Including LCP DHS And DHS Blade DHS/DCS System
Including LCP DHS and DHS BladeDHS/DCS SystemSurgical Technique
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 ofSynthes reusable devices, instrument trays and cases, as well as processing ofSynthes non-sterile implants, please consult the Important Information leaflet(SE 023827) or refer are-maintenance
Table of ContentsIntroductionSurgical TechniqueProduct InformationSystem Overview 3DHS System 6Indications and Contraindications 8Clinical Cases 10DHS Implantation 11DHS Removal 25LTSP and ULTSP Implantation 27LTSP and ULTSP Removal 32DCS Implantation 33DCS Removal 37Implants 38Sets 46Bibliography 49MRI Information 50Surgical TechniqueDHS/DCS System DePuy Synthes1
System OverviewThe Synthes Dynamic Hip System (DHS) offers a varietyof treatment options depending on the fracture site andthe patient.Fixation elementsDHS Screw Stainless steel / TiAl6Nb7 (TAN) Length 50 –145 mm Outer diameter 13 mm Coupling: two notches or octagonalDHS BladeThe DHS Blade reduces the risk of cut-out comparedto the standard DHS Screw.Stainless steel /TANLength 65 – 145 mmOuter diameter 13 mmDHS Emergency Screw Stainless steel Length 50 –145 mm Outer diameter 14 mmPlatesDHS plate with DCP holesUsed for more than 25 years. Stainless steel / TAN Barrel angle 130 –150 2 to 20 holes Barrel length: standard and short Thickness 5.8 mm Fixation with cortex screws B 4.5 mmLCP DHS plateFacilitated fixation on the shaft allows for minimally invasive approach. LCP combi-holes Tapered end Undercuts Barrel angle 130 –150 1 to 20 holes Barrel length: standard and short Thickness 5.8 mm Fixation with locking screws B 5.0 mm, cortex screwsB 4.5 mm or a combination of bothSurgical TechniqueDHS/DCS System DePuy Synthes3
LCP DHS plate with collar LCP combi-holes Tapered end Undercuts Barrel angle 135 and 140 3–5 holes Barrel length: standard SterileDHS Trochanter Stabilizing PlateAll DHS Trochanter Stabilizing Plates can be used withthe conventional DHS or the LCP DHS plate.Conventional DHS Trochanter Stabilizing Plate(TSP) Lateral support Prevents unlimited dynamization Allows for the fixation of the upper trochanterwith cerclage Stainless steel or titanium Two lengths: short (138 mm) and long (148 mm)Locking Trochanter Stabilizing Plate (LTSP) Can be adapted to the anatomical condition Fixation of the upper trochanter with locking screws Lateral support Prevents unlimited dynamization Stainless steel or titanium Length 130 mmUniversal Locking Trochanteric Stabilizing Plate(ULTSP) Can be adapted to the anatomical condition Fixation of the upper trochanter with locking screws Lateral support Prevents unlimited dynamization Stainless steel Length 131 mm4DePuy SynthesDHS/DCS SystemSurgical Technique
System OverviewDCS plate With DCP holesStainless steel or TAN6 to 22 holesBarrel length: shortThickness: 5.4 mmWidth: 16 mmFixation with cortex screws B 4.5 mmDHS/DCS Compression ScrewUsed together with the DHS and DCS plates to compressthe femoral fragments on the proximal and distal sidesof the fracture. Stainless steel or TAN Inner hexagon for Hexagonal Screwdriver(314.120 and 314.270) Length 36 mmDHS/DCS Locking DeviceUsed for locking the sliding mechanism of the DHSScrew or the DHS Blade. Stainless steel or TAN Inner hexagon for Torque-indicating Screwdriver(338.560) Length 35 mmSurgical TechniqueDHS/DCS System DePuy Synthes5
DHS System. The appropriate solutionfor proximal femoral fractures.Modular SystemThe Dynamic Hip System (DHS) from Synthes consists ofthe following options: DHS Screw or DHS Blade Standard plates or LCP plates Locking Trochanter Stabilizing Plate (LTSP)Less cut-outin osteo porotic boneDHS BladeIncreased rotational stabilityThe shape of the blade leads to improved rotational stability of the femoral head-neck fragment, which is vitalfor reducing the risk of cut-out, delayedunion and varus angulation in unstabletrochanteric fractures.1rotational stabilitybone compactionno rotational stabilityno bone compactionDHS BladeDHS ScrewBetter anchorage in the femoral headThe specially designed tip of the blade allows for compaction of the bonewhen the blade is inserted. This compaction leads to improved anchorage ofthe implant in the femoral head, whichis beneficial especially in osteoporoticbone.2Increased support surfaceThe weight-bearing surface of the DHSBlade is greater compared to the surface of the conventional DHS Screw andcan therefore take greater loads. Alarger surface means less pressure fromthe implant onto the bone and less riskfor cut-out.6DePuy Synthes DHS/DCS System Surgical Technique
Locking TrochanterStabilizing Plate (LTSP)Fixation of unstablefractures Acts as lateral support. Reduces excessive secondary fracture impaction and medialization ofthe femoral shaft. Reduces varus angulationand limb shortening. Fixates the greater trochanter, restoring thebiomechanical functionof the gluteus medius.Minimally invasiveapproachLCP DHS plateMinimally invasive approachBetter fixation on the shaft and lower risk of screw pullout allow for the use of a shorter plate, resulting in: Shorter skin incision Shorter surgical procedure Less blood lossConventional screwsFacilitated fixation on the shaft The angular stability prevents the DHS plate frombeing pulled out. Locking screws cannot loosen.Locking screwsbigger resistance areasmall resistance areaSurgical TechniqueDHS/DCS System DePuy Synthes7
Indications and ContraindicationsDHSIncluding all combinations of DHS Screw, DHS Blade,DHS plate with DCP holes, LCP DHS plate and LCP DHSwith collar.Indications DHS Pertrochanteric fractures of type 31-A1 and 31-A2 Intertrochanteric fractures of type 31-A3 Basilar neck fractures 31-B(DHS Screw in conjunction with an antirotation screw) Subtrochanteric fractures31 A1 Wey31-A131-A231-A331-B131-B231-B3Contraindications DHS The DHS is not to be used in cases where there is ahigh incidence of: Sepsis Malignant primary or metastatic tumors Material sensitivity Compromised vascularityRecommendations DHS DHS Blade: for osteoporotic patients DHS Screw B 14 mm: for revisions ofDHS Screws B 13 mm LCP DHS: for the use of shorter plates, especially in thecase of femoral neck fractures For certain subtrochanteric fractures, a 95º DCS plate isrecommended.Trochanter Stabilizing PlateIndications LTSP/ULTSP/TSP Unstable pertrochanteric fractures of type 31-A2 and31-A3, especially multifragmentary fractures witha separated or longitudinally split greater trochanter8DePuy Synthes DHS/DCS System Surgical Technique
DCSIndications DCS Proximal femur: Very proximally located, purely sub trochanteric fractures of types 32-A and 32-B Distal femur: Fractures of type 33-A (extra-articular, supracondylar) and fractures of type 33-C (fully articular fractures)33-A133-A233-A3Contraindications DCS Pertrochanteric fractures or trochanteric fractures withsubtrochanteric expansion (31-A3)33-C133-C2Surgical Technique33-C3DHS/DCS System DePuy Synthes9
Clinical CasesPertrochanteric fracturesSpecial surgical considerations: Implant of choiceRecent metanalysis has shown that the DHS tends tobe statistically superior to intramedullary devices for trochanteric fractures.3,4 Further studies are required todetermine whether different types of intramedullarynails produce similar results, or whether intramedullarynails are advantageous for certain fracture types (e.g.sub trochanteric fractures).4 Prevention of cut-out: correct placement of thescrewThe correct placement of the DHS Screw or Blade hasshown to be one of the main success factors to preventimplant cut-out. The device should ideally be positioned in a center-center position in the femoral headand within 5 mm of subchondral bone.5, 6 See surgicaltechnique page 15.80 year old female,fracture 31-A2.2,preoperativepostoperative3 month follow-up81 year old female,fracture 31-B2.1,preoperativepostoperative3 month follow-upFemoral neck fracturesSpecial surgical considerations: Implant of choiceFor unstable basicervical fractures, the DHS seems biomechanically superior to three cannulated screws.7Never theless, operations of cervical hip fractures with a dynamic hip screw or three parallel screws seem togive similar c linical results.8 Emergency treatmentA femoral neck fracture should be treated surgicallywithin 6 hours of admission whenever possible. Elderlypatients who had surgery within 12 hours 9 or evenwithin 24 hours10 have a significantly lower mortalityrate. Antirotation screw for DHS ScrewIf the DHS Screw is used, an additional antirotationscrew should be placed parallel to the DHS Screw. Inthis case, the DHS Screw needs to be placed more caudally than normal. With the DHS Blade, rotational stability is achieved without an antirotation screw.11DePuy Synthes DHS/DCS System Surgical Technique
DHS Implantation1. Preoperative planningThe size and angle of the plate as well as the length ofthe DHS Blade or Screw can be determined preoperatively by using the DHS Goniometer (Art. No.034.000.185).Note: If the DHS Blade is from 65 to 75 mm, a DHSplate with short barrel should be used to allow forsufficient dynamization.Surgical TechniqueDHS/DCS System DePuy Synthes11
DHS Implantation2. Position patientPlace the patient in a supine position on the operatingtable.3. Reduce fractureIf possible, reduce the fracture under the image inten sifier by means of traction, abduction and internal rotation.4. AccessMake a straight lateral skin incision of approximately15 cm in length, starting two finger-widths proximal tothe tip of the greater trochanter.Split the iliotibial tract lengthwise. Detach the m. vastuslateralis dorsally to the intramuscular membrane, retractventrally and, if necessary, make a slight notch in themuscle in the region of the innominate tubercle. Exposethe proximal femoral shaft without retracting the periosteum.11DePuy Synthes DHS/DCS System Surgical Technique
5. Insert anteversion wireInstrument292.200Kirschner Wire B 2.0 mm with trocartip, length 150 mmDetermine the femoral neck anteversion by inserting anew Kirschner wire anterior to the femoral neck.In the case of unstable fractures, insert several Kirschnerwires into the femoral head to temporarily stabilize the reduced fragments.6. Insert guide wireInstruments338.000DHS/DCS Guide Wire B 2.5 mm338.005DHS Angled Guide 130 338.010DHS Angled Guide 135 338.020DHS Angled Guide 140 338.030DHS Angled Guide 145 338.040DHS Angled Guide 150 Insert a new DHS/DCS guide wire at the desired anglewith the correct angled guide. The guide wire should beplaced in the middle of the femoral head and should extend into the subchondral bone.Check the position of the guide wire in both AP and mediolateral positions.Surgical TechniqueDHS/DCS System DePuy Synthes11
DHS Implantation7. Determine length of DHS Screw /DHS BladeInstrument338.050DHS/DCS Direct Measuring DeviceRead the length of the DHS Screw or Blade directly offthe guide wire with the measuring device.If the guide wire is inserted into the subchondral bone remove 10 mm from the measurement.Example: If you read 110 mm on the direct measuring device, the measured length of the implant is100 mm.11DePuy Synthes DHS/DCS System Surgical Technique
8. Ream for insertion of DHS Screw/DHS BladeA Instruments for DHS Screw338.130DHS Triple Reamer, completeConsisting of:338.100Drill Bit B 8.0 mm338.110DHS Reamer338.120Nut, knurledAlternative instrument for short barrel plates(for DHS screw/blade 75 mm)338.440DHS ReamerB Instruments for DHS Blade03.224.009Triple Reamer for DHS Blade, completeConsisting of:03.224.003Drill Bit B 6.0/10.5 mm338.110DHS Reamer338.120Nut, knurledAlternative instrument for short barrel plates(for DHS screw/blade 75 mm)338.440DHS ReamerAssemble the triple reamer. Slide the reamer over thedrill bit until it clicks into place.Set the triple reamer at the length of the implant selected (100 mm in the example).Secure the reamer by tightening the knurled nut.Surgical TechniqueDHS/DCS System DePuy Synthes11
DHS ImplantationReam down to the stop. When reaming in dense bone,use of continuous irrigation is recommended to preventthermal necrosis.Control guide wire migration during reaming. Removetriple reamer.Check reaming depth under fluoroscopy during reaming.Precaution: It is recommended that the femoral headis temporarily fixated to prevent any inadvertent rotation.Reinsertion of the guide wireIf the guide wire is removed accidentally it should be re inserted. To reinsert the wire push the centering sleeveinto the reamed hole and slide an inverted DHS Screw orDHS Blade into the sleeve. The guide wire can now bereplaced in its original position.11DePuy Synthes DHS/DCS System Surgical Technique
Insertion – DHS Screw9a. Tap for DHS ScrewInstruments338.320DHS/DCS Centering Sleeve338.170DHS/DCS TapMount the centering sleeve from the side onto the tapand lock it into place by turning the inner sleeve clockwise against the outer sleeve.Tap to the measured length. Check insertion depth.Warning: Tap only dense, hard femoral bone. Do nottap o steoporotic bone.Note: For the standard insertion technique, consultthe quick step technique guide 035.000.080 (9a–11).Surgical TechniqueDHS/DCS System DePuy Synthes11
Insertion – DHS Screw10a. Screw in DHS ScrewInstruments338.310Connecting Screw338.300DHS/DCS Wrench for One-StepInsertion Technique (for conventionalDHS Screws)or338.302338.320DHS/DCS Wrench for One-Step Insertion with octagonal couplingDHS/DCS Centering SleeveInsert the connecting screw into the wrench, slide an appropriate DHS plate onto it and connect the DHS Screwto the wrench. For DHS screws shorter than or equal to75 mm, take a DHS plate with short barrel. Mount thecentering sleeve onto the wrench.Warning: To avoid damaging the instruments andthe implant, tighten the connecting screw securely.Slide the assembled instrument over the guide wire andpush the centering sleeve into the pre-drilled hole.Insert the screw to the desired depth.Turn the handle of the wrench until it lies in thesame plane as the femoral shaft. Only in this positioncan the plate be slid over the laterally flattened shank ofthe DHS Screw.Check insertion depth.11DePuy Synthes DHS/DCS System Surgical Technique
Insertion – DHS Blade9b. Hammer in the DHS BladeInstruments03.224.001Insertion Instrument for DHS Blade03.224.007Connecting Screw for Insertionof DHS Blade338.320DHS/DCS Centering SleeveInsert the connecting screw into the insertion instrumentand thread it into the DHS blade. Fully tighten the assembly.Slide the appropriate DHS plate onto the insertion instrument and connect the DHS Blade to the insertion instrument. For DHS blades shorter than or equal to 75 mm,take a DHS plate with short barrel.Warning: Be sure that the DHS Blade is unlockedbefore you insert it.Mount the centering sleeve onto the insertion instrument and insert the DHS Blade with slight hammering.Check insertion depth.Warning: The insertion instrument should not beused for the extraction of the DHS Blade.Surgical TechniqueDHS/DCS System DePuy Synthes11
Insertion – DHS Blade10b. Orient the DHS plate on thefemoral shaftOnce the DHS Blade has been inserted to the correct position, the centering sleeve can be removed. The platecan then be slid over the shaft of the DHS Blade.Due to the free rotation of the blade part relative to theshaft part, the DHS plate can be easily aligned to thefemoral shaft.11 Impact DHS plate onto the boneInstruments338.280or338.140DHS/DCS Impactor, for One-StepInsertion TechniqueDHS/DCS ImpactorThe plate can be impacted onto the bone with one ofthe two impactors.22DePuy Synthes DHS/DCS System Surgical Technique
12. Fix the DHS plate onto the shaftRemove all the insertion instruments and the guide wire.Discard the guide wire. Then fix the plate to the femoralshaft.A Cortex screws for the conventional DHS plateInstruments323.460Universal Drill Guide 4.5/3.2310.310Drill Bit B 3.2 mm319.010Depth Gauge314.150Screwdriver Shaft, hexagonalUse the drill guide and the drill bit to drill holes in a neutral position through the plate holes. Insert self-tapping 4.5 mm cortex screws of appropriate length.Surgical TechniqueDHS/DCS System DePuy Synthes22
Insertion – DHS BladeB Locking screws for the LCP DHS plateInstruments323.042LCP Drill Sleeve 5.0, for Drill BitsB 4.3 mm310.430LCP Drill Bit B 4.3 mm with Stop511.771or 511.774Torque Limiter, 4.0 Nm314.119Screwdriver Shaft Stardrive 4.5/5.0,SD25, self-holdingor314.152397.705Screwdriver Shaft 3.5, hexagonal,self-holdingHandle for Torque LimiterCarefully screw the LCP drill sleeve into the desired LCPhole until it is gripped completely by the thread.Drill the screw hole using the drill bit.Read the screw length directly from the laser mark onthe drill bit.Insert the 5.0 mm self-tapping locking screws with a4 Nm torque limiter.In case a trochanter stabilizing plate is used Use a plate with 4 or more holes. Leave the first and the third stem hole of the plateempty.22DePuy Synthes DHS/DCS System Surgical Technique
13. O nly for DHS Blade: lock theimplantInstruments03.224.004Screwdriver Shaft Stardrive, SD15511.770Torque Limiter, 1.5 Nm397.705Handle for Torque LimiterThe DHS Blade must be locked to be made rotationally stable.Assemble the screwdriver shaft, torque limiter and the handle for torque limiter.Insert the assembled instrument through the cannulationof the DHS Blade and tighten to a torque of 1.5 Nm.Turn the screwdriver clockwise to lock the blade. TheDHS Blade is now rotationally stable.14. Option for DHS Screw: DHS/DCScompression screwInstrumentsX80.990DHS/DCS Compression Screw314.150Screwdriver Shaft, hexagonalX 2: stainless steelX 4: TANFragment compression may also be achieved using DHS/DCS compression screws.Warning: It is not recommended that compressionshould be applied in osteoporotic bone.Surgical TechniqueDHS/DCS System DePuy Synthes22
Insertion – DHS Blade15. O ption for young patients: blockthe dynamizationInstrumentsX80.960DHS Locking Device511.774Torque Limiter, 4 Nm314.150Screwdriver Shaft, hexagonal397.706Handle for Torque LimiterX 2: stainless steelX 4: TANThe DHS locking device can be used in young patients toprevent the dynamization of the DHS Screw. This avoidsany shortening of the leg.Warning: The locking device also fits into the DHSBlade but must not be used in osteoporotic patients,due to the increased risk of cut out.The DHS Screw chosen must be 10 mm shorter than thelength of the reamed hole.Example Measurement: 110 mm Reaming setting: 100 mm Screw length: 90 mmThe DHS Screw must then be advanced 10 mm deeper.Insert the locking device with a 4 Nm torque limitingscrewdriver. The device only works properly if it is completely inserted into the DHS plate barrel.22DePuy Synthes DHS/DCS System Surgical Technique
DHS RemovalA. Removal of DHS with DHS ScrewInstruments338.060DHS/DCS Wrench338.220Connecting Screw, longAfter removing the DHS plate, attach the wrench to theend of the DHS Screw using the connecting screw.Warning: Never use the insertion instruments forimplant removal.The wrench and connecting screw must fit the DHSScrew exactly. The connecting screw must be tightenedsecurely.Surgical TechniqueDHS/DCS System DePuy Synthes22
DHS RemovalB. Removal of DHS with DHS BladeInstruments03.224.005E
Staniel ss steel /TAN Length 65 – 145 mm Outer diameter 13 mm DHS Emergency Screw Stainless steel Length 50 –145 mm Outer diameter 14 mm Plates DHS plate with DCP holes Used for more than 25 years. Stainless steel / TAN Barrel angle 130 –150 2 to 20 holes Barrel length: standard and short Thickness 5.8 mm
Must be used with a Synthes Small Fragment LCP Instrument and Implant Set [105.434] or [145.434]. 323.050 323.053 323.054 323.055 241.901 241.903 Product Information Required Set 105.434 Small Fragment LCP Instrument and Implant Set or 145.434 Small Fragment LCP Instrument and Titanium Implant Set
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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 .
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