IMPLATE ® Surgical Approach

IMPLATE ® Surgical Approach

  • 1. EXPOSURE
    Make an 8cm to 10cm
    longitudinal incision
    centered over Lister’s
    tubercle to expose the
    extensor retinaculum.

  • 2. EPL TENDON SHEATH
    Open the sheath of the
    extensor pollicis longus and
    reflect the tendon radially.

  • 3. EXTENSOR COMPARTMENTS
    Expose and release
    the 2nd and 4th extensor
    compartments.
    If desired, prepare flaps
    to reconstruct the 4th
    compartment.

  • 4. DORSAL CAPSULE
    Open the dorsal wrist
    capsule in an “H” fashion.
    Note:
    Once open, reposition the
    retractors to the plane
    below the retinacular flaps.

  • 5. DECORTICATION
    Position the wrist in flexion
    allowing access to the
    radiocarpal and intercarpal
    joints for complete
    decortication of the
    articular surfaces.

  • 6. METACARPAL NAIL INSERTION POINT
    Mark the distal flare on
    the dorsal surface of the
    capitate in-line with the
    3rd metacarpal.
    Note:
    This location marks the entry
    point for the Metacarpal
    Nail.

  • 7. METACARPAL NAIL INSERTION POINT
    Mark the distal flare on the dorsal surface of the capitate in-line with the 3rd metacarpal.

    Note:
    This location marks the entry point for the Metacarpal Nail

  • 8. OPENING THE METACARPAL CANAL
    Open the medullary canal
    of the 3rd metacarpal by
    inserting the AWL through
    the distal flare of the
    capitate aimed towards the
    head.
    Note:
    Fluoroscopic imaging is
    helpful at this step.

  • 9. K-WIRE PLACEMENT
    Using a 1.5mm K-wire as a
    probe, insert the blunt end
    through the medullary canal
    to locate the head of the
    metacarpal.

  • 10. K-WIRE CONFIRMATION
    Fluoroscopic imaging is
    required to confirm the
    proper placement of the
    K-wire.

  • 11. METACARPAL REAMING
    Ream over the 1.5mm K-wire
    using Metacarpal Reamer
    (MR)1 to the proper depth.
    Remove the K-wire and
    continue reaming to the
    proper diameter.
    Note:
    Each Metacarpal Reamer is
    etched with a “depth mark”
    to ensure that the proper
    depth has been achieved.

  • 12. FINAL METACARPAL REAMING
    The system offers two
    diameters of Metacarpal
    Nails; 4.0mm and 4.6mm.
    Depending on the diameter
    of the medullary canal, use
    MR 3 as the final reamer
    for the 4.0mm nail or MR 5
    as the final reamer for the
    4.6mm nail.

  • 13. FINAL CAPITATE PREPARATION
    Insert the Flaring-Troughing
    Tool into the medullary canal
    up to the line marked “M”.
    This shapes the opening
    of the capitate to accept
    the flared end of the
    Metacarpal Nail.

  • 14. CMC JOINT PREPARATION
    Gain access to the 3rd CMC
    joint space for complete
    decortication of the articular
    surfaces.
    Apply bone graft as
    needed prior to inserting the
    Metacarpal Nail.
    Note:
    Ensure bone graft does not
    enter the medullary canal.

  • 15. METACARPAL NAIL ASSEMBLY
    Secure the appropriate sized
    Metacarpal Nail to the Drill
    Guide using the Lock Screw.
    Note:
    Be sure to fully tighten the
    Lock Screw.

  • 16. METACARPAL NAIL INSERTION
    Insert the Metacarpal Nail
    into the medullary canal
    until the Drill Guide seats
    flush against the capitate.

  • 17. METACARPAL NAIL PREPARATION
    Insert the Drill Sleeve through
    the distal slot of the Drill
    Guide until flush against the
    bone.

    Note:
    If necessary, extend the
    incision distally to allow the
    Drill Sleeve to contact the
    bone.

  • 18. METACARPAL NAIL DRILLING
    Advance the 3.0mm
    Unicortical Drill through
    the near cortex until the
    mechanical stop of the bit
    reaches the Drill Guide.
    Note:
    The 3.0mm Unicortical Drill
    has a built in mechanical
    stop that prevents the
    drill from contacting the
    Metacarpal Nail.

  • 19. UNICORTICAL SCREW SIZING
    Insert the Depth Gauge
    through the Drill Sleeve until
    the far cortex is reached to
    determine the appropriate
    screw length.
    Note:
    The Depth Gauge is
    designed to pass through the
    near cortex and transect the
    Metacarpal Nail until the far
    cortex is reached.
    This determines the longest
    possible Unicortical Screw
    option.
    If between screw lengths,
    choose the shorter screw
    option.

  • 20. SECURING THE METACARPAL NAIL
    Insert the appropriate length
    2.8mm Unicortical Screw and
    engage the Metacarpal
    Nail.
    Note:
    Lifting the distal tip of the Drill
    Guide while advancing the
    Unicortical Screw facilitates
    nail engagement.

  • 21. LOCKING THE METACARPAL NAIL
    Confirm that the Unicortical
    Screw has been fully
    tightened and that the
    Metacarpal Nail is flush to
    the endosteal surface using
    fluoroscopic imaging.
    After confirmation, remove
    the Drill Guide.

  • 22. RADIAL NAIL INSERTION POINT
    Flex the hand to fully visualize
    the distal radius. Mark a
    point on the ridge between
    the scapholunate fossae, just
    below Lister’s tubercle.
    Note:
    This location marks the entry
    point for the Radial Nail.

  • 23. OPENING THE RADIAL CANAL
    Insert the AWL through the
    previously marked entry point
    for the distal radius.
    Confirm that the
    proper trajectory has
    been established using
    fluoroscopic imaging.
    Note:
    Adjustments can be made at
    this time.

  • 24. RADIAL RASPING
    Prepare the medullary
    canal using the two Radial
    Rasps (RR).
    The depth marks on the rasps
    determine the appropriate
    nail length:
    • Rasp to S; use the short
    Radial Nail
    • Rasp to L; use the long
    Radial Nail
    Note:
    Fluoroscopic imaging is
    helpful during this step.

  • 25. FINAL RADIAL PREPARATION
    Insert the Flaring-Troughing
    Tool into the medullary canal
    up to the line marked “R”.
    This shapes the opening of
    the canal to accept the
    flared end of the Radial Nail.

  • 26. RADIAL NAIL INSERTION
    Secure the Radial Nail to the
    Drill Guide using the Lock
    Screw.
    Insert the Radial Nail into the
    medullary canal until the Drill
    Guide seats flush against the
    radius.
    Note:
    If you do not have sufficient
    spacing between the two
    nails, you can remove a
    small amount of bone from
    the dorsal edge of the
    radius, allowing the nail to
    move proximal.

  • 27. SECURING THE RADIAL NAIL
    Provisionally secure the
    Radial Nail to the radius by
    inserting a 1.5mm K-wire
    through the K-wire hole on
    the Drill Guide.
    DO NOT bend this K-wire as
    it will prevent the removal of
    the Drill Guide.
    Note:
    Confirm that the K-wire
    has transected the nail for
    bicortical contact using
    fluoroscopic imaging.

  • 28. RADIAL NAIL DRILLING
    Insert the Drill Sleeve through
    a slot on the Drill Guide until
    flush against the bone:
    A. Long Radial Nail; use all
    three slots
    B. Short Radial Nail; use the
    middle and distal slots
    Advance the 3.0mm Drill Bit
    through the near cortex until
    the mechanical stop of the
    drill is reached.

  • 29. UNICORTICAL SCREW SIZING
    Insert the Depth Gauge
    through the Drill Sleeve until
    the far cortex is reached to
    determine the appropriate
    screw length.
    Note:
    If between screw lengths,
    choose the shorter screw
    option.

  • 30. FINAL DRILLING AND MEASURING
    Loosely thread the
    appropriate length 2.8mm
    Unicortical Screw to
    engage the nail.
    Repeat Steps 28 and 29 for
    the remaining screw hole(s).

  • 31. DRILL GUIDE REMOVAL
    Remove the Drill Guide
    leaving the K-wire in
    place.

  • 32. CONNECTOR SELECTION
    The IMPLATE ® System offers
    connectors in four angle
    variations and in three
    lengths. Final Connector
    length, angle and rotation
    adjustments can be made
    prior to locking the construct.
    “Centering lines” are
    etched on all Connectors
    in the plane formed by the
    angle.
    Insertion depth marks are
    etched on the splines of the
    Connector to confirm proper
    seating into the nails.

  • 33. CONNECTOR ADJUSTMENTS
    Length
    Select the Connector length
    to allow for full seating of
    the splines after construct
    assembly.
    Rotation
    Rotational adjustments
    should be made between
    the Connector and the
    Radial Nail.
    Angulation
    Angled Connectors allow for
    adjustments of wrist flexion-extension
    and radio-ulnar
    deviation.
    To adjust the position of
    the hand in space, rotate
    the Connector until the
    desired compound angle is
    obtained. Then engage the
    splines at both ends.

  • 34. LOADING THE CONNECTOR
    Insert the selected Connector
    into the Metacarpal Nail until
    the splines engage taking
    note of the Connector’s
    orientation.
    Then engage the splines of
    the Connector into the Radial
    Nail taking note of the hands
    rotational position.

  • 35. FINAL HAND POSITIONING
    Ensure that the optimal
    clinical position has been
    achieved.
    Further adjustments can be
    made at this time.
    Note:
    A Spreader is included in
    the system to facilitate the
    removal of the connector.

  • 36. LOCKING THE CONSTRUCT
    Lock the construct using a
    Set Screw in each nail.
    Note:
    Be sure that the splines are
    fully engaged at both ends
    before locking the construct.

  • 37. DISTRACTION – COMPRESSION
    Remove the 1.5mm K-wire
    to allow for distraction or
    compression of the fusion
    site.
    Apply bone graft as needed.

  • 38. LOCKING THE RADIAL NAIL
    After achieving optimal
    compression or distraction,
    fully tighten the Unicortical
    Screws to lock your position.
    Each Unicortical Screw
    will require subsequent
    tightening until the Radial
    Nail fully compresses to the
    endosteal surface.
    Warning: When desired
    results are achieved, confirm
    that ALL screws have been
    fully tightened.
    Note:
    Fluoroscopic imaging is
    helpful during this step.

  • 39. WOUND CLOSURE
    Close the dorsal capsule,
    then repair the extensor
    retinaculum as necessary.
    Repair the remaining soft
    tissues as needed, then close
    the incision.

  • 40. POSTOPERATIVE PROTOCOL
    Post-Operative
    – Apply a post operative
    dressing until the first
    office visit.
    – Recommend full finger
    motion as tolerated and
    non-weight bearing.
    1st Visit (1 Week)
    – Based on clinical
    judgement, apply a
    removable orthotic or
    shortarm cast until fusion
    occurs.