Aesculap OrthopaedicsTargon® F/T

Interlocking Nail Systemfor Femur and Tibia

Operation Technique

F/T

2

The Targon® interlocking nail system is the result of years of clinicalexperience in the application of interlocking nails combined withthe high technical competence of Aesculap. The implants are ana-tomically adapted and easy to implant thanks to simple and logicalinstrumentation.

Proven quality and modern manufacturing processes ensure excel-lent load-bearing capacity in all relevant dimensions. The drilledimplantation technique is supplemented by the drill-free techniquefor situations with a high degree of soft-parts damage, high bloodloss (polytrauma) or severe thoracic trauma.

For the slender nails to withstand alternating flexion loads, thenails and locking screws are made of high-strength titanium alloys– and can still be applied with the same instrument set.

To minimize stock-keeping requirements, for each of the two bones– femur and tibia – implants have been developed that can be usedin either the left or the right leg.

As a result, the Targon® interlocking nail system combines optimalanatomic adaptation, easy handling, biomechanical strength and‘last not least’ economy.

Priv. Doz. Dr. H.-W. StedtfeldCentre for Trauma Surgery, Nuremberg

August, 2008

for strong connections

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OP-Manual Femur

Operation Technique for Targon® “Femoral” Interlocking Nails

OP-Tisch Color

Patient Positioning

The patient is placed on the traction table ina supine position. Traction is exerted on theleg through a supra- or transcondylarSteinmann pin extension applied in the ORunder sterile conditions. The leg should beextended in abduction or neutral position.By means of a traction device or a thoraxbrace, the upper part of the body is shiftedto the opposite, healthy side. This positioningpermits reliable reduction and fixation. Theinclination of the upper body towards theopposite side permits easy access to thetrochanter major.

In certain cases extension can be achievedwith the help of a leather shoe (abductionand inclination!)

It is also possible to perform interlockingnailing without a traction table, if thepatient is in a lateral position. This positionis recommended in case of open fracturesand polytrauma (on a normal operationtable), i.e. in cases where an unreamed nailis indicated.

OP-Manual Femur

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Access

The area of the trochanter tip is approached by a 5 cm long skin incision proximally of the trochantermajor. The fascia lata and the attachment of theM. gluteus medius are split parallelly to the fibres.

Controlled by x-ray, the guide for the reamer isinserted at the medial incline of the trochantermajor, in direction of the center of the medullarycanal up to the guide plate sitting on the trochantertip.

In the axial beam path of the image intensifier thepoint of entry should be at the transition from themiddle to the dorsal third of the trochanter. In theanteroposterior beam path it should be at themediocranial border of the trochanter tip, so thatthe guide plate is placed on the trochanter withits half surface lying free. The reamer is nowmoved over the guide to open the medullary canal.

The diameter of the hole of entry corresponds tothe proximal outer diameter of the solid titaniumnail.

F1

F2 Reaming

After reduction, the guide wire for the intramedul-lary reamer is inserted into the medullary canal.The guide wire is guided past the fracture zoneand the thick end is driven centrally between thefemoral condyles into the compacted spongiosaabove the intercondylar notch. Using the flexibleintramedullary reamer, the intramedullary canal isdrilled open in steps of 0.5 mm (which is differentfrom the conventional Küntscher nailing) up to thecorticalis of the medullary isthmus. With interlok-king nailing it is not necessary to guide the nail allalong the corticalis of the diaphysis. The requirednail diameter equals the diameter of the lastreamer used minus 1 mm.

With distal fractures, a disproportion can resultbetween the curvature of the nail and theantecurvature of the proximal fragment of the

femoral shaft, which causes torsion of the slottednail. In such situations, one should choose a naildiameter that is 1.5 to 2 mm smaller than thediameter of the last reamer used.

Upon completion of the reaming procedure, theteflon tube is applied to replace the guide wirewith the spike for the nail. The teflon tube isremoved. The exact central positioning of the spikefor the nail is checked distally using the imageintensifier. The nail length equals to the differencebetween the total length of the spike (90cm) andthe length of the part which is overlapping of thebone. In case of comminuted fractures, the correctnail length is determined preoperatively on thehealthy femur with the help of the image intensi-fier and a x-ray scale.

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Assembling the targeting and insertion instrument

A nail of the suitable length and diameter ismounted on the combined proximal targeting and insertion instrument.

First the appropriate adapter for the nail is selected(A for nail diameters 8 – 11 mm; B for naildiameters 12 – 15 mm).

The adapter is inserted into the targeting instru-ment so that the arrow on the adapter points tothe arrow on the targeting instrument.

Next, the appropriate adapter screw is pushedthrough the targeting instrument and adapter,thus coupling the system (Table 1 + 2).

Now, the nail and the femoral targeting device aremanually connected with a tightening sleeve untilthe pins of the adapter fit into the grooves of thenail. The tightening sleeve is tightened with the socketkey. Important: The curvature of the nail, whichcan be used both right and left, must correspondto the physiological antecurvature of the femoralshaft.

F 3a

F 3b

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OP-Manual Femur

Inserting the nail

The nail is smoothly inserted with the hammer (in case of a reamed hollow nail over the spike).

Important:The hammer must always hit the inserter boss. Itmust never hit the targeting instrument becausethis would cause the targeting instrument todeform plastically and loose accuracy. The sameapplies should it be necessary to strike back thenail. To do this, always use the knock-out ball nextto the inserter boss, applying the knocking outinstrument and the slotted hammer. In this casethe knocking out instrument is connected with theknock-out ball of the targeting instrument. Neverknock out the nail by striking the hammer on theteflon handle of the targeting device.

Tap in the nail until the adapter approaches theentry of the medullary canal up to 1 cm, controlledby image intensifier.

F4

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F5 Interlocking

For proximal fixation the tissue protecting sleevewith an inner diameter of 8 mm (1 ring) is insertedinto the diagonal hole of the targeting instrumentand pushed through the soft tissue until it reachesthe lateral side of the trochanter major.

The inner drill sleeve, which has an inner diameterof 6 mm (2 rings), is inserted into the tissueprotecting sleeve.

The bone is marked using the trocar. The necessarydrilling and the measuring of the length of thescrew are both done through the inner drill sleeve.The length is indicated on the screw scale at theedge of the drill sleeve. Precise measurement oflength is possible only if the inner drill sleevetouches the bone (verification with imageintensifier possible!). After removal of the drillsleeve, the appropriate interlocking screw isinserted through the tissue protecting sleeve.

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OP-Manual Femur

F6

F7 F8

After removal of the targeting instrument, theproximal end of the nail is closed with theappropriate closure screw to prevent bonyingrowth (Table 1 + 2).

Distal fixation is done free-hand (similar to thelower leg, Fig. T6) at the lateral side of the upperleg.

Important: The image intensifier must be adjusted so that thenail hole through which fixation is to be perfor-med is centered and circular in the image on themonitor.

Unreamed nailing

In case of unreamed nailing, the solid titaniumnail and the targeting device are connected in the same way. The length of the nail is measuredeither with a previously inserted nail spike asexplained above or preoperatively with a x-rayscale to be applied on the healthy femur usingimage intensifier. The interlocking of the solidtitanium nail is performed as described above.

Nail removal

The patient is placed in a semi-lateral position. The fixation screws are removed first. The accessincision is made in the old scar area. The upper end of the nail is exposed and the closure screwremoved. To remove the nail, the appropriateadapter is screwed into the proximal nail threadand the nail is extracted with the knocking-outinstrument and the slotted hammer (Table 1 + 2).

9

ø 12-15 mmø 10-11 mm

Femur “Universal”

A

A

ø 6 mmø 5 mm

ø 4.5 mmø 3.5 mm

ø 8 mm

ø 8 mm

B

B

ø 6 mmø 6 mm

ø 4 .5 mmø 4.5 mm

ø 10 mm

ø 10 mm

Adapter

Adapter screw

Interlocking screw prox.dist.

Drill prox.dist.

Closure screw

Knock-out adapter

ø 8-11 mm

Femur “Solid Titanium”

A

A

ø 6 mmø 4.5 mm

ø 4.5 mmø 3.5 mm

ø 8 mm

ø 8 mm

Adapter

Adapter screw

Interlocking screw prox.dist.

Drill prox.dist.

Closure screw

Knock-out adapter

Table 1

Table 2

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OP-Manual Tibia

Operation Technique for Targon® “Tibial“ Interlocking Nails

Positioning

The patient is placed on the traction table insupine position. Traction is exerted on theleg by means of a calcaneus extension. Theflexion of the knee must be at least 80°.

In order to get a good exposure of the frac-tured leg under image intensifier, the heal-thy leg is held upwards (with the help of aleg support), the hip and knee joint being in flexion.

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Access

A longitudinal skin incision is made between thetip of the patella and the tuberositas tibiae. Thepatella tendon is split longitudinally in the medialthird. Alternatively, access can be done mediallypast the patella tendon. After inserting a bluntretractor, the medullary cavity is opened with theopening reamer on the front side of the head ofthe tibia, after having mobilized Hoffa`s fat padstowards cranial.

Drilling

Once the fracture has been reduced, the guidewire is introduced into the medullary cavity. Theguide wire must be precisely centered distally. Theinsertion of the reamer with rotating reamer headincreases too much the entrance hole towardsdistal (attachment of the patella tendon). There-fore in a first step the reamer head is pushed intothe medullary cavity without any rotation.

In a variation from the conventional Küntscher(Kuentscher) nailing procedure, the medullarycavity is drilled only up to the corticalis of themedullary isthmus. Due to interlocking, it is notnecessary to guide the nail all along the corticalisof the diaphysis. The required nail diameter equalsthe diameter of the last reamer used minus 1 mm.

Upon completion of the drilling procedure, theteflon tube is used to replace the guide wire withthe nail spike. The required nail length equals thedifference between the total length of the nailspike (80 cm) and the length of that part of thespike which projects out of the bone.

Important: In case of comminuted fractures, the required naillength is determined preoperatively on the healthytibia, using an image intensifier and a x-ray scale.

T1 T2

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OP-Manual Tibia

Assembling the targeting andinsertion instrument

First the appropriate adapter is selected (A for nail diameters 8 – 11 mm, B for nail diameters 12 – 14 mm). The adapter is inserted into thetargeting instrument so that the arrow on theadapter points to the arrow on the targetinginstrument.

Next, the appropriate adapter screw is pushedthrough the targeting instrument and the adapter,thus coupling the system (Table 3 + 4).

Now a nail of appropriate length and diameter isconnected with the targeting device. The cambe-red, bevelled, proximal end of nail fits perfectly inthe fish-jaw-type groove of the adapter. After-wards, the adapter screw is tightened with thetightening sleeve using the socked key. Only in thiscase targeting accuracy for proximal interlockingcan be assured.

T 3a

T 3b

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Interlocking

For proximal interlocking the tissue protectingsleeve with an inner diameter of 8 mm (1 ring) isinserted into the hole of the targeting instrumentand pushed through the soft tissue via a 1.5 cmlong skin incision until it reaches the medialcorticalis of the tibia head. The inner drill sleeve,which has an inner diameter of 6 mm (2 rings), isinserted into the tissue protecting sleeve andpushed forward to the bone (Fig. T5a). Thecorticalis is marked with the trocar and theinterlocking hole drilled. The screw is measuredthrough the inner drill sleeve. The inner drill sleeveis removed and the appropriate interlocking screwis inserted through the tissue protecting sleeve(Fig. T5b).

After removal of the targeting instrument theproximal end of the nail is closed with theappropriate closure screw to avoid bony ingrowth(Table 3 + 4).

Inserting the nail

Important: The hammer must always hit the inserter boss. Itmust never hit the targeting instrument, becausethis would cause the targeting instrument todeform plastically and loose accuracy. The sameapplies should it prove necessary to knock out thenail. To do this, always use the knock-out ball nextto the inserter boss, the knocking out instrument,and a slotted hammer. The knocking out instru-ment is coupled to the knock-out ball at the

bottom of the targeting instrument (as shown inFig. F4). Never knock out the nail by striking thehammer on the teflon handle of the targetingdevice!

Tap in the nail under image intensifier, until theproximal nailend is at the same height as thecorticalis of the tibia head.

T 5a

T 5b

T4

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OP-Manual Tibia

Interlocking is done free-hand at the medial sideof the lower leg. The image intensifier must be adjusted so that the nail hole through whichinterlocking is done appears centered and circularin the image on the monitor. The scalpel with thelong handle is held with its tip in the beam pathuntil the x-ray shadow of the tip appears in themiddle of the interlocking hole. Thus, the point forincision is localised. Make a 1.5 cm long skin incision. The subcutaneous tissue is split bluntlydown to the bone with scissors.

Under x-ray beam, the tip of the trocar is guidedto the point where it is in the middle of the inter-locking hole. The tip is then pressed firmly againstthe bone and the trocar is straightened so that itpoints to the middle of the camera housing. Thebone is thoroughly marked by slightly rotating thetrocar while gently tapping it with the hammer.The tip of the twist drill is held against the markedhole (repeat check with image intensifier) and isdrilled forward through both corticalia and thenail hole. When drilling has been done properly,the interlocking hole should appear considerablybrighter in the x-ray image than before. Measuringof the screw length and insertion of the appropriatescrew complete the distal interlocking procedure.The screw is placed correctly if its x-ray shadowdisappears in the shadow of the nail. Afterwards,the proper fit and correct length of the interlockingscrew should always be verified in the a.p. beampath. To reduce the amount of radiation, this well-tried freehand technique with trocar and drill canbe made safer with the help of a targeting trocarand a radiolucient drill attachment.

T6

T7 Nail removal

The interlocking screws are removed first. Thelongitudinal incision and splitting of the patellatendon are carried out in the old position. Theproximal nail end is exposed and the closure screwremoved. To remove the nail, the appropriate knock-outadapter is screwed into the proximal nail threadand removed with the attached extractioninstrument and the slotted hammer (Table 2).

Unreamed nailing

In case of unreamed nailing, the solid titaniumnail and the targeting instrument are connected inthe same way. The length of the nail is determinedeither with a previously inserted nail spike asexplained above, or preoperatively, by applying ax-ray scale on the healthy tibia under imageintensifier. The solid titanium nail is interlocked as describedabove.

T8

15

ø 10-11 mmø 9 mm

Tibia “Universal”

A

A

ø 4.5 mmø 4.5 mm

ø 3.5 mmø 3.5 mm

ø 8 mm

ø 8 mm

A

A

ø 5 mmø 5 mm

ø 3.5 mmø 3.5 mm

ø 8 mm

ø 8 mm

ø 12-14 mm

B

B

ø 5 mmø 5 mm

ø 3.5 mmø 3.5 mm

ø 10 mm

ø 10 mm

Adapter

Adapter screw

Interlocking screw prox.dist.

Drill prox.dist.

Closure screw

Knock-out adapter

ø 8-11 mm

Tibia “Solid Titanium”

A

A

ø 4.5 mmø 4.5 mm

ø 3.5 mmø 3.5 mm

ø 8 mm

ø 8 mm

Adapter

Adapter screw

Interlocking screw prox.dist.

Drill prox.dist.

Closure screw

Knock-out adapter

Table 3

Table 4

Brochure No. O11302

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Aesculap AG

Am Aesculap-Platz78532 TuttlingenGermany

Phone +49 7461 95-0Fax +49 7461 95-2600

www.aesculap.de

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