Cannulated Pediatric OsteotomySystem (CAPOS). A single system ofosteotomy blade plates and cannulatedinstrumentation.
Technique Guide
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page C1
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page C2
Introduction
Surgical Technique
Product Information
Table of Contents
Cannulated Pediatric Osteotomy System (CAPOS) 2
AO Principles 3
Indications 4
Preoperative Planning 5
Place Guide Wire 6
Insert Chisel 9
Perform Osteotomy 12
Insert Plate 13
Secure Plate 14
Postoperative Care and Cleaning Tip 15
Instruments 16
Set Lists 19
Image intensifier control
Synthes
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 1
Cannulated Pediatric Osteotomy System (CAPOS)
The Cannulated Pediatric Osteotomy System (CAPOS) combines implants and instruments in one convenient system. This system offers the advantages of the osteotomyblade plates and cannulated instrumentation. Osteotomyplates provide ease of reduction and good rotational stabilitywhile maintaining bone stock. Cannulated instruments workover a guide wire for precise placement and safety.
Features– Osteotomy plates are offered in a variety of sizes:
infant, toddler, child, and adolescent
– Cannulated chisels and guide wires simplify surgical technique
– Saw guides improve the accuracy of the osteotomy and reduce surgical time
– Two graphic cases provide organization and storage for the complete system
2 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 2
AO Principles
The fundamental aim of long bone osteotomy is to alteranatomy, including axial and rotational alignment. Throughvarus, valgus and/or rotational osteotomy, limb function, patient mobility, and comfort can be improved, while subluxation, dislocation and eventual degeneration of thehip are prevented.
The Cannulated Pediatric Osteotomy System (CAPOS) adheres to the basic principles of internal fixation developedby the AO.1 Osteotomy plates and screws allow reduction ofthe osteotomy, provide stable internal fixation, preserve theblood supply, and in certain cases permit early mobilization.
1. T.P. Rüedi and W.M. Murphy, ed. AO Principles of Fracture Management. New York: Thieme, 2000.
Synthes 3
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 3
The CAPOS System is intended for use in infants, toddlers,children, adolescents, and small-stature adult patients.
Specific indications include:– Intertrochanteric derotation and varus osteotomies
(Osteotomy Plates—Infant, Toddler, Child, Adolescent, and Bifurcated)
– Intertrochanteric valgus osteotomies(95° Condylar Plates—Adolescent and Small Stature Adult)
– Femoral neck and pertrochanteric fractures(130° Angled Blade Plates—Adolescent and Small Stature Adult)
4 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
Indications
4 Synthes Cannulated Pediatric Osteotomy System (CAPOS)
Please see the package insert for a complete list of contraindications, warnings, precautions, and adverse effects.
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 4
1Preoperative planning
Preoperatively evaluate and plan the surgical procedure. Determine the appropriate osteotomy plate by blade length,angle, and displacement. Note the corresponding guide wirediameter. The AO Preoperative Planner (6000) assists in selection of the appropriate osteotomy plate; it contains Müller’s classic description2 of osteotomy surgical technique. The osteotomy plates are available with various offsets. Theplate offset is designed to create “medialization” of the distal fragment to restore the proper mechanical axis of thelong bone. In a valgus or purely derotational osteotomy, a smaller offset is typically best. In a large, angled varus osteotomy, a larger offset is often best.
Note: The technique described in this guide is for a varusderotational osteotomy of the proximal femur, utilizing a 90° osteotomy blade plate. Steps may differ for alternativeosteotomy techniques or fracture repair.
2Position the patient
Surgery is typically performed on a radiolucent operatingtable. Position the patient for AP views of the hip underimage intensification. Obtain lateral views of the hip by flexing and abducting the leg.
3Surgical approach
Use a standard lateral approach to the proximal femur.3
Synthes 5
Preoperative Planning
2. T.P. Rüedi and W.M. Murphy, ed. AO Principles of Fracture Management. New York: Thieme, 2000.
3. Raymond T. Morrissy. Atlas of Pediatric Orthopaedic Surgery.Philadelphia: J. B. Lippincott Company, 1992.
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 5
Place Guide Wire
6 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
4Place guide wire
Instruments
314.070 Small Hexagonal Screwdriver
333.683 Adjustable Wire Guide
A guide wire may be held on the anterior side of the femoral neck to assist in determination of the direction that the definitive guide wire will take.
Set the adjustable wire guide to the angle determined in thepreoperative plan, using the small hexagonal screwdriver. Forexample, if a 30° varus osteotomy is planned, using a 90° osteotomy plate, then the adjustable wire guide should beset at 120° (= 30°+90°).
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 6
Synthes 7
Choose the guide wire that correspondswith the cannulated chisel and osteotomyplate selected.
Load the guide wire through the adjustable wire guide. Insert the wireinto the femoral neck (Figures 1, 2 and3a). Optimal placement of the guidewire is inferior in the neck, above thecalcar region as seen in the AP view. Inthe lateral view, the guide wire shouldbe located centrally in the femoral neck.
Verify final placement of the guide wire in both views, under image intensification (Figure 3b).
Note: Be aware that marginal placementof the guide wire could cause the chiseland osteotomy plate to penetrate themedial, anterior or posterior cortex.
Direct Cannulated Saw Implant Size Guide Wire Measuring Chisel Guide Device
Infant 292.722 (1.6 mm) 319.17 332.173 332.356
Toddler 292.652 (2.0 mm) 319.21 332.174 332.355
Child/Adolescent 292.652 (2.0 mm) 319.21 332.175 332.354
Figure 1 Figure 2
Figure 3a Figure 3b
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 7
Place Guide Wire continued
4Place guide wire continued
Instrument
319.17 Cannulated Screw (Direct) Measuring Device or 319.21
Slide the appropriate direct measuring device over the guide wire. Determine and record the insertion depth of the guide wire. This measurement is critical in determiningappropriate chisel insertion in the next step. The properblade length of the osteotomy plate will typically be the next size smaller than the measurement taken with the direct measuring device.
8 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 8
Insert Chisel
5Insert chisel
Instruments
332.09 Chisel Guide
332.173– Cannulated Chisels332.175
Place the cannulated chisel in the chisel guide and over the guide wire. The chisel and chisel guide assembly can be rotated in the anterior or posterior direction to achieve flexionor extension, respectively. Should a neutral position be desired,the chisel guide should align with the femoral shaft.
Anterior angulation = flexion at the osteotomy sitePosterior angulation = extension at the osteotomy site
Synthes 9
Neutral
Flexion
Extension
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 9
Insert Chisel continued
5Insert chisel continued
Instrument
319.17 Cannulated Screw (Direct) Measuring Device or 319.21
399.42 Hammer
Correct insertion depth can be calculated by taking themeasurement obtained with the direct measuring device andsubtracting the osteotomy plate blade length. This figureshould correspond with the appropriate chisel insertiondepth as measured by the calibrated window of the chisel.
Note: Direct measuring device (DMD) measurement (see Step 4) minus implant blade length equals insertionmeasurement on chisel window (see example).
Use the hammer to drive the cannulated chisel along theguide wire and into the femoral neck. During hammering of the chisel, take care to keep the chisel properly trackingover the guide wire and avoid any bending force on the wire.It is often advantageous to intermittently withdraw the chisel during insertion.
10 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
Example:44 mm (DMD measurement)
–38 mm (implant blade length) 6 mm
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 10
During chisel insertion, verify proper tracking over the guide wireby periodically checking progress with image intensification.
Monitor insertion depth by observing the position of the guidewire in the calibrated window of the chisel. Stop insertiononce the predetermined insertion measure ment is achieved.
Synthes 11
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 11
Perform Osteotomy
6Perform osteotomy
Instruments
332.173– Cannulated Chisels332.175
332.20 Slotted Hammer
332.354, Saw Guides332.355 or 332.356
Before beginning the osteotomy, ensure that the chisel isloosened slightly, with a reverse impact with the slotted hammer.
Insert rotation guide wires above and below the osteotomysite in a manner that will not interfere with plate placement.Protect the medial soft tissues with retractors.
Slide the appropriate saw guide on the inferior side of thecannulated chisel. With image intensification, check that thesuperior cut will be below the level of the femoral neck. Using appropriate power equipment and saw, perform thefirst osteotomy cut parallel to the saw guide (Figure 1).
Using the cannulated chisel as a lever, carefully tilt the proximalbone fragment to the desired position. Make the second cutstarting at the same point on the lateral cortex, but directedperpendicular to the femoral shaft (Figure 2). Remove thewedge of bone from the distal segment of the femur.
Note: In some cases, particularly of neuromuscular disease,the bone may be extremely soft.
Alternative techniqueThe first osteotomy cut may be made at a right angle (perpendicular) to the femoral shaft, at the level determinedfrom the preoperative plan. The second cut is then made tothe distal bone fragment and the wedge of bone is removed.4
If this technique is chosen, the saw guide may still be used,exercising the proper degree of caution to prevent sawincursion into the femoral neck.
12 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
4. T.P. Rüedi and W.M. Murphy, ed. AO Principles of Fracture Management. New York: Thieme, 2000.
Figure 1
Figure 2
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 12
Insert Plate
7Insert plate
Instruments
321.20 Ratchet Wrench
332.21 Impactor
332.352 or Inserter /Extractors332.353
333.060, Triangular Positioning Plates333.070 or 333.080
398.811*, Plate Holding Forceps with swivel foot398.812* or (size 0, 1 or 2)398.813*
Carefully remove the cannulated chisel, saw guide, andguide wire.
Insert the selected osteotomy plate by hand, ensuring thatthe plate follows the path created by the chisel. It is best toavoid using a hammer during initial insertion, so that onecan feel the plate tracking properly along the chisel path.Verify with image intensification that the plate is followingthe chisel track.
After the plate has been inserted sufficiently, affix the properinserter/extractor and tighten with the ratchet wrench. Thiswill provide control of the proximal fragment. Continue insertion using the hammer (Figure 3).
Reduce the proximal and distal segments. Provisionally clampthe distal segment to the plate, using plate holding forceps.Check varus, flexion, and extension alignment. Remove theinserter/extractor. Use the impactor to completely insert theplate into the femoral neck (Figure 4).
Use the previously placed guide wires to adjust rotation. Normalanteversion is approx imately 20°, but other anteversion valuesmay be appropriate. The triangular positioning plates can beused to measure rotation.
Examine osteotomy alignment with image intensification.
Synthes 13
Figure 3
Figure 4
*Also available
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 13
Secure Plate
8Secure plate
Instrument
332.352 or Inserter /Extractors332.353
Secure the plate to the femoral shaft using standard DCP screw insertion technique, selecting the appropriate size cortex screws.
The final result should be verified with AP and lateral views.
14 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
332.352 and plate
332.353 and plate
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 14
Postoperative Care and Cleaning Tip
Postoperative care
Postoperative care depends on many factors and needs to be individualized by the surgeon. Bed rest, spica casting, ormobilization with partial weight bearing is dependent uponpatient age, compliance, and diagnosis.
Cleaning tip
Instruments
319.26 or Cleaning Brushes (1.75 mm or 2.1 mm)319.27
319.35 or Cleaning Stylets (1.6 mm or 2.0 mm)319.36
Cleaning the cannulation of the chisels is imperative to prevent accumulation of debris. Instruments can be cleanedintraoperatively using the cleaning stylets and postoperativelyusing the cleaning brushes.
Synthes 15
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 15
Selected Instruments from CAPOS Instrument Set (105.364)
319.26 1.75 mm Cleaning Brush319.27 2.1 mm Cleaning Brush
319.35 1.6 mm Cleaning Stylet319.36 2.0 mm Cleaning Stylet
332.09 Chisel Guide, with adjustable angle
332.173 Cannulated Chisel, for use with Infant Osteotomy Plates
332.174 Cannulated Chisel, for use with Toddler Osteotomy Plates
332.175 Cannulated Chisel, for use with Child and Adolescent Osteotomy Plates
16 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 16
332.352 Inserter/Extractor, for bifurcated, infant, and toddler osteotomy plates
332.353 Inserter/Extractor, for Child and Adolescent Osteotomy Plates
332.354 Saw Guide, for Child/Adolescent Osteotomy Plates
332.355 Saw Guide, for Toddler Osteotomy Plates
332.356 Saw Guide, for Infant Osteotomy Plates
Synthes 17
332.21 Impactor
Bottom Side
Bottom Side
Bottom Side
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 17
Selected Instruments from CAPOS Instrument Set (105.364) continued
333.060 90° /50° /40° Triangular Positioning Plate
333.070 80° /70° /30° Triangular Positioning Plate
333.080 100°/60° /20° Triangular Positioning Plate
333.683 Adjustable Wire Guide, for 1.6 mm to 2.0 mm Guide Wires
18 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 18
Cannulated Pediatric Osteotomy System (CAPOS) Instrument Set (105.364)
Graphic Case690.364 Cannulated Pediatric Osteotomy System
Instrument Set Graphic Case
Instruments292.20 2.0 mm Kirschner Wire, 150 mm, trocar
point, 1 pkg. of 10
292.652 2.0 mm Non-Colored Threaded Guide Wire, 230 mm, spade point, 4 ea.
292.722 1.6 mm Non-Colored Threaded Guide Wire, 150 mm, spade point, 4 ea.
310.25 2.5 mm Drill Bit, quick coupling, gold, 110 mm, 2 ea.
310.31 3.2 mm Drill Bit, quick coupling, 145 mm, 2 ea.
311.32 Tap for 3.5 mm Cortex Screws, gold, 110 mm
311.44 T-Handle, with quick coupling
311.46 Tap for 4.5 mm Cortex and 4.5 mm Shaft Screws, 130 mm, 57 mm tap depth
312.20 2.0 mm Parallel Drill Guide and Drill Sleeve
314.03 Small Hexagonal Screwdriver Shaft, quick coupling
314.070 Small Hexagonal Screwdriver, 2.5 mm width across flats
314.09 Holding Sleeve (for small hexagonalscrewdrivers)
314.11 Holding Sleeve (for large hexagonalscrewdrivers)
314.15 Large Hexagonal Screwdriver Shaft, quick coupling
314.27 Large Hexagonal Screwdriver
319.04 Depth Gauge, for 2.7 mm and small screws
319.10 Depth Gauge, for large screws
319.17 Cannulated Screw (Direct) Measuring Device, for use with 4.5 mm Cannulated Screws
319.21 Cannulated Screw (Direct) Measuring Device, for use with 7.0 mm Cannulated Screws
Synthes 19
Note: For additional information, please refer to package insert.
For detailed cleaning and sterilization instructions, please refer tohttp://us.synthes.com/Medical+Community/Cleaning+and+Sterilization.htmor to the below listed inserts, which will be included in the shipping container:—Processing Synthes Reusable Medical Devices—Instruments, Instrument Trays
and Graphic Cases—DJ1305—Processing Non-sterile Synthes Implants—DJ1304
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 19
Cannulated Pediatric Osteotomy System (CAPOS) Instrument Set (105.364) continued
20 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
Instruments continued
319.26 1.75 mm Cleaning Brush
319.27 2.1 mm Cleaning Brush
319.35 1.6 mm Cleaning Stylet
319.36 2.0 mm Cleaning Stylet
321.12 Articulated Tension Device, with gauge, span 20 mm
321.20 Ratchet Wrench, 11 mm width across flats
323.36 3.5 mm Universal Drill Guide
323.46 4.5 mm Universal Drill Guide
332.09 Chisel Guide, with adjustable angle
332.173 Cannulated Chisel, for use with Infant Osteotomy Plates
332.174 Cannulated Chisel, for use with Toddler Osteotomy Plates
332.175 Cannulated Chisel, for use with Child and Adolescent Osteotomy Plates
332.20 Slotted Hammer
332.21 Impactor
332.352 Inserter/Extractor, for bifurcated, infant, andtoddler osteotomy plates
332.353 Inserter /Extractor, for Child and AdolescentOsteotomy Plates
332.354 Saw Guide, for Child /Adolescent Osteotomy Plates
332.355 Saw Guide, for Toddler Osteotomy Plates
332.356 Saw Guide, for Infant Osteotomy Plates
333.060 90°/50°/40° Triangular Positioning Plate
333.070 80°/70°/30° Triangular Positioning Plate
333.080 100°/60°/20° Triangular Positioning Plate
333.683 Adjustable Wire Guide, for 1.6 mm to 2.0 mm Guide Wires
359.204 Locking Pliers
399.42 Hammer, 500 grams
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 20
Cannulated Pediatric Osteotomy System (CAPOS) Implant Set (105.365)
Graphic Cases and Trays60.108.010 Cannulated Pediatric Osteotomy System
Implant Graphic Case
Implants (in 60.108.010)3.5 mm Cortex Screws, self-tapping, 8 ea.
Length (mm) Length (mm)
204.814 14 204.824 24204.816 16 204.826 26204.818 18 204.828 28204.820 20 204.830 30204.822 22
115° Bifurcated Plates, 2 holes, 2 ea.
Blade Length (mm) Displacement (mm)
236.400 30 5236.430 35 5
90° Infant Osteotomy Plates, 2 ea. Blade Length (mm) Displacement (mm)
236.250 25 7236.260 32 7236.350 25 12236.360 32 12
90° Toddler Osteotomy Plates, 2 ea.
Blade Length (mm) Displacement (mm)
236.001 26 4236.002 32 4236.011 26 8236.012 32 8236.013 38 8
100° Toddler Osteotomy Plates, 2 ea.
Blade Length (mm) Displacement (mm)
236.101 26 4236.102 32 4236.103 38 4236.104 44 4236.111 26 8236.112 32 8236.113 38 8236.114 44 8
Synthes 21
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 21
Cannulated Pediatric Osteotomy System (CAPOS) Implant Set (105.365) continued
22 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide
Implants (in 60.108.010)4.5 mm Cortex Screw, self-tapping, 8 ea.
Length (mm) Length (mm)
214.816 16 214.826 26214.818 18 214.828 28214.820 20 214.830 30214.822 22 214.832 32214.824 24
80° Child Osteotomy Plates, 2 ea.
Blade Length (mm) Displacement (mm)
235.170 35 8235.190 45 8
90° Child Osteotomy Plates, 2 ea.
Blade Length (mm) Displacement (mm)
235.270 35 8235.290 45 8
100° Child Osteotomy Plates, 2 ea.
Blade Length (mm) Displacement (mm)
235.370 35 8235.390 45 8
90° Adolescent Osteotomy Plates, 2 ea.
Blade Length (mm) Displacement (mm)
235.600 50 10235.680 40 10235.700 50 15235.720 60 15235.780 40 15
100° Adolescent Osteotomy Plates, 2 ea.
Blade Length (mm) Displacement (mm)
235.601 50 10235.681 40 10235.701 50 15235.721 60 15235.781 40 15
Instrument319.97 Screw Forceps
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 22
Synthes 23
Also Available
90° Infant Osteotomy Plates Blade Length (mm) Displacement (mm)
236.352 37 12236.354 42 12
90° Toddler Osteotomy Plate
Blade Length (mm) Displacement (mm)
236.003 38 4
95° Condylar Plates, 5 holes
Blade Length (mm) Shaft Length (mm)
282.50 50 92282.52 60 92282.54 70 92282.58 40 92
95° Condylar Plates, 7 holes
Blade Length (mm) Shaft Length (mm)
282.70 50 124282.72 60 124282.74 70 124282.78 40 124
95° Condylar Plates, 9 holes
Blade Length (mm) Shaft Length (mm)
282.90 50 156282.92 60 156282.94 70 156282.98 40 156
*Note: Seating Chisel (332.19) is needed for use with these plates.
130° Angled Blade Plates, 4 holes*
Blade Length (mm) Shaft Length (mm)
283.40 50 60283.42 60 60283.44 70 60283.46 80 60
130° Angled Blade Plates, 6 holes*
Blade Length (mm) Shaft Length (mm)
283.60 50 104283.62 60 104283.64 70 104283.66 80 104
130° Angled Blade Plates, 9 holes*
Blade Length (mm) Shaft Length (mm)
283.90 50 152283.92 60 152283.94 70 152283.96 80 152
332.19 Seating Chisel
398.811 Plate Holding Forceps with swivel foot, size 0
398.812 Plate Holding Forceps with swivel foot, size 1
398.813 Plate Holding Forceps with swivel foot, size 2
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 23
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 24
23361_J4287F_Tech Guide 9/13/10 3:04 AM Page C3
Synthes (USA)1302 Wrights Lane EastWest Chester, PA 19380Telephone: (610) 719-5000To order: (800) 523-0322Fax: (610) 251-9056
Synthes (Canada) Ltd.2566 Meadowpine BoulevardMississauga, Ontario L5N 6P9Telephone: (905) 567-0440To order: (800) 668-1119Fax: (905) 567-3185
© 2003 Synthes, Inc. or its affiliates. All rights reserved. DCP and Synthes are trademarks of Synthes, Inc. or its affiliates. Printed in U.S.A. 8/10 J4287-F
www.synthes.com
23361_J4287F_Tech Guide 9/13/10 3:03 AM Page C4