Synthes TFN Technique Manual
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Synthes TFN Technique Manual

Titanium trochanteric fixation nail system
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Technique Guide
This publication is not intended for
distribution in the USA.
Instruments and implants
approved by the AO Foundation.
TFN – Titanium Trochanteric Fixation
Nail System. For intramedullary
fixation of proximal femur fractures.

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Summary of Contents for Synthes TFN

  • Page 1 TFN – Titanium Trochanteric Fixation Nail System. For intramedullary fixation of proximal femur fractures. Technique Guide This publication is not intended for distribution in the USA. Instruments and implants approved by the AO Foundation.
  • Page 2 For general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, as well as processing of Synthes non-sterile implants, please consult the Important Information leaflet (SE_023827) or refer to: www.synthes.com/reprocessing...

  • Page 3: Table Of Contents

    Table of Contents Introduction TFN – Titanium Trochanteric Fixation Nail System Biomechanical Features AO Principles Indications Clinical Cases Surgical Technique Preoperative Implant Selection Open Proximal Femur Insert Nail Proximal Locking Distal Locking – Short Nails SureLock Distal Targeting Device – Long Nails Freehand Distal Locking –...

  • Page 4: Tfn – Titanium Trochanteric Fixation Nail System

    The Synthes Titanium Trochanteric Fixation Nail (TFN) System permits an intramedullary approach for the fixation of frac- tures of the femur. The TFN System consists of a series of cannulated nails, cannulated helical blades, cannulated femoral neck screws, cannulated end caps, and locking bolts and screws.

  • Page 5: Biomechanical Features

    Proximal femur fixation device cut-out (Unstable pertrochanteric fracture using simulated cancellous bone) The helical blade of the Titanium Trochanteric Fixation Nail (TFN) System provides increased resistance to cut-out. 1.8 (405 lbs.) 1.6 (360 lbs.) The innovative helical blade design was proven to provide 1.4 (315 lbs.)
  • Page 6 M.B. Sommers, M. Bottlang, C. Roth, H. Hall, J.C. Krieg (2004) A laboratory model to evaluate cutout resistance of implants for pertrochanteric fracture fixation. Journal of Orthopaedic Trauma, Vol 18(6):361–368 lbid. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 7 Lag Screw 0.5 (112 lbs) 1000 10,000 100,000 1,000,000 10,000,000 Cycles Test conducted at Legacy Research and Technology Center, Portland, OR. Test conducted at Synthes Mechanical Testing Lab, West Chester, PA. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...

  • Page 8: Ao Principles

    D. Hardy, P. Descamps, P. Krallis, et al (1998). Use of an Intramedullary Hip-Screw Compared with a Compression Hip-Screw with a Plate for Intertrochanteric Femoral Fractures. The Journal of Bone and Joint Surgery, 80-A(5), 618–630 Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...

  • Page 9: Indications

    Indications The Synthes Titanium Trochanteric Fixation Nail (TFN) is in- ated with shaft fractures, pathologic fractures of osteo- tended to treat stable and unstable pertrochanteric fractures, porotic bone (including prophylactic use) in both trochanteric intertrochanteric fractures, basal neck fractures, and combi- and diaphyseal regions, long subtrochanteric fractures, proxi- nations thereof.

  • Page 10: Clinical Cases

    Clinical Cases Case 1 Preoperative AP Preoperative lateral Postoperative AP Postoperative lateral Case 2 Preoperative AP Preoperative lateral Postoperative AP Postoperative lateral Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...

  • Page 11: Preoperative Implant Selection

    – 420/1.05 = 400 – Estimated nail length is 400 mm When selecting nail size, consider canal diameter, fracture pattern, patient anatomy, and postoperative protocol. * Magnification factor may vary TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...

  • Page 12: Open Proximal Femur

    125°, 130°, or 135°. Position the ruler over the proximal femur and take an AP image. Select the angle that most closely matches the angle of the femoral neck. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 13 Alternative technique Instrument 360.255 Measuring Device for Reaming Rod for TFN Nail length may also be determined by using the reaming rod measuring device and a 950 mm reaming rod or guide rod. Insert the reaming rod to hold fracture reduction. Position the image intensifier over the distal femur and take an image to confirm reaming rod insertion depth.
  • Page 14 Note: Take into consideration that the ruler is not at the same level as the femur. This will affect the accuracy of the measurement. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 15 The guide wire will be centered in the canal in the lateral view. The guide wire can be inserted either manually with the universal chuck with T-handle or with a power drill. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 16 Insert the guide wire through the protection sleeve and drill sleeve. Confirm guide wire placement in both the AP and lateral planes. Insert to a depth of approximately 15 cm. Re- move the drill sleeve. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 17 Take care to remove the bone on the medial segment of the fracture to prepare an adequate opening for the proximal end of the nail. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 18 Reaming guidelines (optional) Instrument 360.255 Measuring Device for Reaming Rod for TFN Using image intensification, ensure that fracture reduction has been maintained. Insert the 2.5 mm reaming rod with olive ball tip into the medullary canal to the desired insertion depth.

  • Page 19: Insert Nail

    Important: Ensure that the connecting screw is tight to avoid misalignment when inserting the head element through the aiming arm. Do not attach the aiming arm to the handle until after the nail is fully inserted. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 20 Use the insertion assembly to manipulate the nail across the fracture. When inserting a short nail, no hammer blows should be required. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 21 For long nails, insertion can be aided by light hammer blows. When using a hammer, monitor the tip of the nail using image intensification. Verify that there is no evidence of im- pingement distally. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes Synthes...
  • Page 22 If a reaming rod has been used, it should be removed once the nail has crossed the fracture site. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...

  • Page 23: Proximal Locking

    Take a lateral image of the proximal femur to verify nail rotation and ensure that the head element will be aimed toward the center of the femoral head. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 24 Proximal Locking Insert blade guide sleeve Instruments 357.369 Guide Sleeve for Helical Blade for TFN 357.371 Buttress/Compression Nut, for No. 357.369 357.381 Drill Sleeve 11.0/3.2, length 222 mm, for No. 357.369 357.383 Trocar 3.2 mm, length 232 mm, for No. 357.381 Thread the buttress/compression nut onto the blade guide sleeve.
  • Page 25 Take an AP C-arm image to confirm that the blade guide sleeve is on the lateral cortex. Reconfirm fracture reduction using image intensification. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 26 Do not pull on the blade guide sleeve or the guide wire to make this adjustment as this could affect the accuracy of the aiming assembly. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 27 Do not pull on the blade guide sleeve or the guide wire to make this adjustment as this could affect the accuracy of the aiming assembly. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 28 The guide wires should be used for provisional fixation only and re- moved once the head element has been inserted. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 29 Measure for length of head element Instruments 357.369 Guide Sleeve for Helical Blade for TFN 357.385 Measuring Device for Guide Wire 3.2 mm, for No. 357.399 Using the measuring device for guide wire, measure for head element length. Pass the measuring device over the guide wire to the back of the blade guide sleeve.
  • Page 30 Proximal Locking Drill for head element Instruments 357.369 Guide Sleeve for Helical Blade for TFN 357.403 Reamer 6.0/10.0 mm, cannulated, length 435 mm, for Quick Coupling No. 511.760 357.404 Drill Bit 11.0 mm, conical, cannulated, length 280 mm, for Quick Coupling No. 511.760 357.405...
  • Page 31 357.430 Tap/Reamer for TFN Femoral Neck Screw Important: Only use the tap/reamer when proximal locking is done with the TFN screw. The tap/reamer may be used to prepare a pathway for the TFN screw. Important: Only use the tap/reamer in dense bone.
  • Page 32 357.372 Impactor for Helical Blade for TFN 357.377 Connecting Screw for Helical Blade for TFN Insert the cannulated helical blade connecting screw into the impactor for helical blade. Select the appropriate length 11.0 mm helical blade as measured. Align the back end of the helical blade with the impactor.
  • Page 33 Proximal locking with screw Instruments 357.052 Compression Nut, for No. 357.048 357.377 Connecting Screw for Helical Blade for TFN 357.428 Inserter/Extractor for TFN Femoral Neck Screw Thread the compression nut completely onto the screw in- serter/extractor. Insert the helical blade connecting screw into the screw inserter/extractor.
  • Page 34 – When aligning the inserter handle, always rotate the handle clockwise, further engaging the screw in the bone. Do not rotate counterclockwise, as this will leave a gap between the screw and the bone. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 35 Note: If the locking mechanism is not advanced, use of an end cap is not possible. Figure B: Locking mechanism engaged TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 36 5.0 mm flexible hexagonal screwdriver to loosen the connection. Remove the blade guide sleeve from the aiming arm by depressing the button on the aiming arm and pulling out the blade guide sleeve. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...

  • Page 37: Distal Locking – Short Nails

    Note: Ensure that the path of the incision and dissection of the fascia are in line with the path of the protection sleeve. Insert the triple trocar assembly through the aiming arm to the bone. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 38 Read the length of the locking bolt directly from the drill bit at the back of the drill sleeve. Press the drill sleeve to the bone to ensure accurate measurement. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 39 Note: In order to pass the measuring hook through the protection sleeve, the sleeve of the depth gauge must be re- moved. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 40 This will help in end cap selection. Remove the connecting screw and insertion handle using the ball hexagonal screwdriver or the cannulated shaft and ratchet wrench. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...

  • Page 41: Surelock Distal Targeting Device – Long Nails

    Long Nails (300 mm to 460 mm) 01.010.201 SureLock Distal Aiming Device for long Proximal Femoral Nails (PFN, PFNA and TFN) in Vario Case The SureLock device is designed to facilitate distal locking of Synthes titanium trochanteric fixation nails, by providing: – Simple, precise targeting –...

  • Page 42: Freehand Distal Locking – Long Nails

    Align the image intensifier with the hole in the nail until a perfect circle is visible in the center of the screen. Important: Confirm that the nail is securely connected to the insertion handle, especially after hammering. Round (correct) Oblique (incorrect) Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 43 Keep the drill bit oblique to the x-ray beam until the tip is centered in the locking hole. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 44 Measure Instrument 357.402 Depth Gauge for Locking Screws 5.0 mm Use the depth gauge to measure locking bolt length. Read locking bolt length directly from the depth gauge. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 45 Standard freehand technique Instrument 315.400 Drill Bit 4.0 mm, length 195/170 mm, 3-flute, for Quick Coupling Use the 4.0 mm three-fluted drill bit to perform freehand distal locking. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...

  • Page 46: Insert End Cap

    The 5.0 mm flexible hexagonal screwdriver, the 5.0 mm hexagonal screwdriver or the 5.0 mm hexagonal shaft and ratchet wrench may also be used to insert the end cap with- out the use of the guide wire. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...

  • Page 47: Implant Removal

    Important: Do not attempt to extract the nail at this point. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 48 Hold onto the shaft of the helical blade extractor and use light blows of the slide hammer to remove the helical blade. Remove the locking bolt using the 3.5 mm hexagonal screw- driver. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 49 Option B Remove screw and locking bolt Instruments 357.377 Connecting Screw for Helical Blade for TFN 357.428 Inserter/Extractor for TFN Femoral Neck Screw 314.750 Screwdriver, hexagonal, large, 3.5 mm, with Groove, length 280 mm Align the inserter/extractor with the back end of the screw.
  • Page 50 To remove the nail, thread the hammer guide and slide ham- mer assembly onto the back end of the nail extraction screw. Hold onto the extraction screw and use light hammer blows to extract the nail. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 51 Use the extraction screw guide to help center the extraction screw in the top of the nail. The conical extraction bolt can be used instead of the extrac- tion screw. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 52 Begin with Steps 1 and 2 of Implant Removal, then remove the extraction screw from the nail. * Available nonsterile or sterile-packed. Add “S” to catalog number to order sterile product. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 53 Extract nail Extract both nail fragments. Note: Keep the patient’s limb restrained to increase the efficiency of the extraction force. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 54 Align extraction hook Insert the extraction hook and explanted near nail fragment into the medullary canal. The near nail fragment aligns the extraction hook with the cannulation of the distant nail fragment. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 55 Extract nail Extract both nail fragments. Note: Keep the patient’s limb restrained to increase the efficiency of the extraction force. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...

  • Page 56: Instrument Cleaning

    Instrument Cleaning Intraoperative and postoperative cleaning of instruments Instruments 357.369 Guide Sleeve for Helical Blade for TFN 357.408 Cleaning Stylet 3.2 mm Clear the cannulations of the instruments intraoperatively using the cleaning stylet. Always ensure that the grooves in the blade guide sleeve are free of debris.

  • Page 57: Locking Mechanism Assembly

    5 Back the locking mechanism off the head element by turning the screwdriver in a counterclockwise direction one full turn, and remove the head element. The nail is now ready for insertion. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...

  • Page 58: Implants

    Femoral Neck Screw for TFN 11.0 mm, Titanium Alloy (TAN), gold, sterile Length Length (mm) (mm) 04.032.070S 04.032.105S 04.032.075S 04.032.110S 04.032.080S 04.032.115S 04.032.085S 04.032.120S 04.032.090S 04.032.125S 04.032.095S 04.032.130S 04.032.100 * Titanium-6% aluminum-7% niobium Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 59 End Caps (green) – Titanium alloy* – 0 mm, 5 mm, and 10 mm extensions – Cannulated End Cap for TFN, Titanium Alloy (TAN), green, sterile Extension (mm) 456.311S 456.312S 456.313S * Titanium-6% aluminum-7% niobium TFN – Titanium Trochanteric Fixation Nail System...
  • Page 60 459.760 459.420 459.800 459.440 459.850 459.460 459.900 459.480 459.950 459.500 459.100 459.520 * Titanium-6% aluminum-7% niobium ◊ Available nonsterile or sterile-packed. Add “S” to catalog number to order sterile product. Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...

  • Page 61: Titanium Trochanteric Fixation Nails (Green) – Short

    – Static interlocking – Universal design for left and right femurs 235 mm nail 0 mm Distal locking slot accepts 4.9 mm locking bolts or 5.0 mm locking screws TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 62 TFN – Cannulated Trochanteric Fixation Nail, length 235 mm, Titanium Alloy (TAN), green, sterile Diameter (mm) Angle 456.324S 125° 456.325S 130° 456.326S 135° 456.327S 125° 456.328S 130° 456.329S 135° 456.510S 125° 456.511S 130° 456.512S 135° Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...

  • Page 63: Titanium Trochanteric Fixation Nails (Green) – Long

    4.9 mm locking bolts or – Anatomic 10° anteversion 5.0 mm locking screws – Nail designs for both left and right femurs * 14 mm diameter nails are available in 130° only TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 64 Titanium Trochanteric Fixation Nails (green) – Long TFN – Cannulated Trochanteric Fixation Nail, length 300 – 400 mm, Titanium Alloy (TAN), green, sterile 10 mm 10 mm Length Angle 11 mm 11 mm Length Angle distal dia. distal dia. (mm) distal dia.
  • Page 65 TFN – Cannulated Trochanteric Fixation Nail, length 300 – 460 mm, Titanium Alloy (TAN), green, sterile 12 mm 12 mm Length Angle 14 mm 14 mm Length Angle distal dia. distal dia. (mm) distal dia. distal dia. (mm) right left...

  • Page 66: Instruments

    Instruments 03.010.405 Insertion Handle, radiolucent, for PFNA 03.010.412 Aiming Device for Guide Wire, for PFNA and TFN, for AP Orientation 03.010.415 Connecting Screw for TFN, for No. 03.010.412 03.010.427 Curved Awl 8.0 mm, for intramedullary Reduction 03.010.471 Guide Wire Aiming Device Offset Block, 100 mm 03.010.474...
  • Page 67 Ratchet Wrench for Nut, hexagonal, 11.0 mm 321.250 Spanner Wrench, for Nos. 357.180, 357.181, 359.201 and 359.219 * Available nonsterile or sterile-packed. Add “S” to catalog number to order sterile product. TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 68 Hammer Guide, for No. 357.250 357.250 Slide Hammer, for Nos. 357.220 and 357.221 357.365 Aiming Arm for TFN, 125° 357.366 Aiming Arm for TFN, 130° 357.367 Aiming Arm for TFN, 135° Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 69 357.369 Guide Sleeve for Helical Blade for TFN 357.371 Buttress/Compression Nut, for No. 357.369 357.372 Impactor for Helical Blade for TFN 357.377 Connecting Screw for Helical Blade for TFN 357.378 Extraction Instrument for Helical Blade for TFN 357.381 Drill Sleeve 11.0/3.2, length 222 mm, for No.
  • Page 70 Drill Bit 17.0 mm, cannulated, length 300 mm, for Quick Coupling No. 511.760 357.395 Connector for TFN, for No. 357.411 357.396 Extraction Screw for TFN 357.397 Connecting Screw, cannulated, for TFN Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 71 Quick Coupling No. 511.760 357.405 Fixation Sleeve 357.406 Screwdriver, hexagonal, 5.0 mm, flexible 357.407 Drill Bit 4.0 mm, calibrated, length 260/60 mm, 3-flute, for Quick Coupling 357.410 Protection Sleeve 22.0/17.0, for No. 357.394 TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 72 Insertion Handle for TFN 357.412 Awl for TFN 357.413 Drill Sleeve 5.6/3.2, length 198 mm 357.414 Socket, hexagonal, 11.0 mm, length 180 mm 357.415 Shaft, hexagonal 5.0 mm, length 210 mm Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 73 Conical Extraction Bolt for TFN 357.421 Extraction Screw Guide for TFN 357.427 Screwdriver, hexagonal 5.0 mm 357.428 Inserter/Extractor for TFN Femoral Neck Screw 357.430 Tap/Reamer for TFN Femoral Neck Screw TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 74 Aiming Jig for “Miss-A-Nail” Technique for TFN 360.253 Locking Device for Holding Sleeve No. 314.110 360.255 Measuring Device for Reaming Rod for TFN 393.100 Universal Chuck with T-Handle 399.420 Hammer 500 g Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...

  • Page 75: Sets

    Insertion Handle for TFN 357.412 Awl for TFN 357.515 Screwdriver, hexagonal, with spherical head 8.0 mm 360.255 Measuring Device for Reaming Rod for TFN 393.100 Universal Chuck with T-Handle 399.420 Hammer 500 g TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 76 357.365 Aiming Arm for TFN, 125° 357.366 Aiming Arm for TFN, 130° 357.367 Aiming Arm for TFN, 135° 357.369 Guide Sleeve for Helical Blade for TFN 357.371 Buttress/Compression Nut, for No. 357.369 357.372 Impactor for Helical Blade for TFN 357.377 Connecting Screw for Helical Blade for TFN 357.378...
  • Page 77 Socket, hexagonal, 11.0 mm, length 180 mm 357.415 Shaft, hexagonal 5.0 mm, length 210 mm 357.920 Aiming Jig for “Miss-A-Nail” Technique for TFN 360.253 Locking Device for Holding Sleeve No. 314.110 TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 78 690.474 Graphic Case for TFN Auxiliary Instrument Set, without Contents Instruments 03.010.412 Aiming Device for Guide Wire, for PFNA and TFN, for AP Orientation 03.010.415 Connecting Screw for TFN, for No. 03.010.412 03.010.427 Curved Awl, 8 mm intramedullary reduction tool (for intramedullary reduction) 03.010.471...

  • Page 79: Also Available

    Coupling for RDL 530.100 Power Drive 530.200 Battery for Power Drive 530.250 Sterile Cover for Power Drive, for No. 530.280 530.280 Battery Casing for Power Drive, for No. 530.200 TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 80 Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 81 TFN – Titanium Trochanteric Fixation Nail System Technique Guide Synthes...
  • Page 82 Synthes TFN – Titanium Trochanteric Fixation Nail System Technique Guide...
  • Page 84 Ö036 000 288öAC†ä Synthes GmbH Synthes GmbH This publication is not intended for distribution in the USA. Eimattstrasse 3 Eimattstrasse 3 CH-4436 Oberdorf CH-4436 Oberdorf All surgical techniques are available as PDF files at 0123 www.depuysynthes.com www.depuysynthes.com www.synthes.com/lit...

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