Tailored to the needs of the clinic available as:–– an upgrade set for adolescents to Expert Lateral FemoralSystem for adultsor–– a standard Instrument Set for Expert Adolescent L ateralFemoral Nail
Standard locking screws–– Double-lead thread for ease of insertion–– Thread closer to screw head provides better bone purchase in the near cortex and improved stability–– Titanium alloy* for improved mechanical and fatigueproperties–– Self-tapping blunt tip–– Self-retaining T25 Stardrive recess allows improved torquetransmission, increased resistance to stripping relative to ahex recess, and secure locking screw pickup–– 4.0 mm diameter5.0 mm hip screws–– Lengths from 50 mm to 125 mm in 5 mm increments–– Self-retaining T25 Stardrive recess–– Titanium alloy** Titanium/6% aluminum/7% niobium alloyExpert ALFNSurgical TechniqueDePuy Synthes3
AO PrinciplesIn 1958, the AO formulated four basic principles, which havebecome the guidelines for internal fixation.1,2Anatomic reductionFracture reduction and fixation to restore anatomical relationships.1Early, active mobilizationEarly and safe mobilization and rehabilitation of the injured part andthe patient as a whole.4 üller ME, M Allgöwer, R Schneider, H Willenegger. Manual of InternalMFixation. 3rd ed. Berlin Heidelberg New York: Springer. 19912 Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management.2nd ed. Stuttgart, New York: Thieme. 200714DePuy Synthes Expert ALFN Surgical Technique23Stable fixationFracture fixation providing absoluteor relative stability, asrequired by the patient, the injury,and the personality of thefracture.Preservation of blood supplyPreservation of the blood supply tosoft tissues and bone bygentle reduction techniques andcareful handling.
Indications and ContraindicationsIndicationsThe Expert Adolescent Lateral Femoral Nail is indicated foruse in adolescent and small-stature adult patientsto stabilize:–– Fractures of the femoral shaft–– Subtrochanteric fractures–– Ipsilateral neck/shaft fractures–– Impending pathologic fractures–– Nonunions and malunionsNote: ASLS, the Angular Stable Locking System, isindicated in cases where increased stability is neededin fractures closer to the metaphyseal area or in poorquality bone. For more details regarding the intra medullary fixator principle, please consult the ASLStechnique guide (036.000.708) and concept flyer(036.001.017).ContraindicationsNo specific contraindications.Expert ALFNSurgical TechniqueDePuy Synthes5
Clinical CasesCase 1 – standard transverse locking– 16-year-old female, 45 kg– Isolated transverse femoral shaft fracturePreoperativeCase 2 – antegrade locking– 15-year-old male, 55 kg– Oblique midshaft femoral shaft fracturePreoperative6DePuy Synthes Expert ALFN Surgical Technique
IntraoperativeFollow-up (6 weeks after surgery)PostoperativeFollow-up (4 months after surgery)Expert ALFNSurgical TechniqueDePuy Synthes7
Clinical CasesCase 3 – recon locking–– 12-year-old male, 43 kg–– Pathologic proximal femoral shaft fracturePreoperativeCase 4 – distal locking–– 12-year-old male, 30 kg–– Oblique distal third femoral shaft fracturePreoperative8DePuy Synthes Expert ALFN Surgical Technique
PostoperativeFollow-up (3 weeks after surgery)PostoperativeFollow-up (1 month after surgery)Expert ALFNSurgical TechniqueDePuy Synthes9
Preoperative PlanningExpert Adolescent Lateral Entry Femoral Nail for Right Femur10203040380 mm360 mm340 mm320 mm300 mm280 mm400 mm301000641.0 Magnification0 12/2009 Synthes, Inc. or its affiliates All rights reserved Synthes and Expert are trademarks of Synthes, Inc. or its affiliates380 mmExpert AdolescentLateral Entry Femoral Nailfor Right Femur360 mm340 mm320 mm300 mm260 mm280 mm240 mm240 mm260 mm 8.2 mm 8.2 mm 9 mmHip Screw Stardrive 5.0 mm, TAN [04.031.020 – 04.031.035]5060708090100mmFor use only with the Original AO System ofInstruments and Implants1Position patientPosition the patient in the lateral decubitus or supine position on a fracture table or radiolucent operating table. Position the C-arm to allow visualization of theproximal femur in both the AP and lateral planes.To facilitate access to the medullary canal, abduct the upperpart of the body approximately 10 –15 to the contralateralside and adduct the affected limb by 10 –15 .Affected leg10º–15º adductionDePuy Synthes Expert ALFN Surgical Technique 10 mmLocking Screw Stardrive 4.0 mm, TAN [04.005.408 – 04.005.470]Note: Templates are available in two sizes: actualsize and 115% magnification in which the image is enlarged 15% to correspond to typical radiographicmagnification; however, variations in magnificationlevels are common.11 9 mm15 mm10 mm5mm0mmEnd Caps5 mm0 mm15 mm10 mmLateral View400 mmTo estimate nail length, place the template on the AP x -rayof the uninjured femur and select the appropriate nail lengthbased on patient anatomy. When selecting nail size, considercanal diameter, fracture pattern, p atient anatomy and postoperative protocol. 10 mmA-P ViewTo estimate medullary canal diameter, place the template onthe AP or lateral x-ray of the femur and measure the dia meter of the medullary canal at the narrowest part that willcontain the nail.Ö034.000.600 AAjä8.2 mm, 9 mm and 10 mm diameter 240 mm to 400 mm lengthsSynthes GmbHEimattstrasse 3CH-4436 Oberdorfwww.synthes.com034.000.600 AAUse the AO preoperative planner templates for the ExpertAdolescent Lateral Femoral Nail (034.000.600/605) to estimate nail length and medullary canal diameter.
2Reduce fracturePerform closed reduction manually by axial traction u nderimage intensifier control. The use of the large d istractormay be appropriate in certain circumstances (refer to thesurgical technique 036.000.038).3Confirm nail lengthInstrument03.010.020 Radiographic Ruler for ExpertFemoral NailsThe required nail length must be determined after reductionof the femoral fracture.Position the C-arm for an AP view of the proximal femur.With long forceps, hold the ruler alongside the lateral thigh,parallel to and at the same level as the femur. Adjust theruler until the proximal end is at the desired nail insertion.Expert ALFN Surgical TechniqueDePuy Synthes11
Preoperative PlanningMove the C-arm to the distal femur. Verify fracture reduction. Align the proximal end of the radiographic rulerto the skin mark, and take an AP image of the distal femur.Read nail length directly from the ruler image, selecting themeasurement proximal to the epiphysis, or at the chosen insertion depth.Notes: It is recommended to treat the fracture with thelongest nail possible without crossing the physis, taking into account patient anatomy or a previous implant. The distal end of the nail should be 15 mmfrom the physis. Compression (with the conventional backstroketechnique) or dynamization must be taken intoaccount when determining the nail length.A shorter nail should be chosen when backhammer ing or dynamization is planned for theprocedure (the dynamic slot allows for 7 mm ofmovement).4Confirm canal diameterInstrument03.010.023 Radiographic Ruler for Nail Diameters forExpert Femoral Nails, length 365 mmThe required nail length must be determined after reductionof the femoral fracture.Position the C-arm for an AP or lateral view of the femur atthe level of the isthmus. Hold the radiographic canal widthestimator over the femur with the diameter gauge centeredover the narrowest part of the medullary canal. Read the estimated diameter measurement on the circular indicatorthat fills the canal.11DePuy Synthes Expert ALFN Surgical TechniqueNotes: If the reamed technique is used, the diameterof the largest medullary reamer must be at least1.0 mm greater than the nail diameter. The ruler provides only an estimate of the canaldiameter as it is not at the same level as thefemur.
Opening the Femur1ApproachPalpate the posterior edge of the greater trochanter.Make a 3 cm incision in line with the central axis of the intramedullary canal in the lateral view, and depending onthe anatomy of the patient, 2–5 cm proximal to the tip ofthe greater trochanter.2Determine entry point12 The insertion point is 12 lateral to the greater trochanter, asmeasured from a point 20 mm distal to the lesser trochanter.The entry point can also be described as lateral to thegreater trochanter at the same level as the superior aspect ofthe base of the femoral neck (just above the piriformis fossa).This point can be found by extending a line horizontally fromthe base of the femoral neck to the lateral side of the femur.20 mmNote: To ensure a correct entry point the preoperativeplanner template for the ALFN can be used.Expert ALFNSurgical TechniqueDePuy Synthes11
Opening the Femur3Insert guide wireInstruments03.010.500Handle, with Quick Couplingand03.010.504 Protection Sleeve 13.0 for Expert Adolescent Lateral Femoral Nail,with Quick Couplingand03.010.509 Multihole Drill Guide for ProtectionSleeve 13.0, for Expert Adolescent LateralFemoral Nailor03.010.031 Drill Sleeve 13.0/3.2, for antegrade approach, for No. 03.010.030and03.010.229 Protection Sleeve 15.5/13.7,length 122.5 mmand357.393 Trocar B 3.2 mm, length 172 mm,for No. 357.392357.399Guide Wire B 3.2 mm, length 400 mmInsert the protection sleeve, wire guide and trocar assemblyinto the incision site and to the bone.Remove the trocar. Insert the guide wire through the wireguide.The guide wire must be inserted laterally at an angle of 12 to the center of the medullary canal. The tip of the guidewire should be centered in the medullary canal 20 mm distalto the lesser trochanter.Verify that the guide wire position allows adequate clearanceon the lateral side of the femur for the opening drill bit.The guide wire is inserted with it centered in the lateral view.Precaution: The correct entry point and angle areessential for a successful result. To ensure the correctposition of the guide wire, hold a sterile AdolescentLateral Femoral Nail onto the femur and check radio graphically.11DePuy Synthes Expert ALFN Surgical Technique
4Open proximal femur to medullary canalInstruments03.010.229P rotection Sleeve 15.5/13.7,length 122.5 mmor03.010.509 Multihole Drill Guide for ProtectionSleeve 13.0, for Expert Adolescent LateralFemoral Nailand03.010.500Handle, with Quick Coupling351.270 Drill Bit B 13.0 mm, cannulated,length 290 mm, 3-flute,for Quick Coupling No. 511.760357.399Guide Wire B 3.2 mm, length 400 mmDrill to open cortexDrill through the protection sleeve. Drill the cortex until thedrill bit stops in the sleeve.Remove the guide wire, drill bit and protection sleeve.Precaution: Dispose of the guide wire. Do not reuse.Alternative technique to open proximal femurInsert the 2.5 mm reaming rod. Use a reaming system intended for femoral reaming procedures to open the proximalfemur to a depth of approximately 75 mm, starting with an8.5 mm reamer and ending with a 13.0 mm reamer.If reaming the medullary canal, proceed to page 17.75 mmExpert ALFNSurgical TechniqueDePuy Synthes11
Opening the FemurAlternative technique (with awl)Alternative instruments03.010.041 Awl B 14.0/3.2 mm, cannulated357.399Guide Wire B 3.2 mm, length 400 mmPlace the cannulated awl over the guide wire and open themedullary canal. Use a twisting motion to advance the awlto a depth of approximately 75 mm.Remove the guide wire and awl.Precaution: After opening the proximal femur, disposeof the guide wire. Do not reuse.11DePuy Synthes Expert ALFN Surgical Technique
5Ream medullary canal (optional)Instrument03.010.093 Rod Pusher for Reaming Rod withHexagonal Screwdriver B 8.0 mmNote: For the detailed reaming procedure, please consult SynReam Surgical Technique.If necessary, use a reaming system intended for femur reaming procedures to enlarge the medullary femoral canal to thedesired diameter.Check fracture reduction under image intensifier.Insert reaming rodInsert a 2.5 mm reaming rod into the medullary canaluntil the desired insertion depth. The tip must be correctlypositioned in the medullary canal since it determines the final distal position of the Expert ALFN. The use of the Reduction Instrument for Medullary Nails may be helpful incertain circumstances.ReamingStarting with the smallest diameter reaming head, ream to adiameter of 0.5 to 1.5 mm greater than the nail d ia meter.Ream in 0.5 mm increments and advance the reamer withsteady, moderate pressure. Do not force the reamer. Partiallyretract the reamer repeatedly to clear debris from the medullary canal.Use the holding forceps to retain the reaming rod whilereaming and to prevent it from rotating.Expert ALFNSurgical TechniqueDePuy Synthes11
Inserting the Nail1Assemble insertion instrumentsInstruments03.010.146 Connecting Screw, cannulated,with Internal M6x1 Threadand03.010.488 Insertion Handle, radiolucent,length 100 mm, for ALFNor03.010.044 Connecting Screw, cannulated, for ExpertTibial and Femoral Nails, forNo. 03.010.045and03.010.226 Insertion Handle for Expert AdolescentLateral Femoral Nail03.010.093 Rod Pusher for Reaming Rod with Hexagonal Screwdriver B 8.0 mm03.010.092 Screwdriver, hexagonal with sphericalhead B 8.0 mmor03.010.517 Screwdriver, hexagonal B 8.0 mm,with T-Handle, with spherical head, length322 mmMatch the tangs on the handle to the notches in the ExpertAdolescent Lateral Femoral Nail.Place the connecting screw into the insertion handle andthread it into the proximal nail end, using the 8 mm hexa gonal screwdriver with spherical head.The Expert Adolescent Lateral Femoral Nails are labeled leftor right on the proximal nail end.11DePuy Synthes Expert ALFN Surgical Technique
Slide the connecting screw onto the reaming rod push rod.Slide the assembly through the insertion handleand match the tangs on the handle to the nail. Tighten usingthe hex on the reaming rod push rod.Secure the assembly using the 8 mm hexagonal screwdriverwith spherical head.Note: The anatomical design of the AdolescentsLateral Femoral Nail requires left and right versionnails. The nails are therefore labeled left or right onthe proximal anterior end.Precaution: Check that the connecting screw iscorrectly tightened. Do not overtighten.Expert ALFN Surgical TechniqueDePuy Synthes11
Inserting the Nail2Insert nailInstruments03.010.523 Driving Cap with thread,for Insertion Handleand03.010.522Combined Hammer, 500 gand03.010.170Hammer Guideor03.010.047 Connector, length 141 mm,for Insertion Handleand03.010.056 Combined Hammer 700 g, can bemounted, for No. 357.220and357.220Hammer Guide, for No. 357.25003.010.092 Screwdriver, hexagonal with sphericalhead B 8.0 mmor03.010.517 Screwdriver, hexagonal B 8.0 mm,with T-Handle, with spherical head,length 322 mm321.170Pin Wrench B 4.5 mm, length 120 mm321.160Combination Wrench B 11.0 mm357.398 Shaft, hexagonal, B 8.0 mm, cannulated,short, length 125 mm22DePuy Synthes Expert ALFN Surgical Technique
Slide the connector into the groove on the insertion handleand secure it using the 11 mm ratchet wrench.If patient anatomy allows, attach the driving cap in the medial position.Orient the insertion handle in an anterior position. Use theC-arm to verify fracture reduction. Insert the nail as far aspossible.The nail rotates approximately 90 during insertion.The insertion handle rotates from an anterior to a lateral position during insertion of the last one-third of the nail length.If the nail does not rotate to the lateral position, remove thenail and reinsert it with the handle slightly lateral to the sagittal plane.Monitor nail passage across the fracture, and controlin two planes to avoid malalignment.Expert ALFN Surgical TechniqueDePuy Synthes22
Inserting the NailIf desired, insert the nail using light hammer blows.Lock the head of the hammer in place by tightening the nutonto the threads located below the hammer head. Use thepin wrench if necessary. Strike the driving cap directly.Optionally, the hammer guide can be threaded onto the driving cap and the hammer can be used as a slide hammer.Loosen the nut from the threads located below the hammerhead and secure the nut onto the threads located above thehandle.Precautions: Do not mount the aiming arm until the nail hasbeen completely inserted. If nail insertion is difficult, choose a smaller diame ter nail or ream the intramedullary canal to a largerdiameter. Do not hammer directly onto the insertion handle.Retighten and confirm that the nail is securely con nected to the insertion handle.22DePuy Synthes Expert ALFN Surgical Technique
3Check proximal nail positionInsert the nail until it is at or below the femoral opening.Check final nail position under image intensification in APand lateral views.If primary compression or secondary dynamization isplanned, it is recommended to overinsert the nail by morethan 7 mm, which corresponds to the maximum distance between the positions in static and dynamic modes.Note: The distance between the markings on the insertion handle is 5 mm and corresponds to the extensions of the end caps. This feature can beused f
surgical technique 036.000.038). 3 Confirm nail length Instrument 03.010.020 Radiographic Ruler for Expert Femoral Nails The required nail length must be determined after reduction of the femoral fracture. Positi
Posterior wall (floor) - from medial to lateral: adductor longus, pectineus, psoas major and iliacus Apex: continuous with adductor canal. Contents of Femoral Triangle Contain: 1. Femoral nerve 2. Femoral artery 3. Femoral vein 4. Femoral canal –contains deep inguinal lymph nodes and vessels.
12 Synthes LCP Proximal Femoral Hook Plate 4.5/5.0 Technique Guide Surgical Technique 6 Approximate plate to femoral diaphysis Instrument 321.120 Tension Device, articulated Secure the plate to the lateral femoral shaft with bone hold-ing forceps, adjusting horizontal plane alignment (rotation) as appropriate. Length restoration and fracture .
14 Synthes LCP Proximal Femoral Plate 4.5/5.0 Technique Guide 6 Approximate the plate to the femoral diaphysis Instrument 321.120 Tension Device, articulated, span 20 mm Secure the plate to the lateral femoral shaft with bone hold-ing forceps, adjusting horizontal plane alignment (rotation) as appropriate. Length restoration and fracture .
The indications and contraindications for distal femoral osteotomy are similar to those for high tibial osteotomy. Surgical Technique A lateral approach is used to perform a distal femoral osteotomy. The iliotibial band is split along its fibers and the vastus lateralis is elevated off the femur to expose the femoral shaft and metaphysis. A .
10 DePuy Synthes Expert A2FN Surgical Technique Open Femur 3 Confirm nail length and diameter Instruments 03.010.020 Radiographic Ruler for Femoral Nails 03.010.023 Radiographic Ruler for Nail Diameters for Expert Femoral Nails The required nail length must be determined after reduction of the femoral fracture.
Development plan. The 5th "Adolescent and Development Adolescent - Removing their barriers towards a healthy and fulfilling life". And this year the 6th Adolescent Research Day was organized on 15 October 2021 at the Clown Plaza Hotel, Vientiane, Lao PDR under the theme Protection of Adolescent Health and Development in the Context of COVID-19.
The image selected for distal femur is one at transepicondylar level showing most prominent epicondyles (13). Following image shows the measurements of femoral medial lateral (fML), femoral medial condyle anterior-posterior (fMAP), femoral lateral condyle anterior-posterior diameter (fLAP).
The American Petroleum Institute Manual of Petroleum Measurement Standards (API MPMS) Chapter 19 details equations for estimating the average annual evaporation loss from storage tanks. These equations are based on test tank and field tank data and have been revised since initial publication for more accurate estimations. WHAT IS EVAPORATION? Evaporation is when a substance changes from the .
