TI

BIA
I
ntr
amedul
l
aryNai
l(TI
N)
Cont
ent
s

I
mpl
ant
sandI
nst
rument
s 3-4

Feat
ures 5-6

Thedi
f
fer
enc
eswhi
chc
anbes
uper
i
ort
otheot
hernai
l
s 6

Sur
gi
cal
Tec
hni
que 7-1
1

Oper
ati
onX-
Ray 12-13

Anal
ysi
s 14

Li
t
erat
ure 15

2
I
mpl
ant
sandI
nst
rument
s

DSBLSGui
de

Compressi
on
Scr
ew
TI
N
Lengt
heni
ngScr
ew

Cor
ti
calScr
ew

Di
stalK.
Wir
e Di
stalDr
il
lGui
de
Guide Ø 5mm

DSBLS

SetScr
ew Proxi
malLocki
ng Nai
lHol
der-I
nser
ter
ScrewGuide
TI
N

Nai
lDr
iver

Fl
exi
bleReamer
Pr
oxi
malGui
de

BoneDr
il
lBi
tØ 4.
2X250mm

DSBLSHol
der
-I
nser
ter
Cannul
atedDr
il
lBi
tØ 5mm

AA2,
5Scr
ewDr
iver

Gr
adedCannul
atedDr
il
lBi
tØ 8.
5X5.
0mm

AA3,
5Scr
ewDr
iver
Nai
lExt
ract
er

Scr
ewLengt
hGauge

Di
st
alScr
ewLengt
hGauger

Ki
rschnerWi
re2x250mm

Proxi
mal Art
icul
ated Pat
ell
a AWL Hammer
Dr
il
lGuide Hammer Prot
ect
or
St
ainl
essRul
er

3
Ti
biaI
ntr
amedul
lar
yNai
ls Scr
ews

81520280710 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X7X280mm Ti 81521500001 SETSECREW 15mm
81520300710 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X7X300mm Ti 81521700001 SETSECREW 17mm
81520320710 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X7X320mm Ti 81521900001 SETSECREW 19mm
81520340710 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X7X340mm Ti 81522000001 SETSECREW 20mm
81520340710 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X7X360mm Ti 81522300001 SETSECREW 23mm
81520340710 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X7X380mm Ti 20124300050 CORTEXSCREW FORNAI
LSØ5X30MM TI
81520280810 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X8X280mm Ti 20124350050 CORTEXSCREW FORNAI
LSØ5X35MM TI
81520300810 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X8X300mm Ti 20124400050 CORTEXSCREW FORNAI
LSØ5X40MM TI
81520320810 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X8X320mm Ti 20124450050 CORTEXSCREW FORNAI
LSØ5X45MM TI
81520340810 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X8X340mm Ti 20124500050 CORTEXSCREW FORNAI
LSØ5X50MM TI
81520360810 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X8X360mm Ti 20124550050 CORTEXSCREW FORNAI
LSØ5X55MM TI
81520360810 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X8X380mm Ti 20124600050 CORTEXSCREW FORNAI
LSØ5X60MM TI
81520360810 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X8X400mm Ti 20124650050 CORTEXSCREW FORNAI
LSØ5X65MM TI
81520300910 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X9X300mm Ti 20124700050 CORTEXSCREW FORNAI
LSØ5X70MM TI
81520320910 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X9X320mm Ti 20124750050 CORTEXSCREW FORNAI
LSØ5X75MM TI
81520340910 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X9X340mm Ti 20124800050 CORTEXSCREW FORNAI
LSØ5X80MM TI
81520360910 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X9X360mm Ti 20124850050 CORTEXSCREW FORNAI
LSØ5X85MM TI
81520380910 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X9X380mm Ti 20124900050 CORTEXSCREW FORNAI
LSØ5X90MM TI
81520380910 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X9X400mm Ti 20124950050 CORTEXSCREW FORNAI
LSØ5X95MM TI
81520301010 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X10X300mm Ti 20124100050 CORTEXSCREW FORNAI
LSØ5X100MM TI
81520321010 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X10X320mm Ti 81520001000 TI
NCOMPRESSI
ONSCREW 0mm
81520341010 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X10X340mm Ti 81520001000 TI
NLENGTHENI
NG SCREW 5mm
81520361010 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X10X360mm Ti 81520001000 TI
NLENGTHENI
NG SCREW 10mm
81520381010 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X10X380mm Ti 81520001500 TI
NLENGTHENI
NG SCREW 15mm
81520381010 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)10X10X400mm Ti 81520002000 TI
NLENGTHENI
NG SCREW 20mm
81520301
111 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)1
1X1
1X300mm Ti
81520321
111 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)1
1X1
1X320mm Ti
81520341
111 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)1
1X1
1X340mm Ti
81520361
111 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)1
1X1
1X360mm Ti I
nst
rument
s
81520381
111 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)1
1X1
1X380mm Ti
81520381
111 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)1
1X1
1X400mm Ti 08050000000 NAI
LHOLDER-
INSERTER
81520341212 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)12X12X340mm Ti 08050000005 DSBLSGUI
DE
81520361212 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)12X12X360mm Ti 08050000007 PROXI
MALLOCKI
NG SCREW GUI
DE
81520381212 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)12X12X380mm Ti 08050000006 PROXI
MALDRI
LLBI
TGUI
DE
81520401212 TI
BIAI
NTRAMEDULLARYNAI
L(TI
N)12X12X400mm Ti 22310250042 BONEDRI
LLBI
T 4.
2X250mm
8152000341
1 DI
STALSUPPORTI
VEBOL
TLOCKI
NG SCREW 1
1X34mm 08050000008 AA3,
5SCREWDRI
VER
8152000351
1 DI
STALSUPPORTI
VEBOL
TLOCKI
NG SCREW 1
1X35mm 08050000009 AA2,
5SCREWDRI
VER
8152000361
1 DI
STALSUPPORTI
VEBOL
TLOCKI
NG SCREW 1
1X36mm 08201000003 PROXI
MALENTRYHOLEOPENI
NG DEVI
CE(
AWL)
8152000371
1 DI
STALSUPPORTI
VEBOL
TLOCKI
NG SCREW 1
1X37mm 08050000018 GRADEDCANNULATEDDRI
LLBI
T8.
5X5.
0mm
8152000381
1 DI
STALSUPPORTI
VEBOL
TLOCKI
NG SCREW 1
1X38mm 08050000010 0 ALUMI
NIUM PLATE(
PATELLAPROTECTOR)
8152000401
1 DI
STALSUPPORTI
VEBOL
TLOCKI
NG SCREW 1
1X40mm 0805000001
1 400mm LONG STAI
NLESSRULER
8152000421
1 DI
STALSUPPORTI
VEBOL
TLOCKI
NG SCREW 1
1X42mm 08050000012 FLEXI
BLEREAMERØ 7mm
08050000013 FLEXI
BLEREAMERØ 8mm
08050000014 FLEXI
BLEREAMERØ 9mm
08050000015 FLEXI
BLEREAMERØ 10mm
08050000016 FLEXI
BLEREAMERØ 1
1mm
08050000017 FLEXI
BLEREAMERØ 12mm
08050000019 DI
STALKI
RSCHNERWI
REGUI
DE
23410250120 KI
RSCHNERWI
RE2X250mm
02051000450 CANNULATEDDRI
LLBI
T Ø 5mm
08050000023 DI
STALGUI
DEFORCANNULATEDDRI
LLBI
TØ 5mm
08050000024 DI
STALGUI
DEFORGRADEDDRI
LLBI
T
08040000400 HAMMER
08050000004 NAI
LEXTRACTER
08201000006 ARTI
CULATEDHAMMER
08050000002 NAI
LDRI
VER
08050000001 DSBLSHOLDER-
INSERTER
08050000021 SCREW LENGTHGAUGE
08050000022 DI
STALSCREW LENGTHGAUGE

4
TI
BIA I
ntr
amedul
lar
yNai
l

I
ntr
oduct
ion

Al
otdi
f
fer
entf
i
xat
i
onmet
hodsar
eus
edi
npr
obl
emsr
egar
dingTi
bi
abone.
Asi
ntheot
herl
ong
bones(
tubul
ar)
,Int
ramedul
l
aryl
ock
ingnai
lf
ix
ati
onf
orTi
bi
atooi
swi
des
preadus
edi
nthemos
t
r
ecenty
ear
sasi
ndi
cat
i
onsar
eget
ti
ngex
panded.

Nai
lsy
stemswhi
cht
heyf
unc
ti
onaspr
ovi
di
ngl
ock
ingi
nthepr
oxi
mal
anddi
st
alwi
t
hthei
nt
erl
ock
ing
s
crewsi
spr
efer
abl
e.Howev
erel
i
minat
i
ons
tudi
esofnai
lands
crewbr
eak
agepr
obl
emsandof
di
f
fi
cul
t
iesi
npl
aci
ngt
hedi
st
all
ocki
ngscr
ews(
int
ensi
vescopyusage)ar
eget
ti
ngcont
inued.

Newnai
lsy
stem s
ear
chi
ngsar
efort
hati
deal
int
ramedul
l
aryf
i
xat
i
onmet
hodhasnotbeabl
eto
bedev
eloped.Newi
ntr
amedul
l
aryl
ock
ingnai
lsy
stem whi
chc
ani
ncl
udet
headv
ant
agesoft
he
i
nt
ramedul
l
aryf
i
xat
i
onmet
hodt
hemos
t,whi
chi
t
sdi
st
all
ock
ingdes
igni
stoodi
f
fer
ent
andc
anper
for
m
anyr
equi
redf
unct
ionwi
thonl
yonescr
ewi
never
ydi
rect
ions,hasbeendevel
opedf
orTi
bia.

Ai
ms(
Needf
orDevel
opment
)

 T
odec
reas
ethenumber
sof
thes
urgi
cal
dev
ices(
tool
-
equi
pment
,i
nst
rument
)whi
chwi
l
lbeus
ed.
 Tobeabl
etoi
nser
tandext
racteasi
l
yandsot
odecr
easet
heoper
ati
ont
ime.
 Tobeabl
etoper
for
m cont
rol
l
edcompr
essi
on.
 T
opr
ovi
det
hema
ximu
mne
ces
sar
yre
sis
tan
cea
gai
nst
tot
her
ot
at
io
nan
dan
gul
at
io
n(b
end
ing
)f
or
ces
.
 T
obea
blet
obep
erf
or
mth
elo
cki
ngi
nbo
the
nds(
pr
oxi
mal
andd
ist
al
)ea
sil
yase
li
min
ati
ngt
hen
eedo
fsc
opy
andgui
deordec
reas
ingi
tt
othel
eas
t(t
omi
ni
miz
e).
 Toel
i
minat
ethenai
lmi
grat
i
onont
heends(
proxi
mal
anddi
stalmi
grat
ion)
.
 Topr
eventt
hebr
eakageoft
hescr
ewandnai
l
.
 Topr
eventscr
ewr
emoval
.
 T
opr
eve
ntt
r
ans
lat
i
ona
sth
ena
ilb
ein
gat
thes
ing
lep
lan(
pro
fi
le
)an
dwi
t
hth
esi
ngl
edi
st
all
ock
ings
cre
w.
 T
opr
ovi
den
ece
ssa
rya
ndp
oss
ibl
eth
emo
sts
tr
ongf
i
xat
i
on(
max
imu
mst
abi
l
i
zat
i
on)
ona
llo
fth
epl
ane
s.
 Toel
i
minat
etheneedofext
ernalf
ixat
ion,andt
oper
for
mint
ramedul
l
aryf
ixat
ionwhi
ch
al
l
owsear
lymovementandl
oadi
ng.

5
I
ndi
cat
ions

 For
all
oft
heT
ibi
afr
act
ur
easf
r
om4
.5c
mdi
st
alo
fTi
bi
apr
oxi
mal
j
oin
tsu
rf
acet
o2.
5cmp
rox
ima
lof
thed
ist
alj
oi
nts
urf
ace
.
 I
ntheevent
sofmal
uni
onornon-
uni
on(
pseudoar
thr
osi
s)
 Ost
eot
omi
esf
orshor
theni
ng
 Ost
eot
omi
esf
orl
engt
heni
ng
 Tumorr
esect
ion

Feat
ures(Def
ini
ti
onoft
heNai
l-
Desi
gn)

 Sol
i
d/Cannul
ated-Round
 Unr
eamed–Reamed
 Wedgef
ormeddi
st
alend
 Ti
tani
um f
lexi
bil
i
tyandbi
ocompat
i
bil
i
ty
 4.
5cm par
tasf
rom t
hepr
oxi
mal
has10mm di
amet
er(
for6-
10mm nai
l
s),1
1mm,
12mm,
13mm di
amet
er
 I
ncl
udi
ng3hol
est
hathave5.
3mm di
amet
erandpr
ovi
del
ocki
ngonmul
tipl
ansand1hol
ethathas
5.
3x10mm di
ment
ionandal
l
owscompr
essi
on,t
otalar
e4l
ocki
nghol
esont
hepr
oxi
mal
 Ther
ear
echoi
cesi
nlengt
hsas280mm,
300mm,
……400mm f
ort
hedi
amet
ers6mm,7mm,8mm,9mm,
10mm oft
hedi
stalpar
t;as300-
400mm l
engt
hsf
ort
hedi
amet
ers11mm,12mm oft
hedi
stalpar
t
 Di
st
alSuppor
ti
veBol
tLoc
kingSc
rew(
DSBLS)
'whi
chi
sas
pec
ial
des
igni
sus
edf
ort
hedi
st
all
ock
ing.
 Thesamenai
lsyst
em i
susedf
ort
hel
eftandt
her
ight
 Ther
eisnoneedofusageofscopyorgui
def
ort
hedi
stal
locki
ng(
ifdesi
red,
thi
sopt
ionofusageof
scopyorgui
dei
sappl
ied)
 Gui
dei
susedf
ort
hepr
oxi
mall
ocki
ng
 New,er
gonomi
candsi
mpl
edr
ivi
ng,ext
ract
ingandl
ocki
ngsyst
em i
sdesi
gned

Thedi
ff
erenceswhi
char
esuper
iort
otheot
hernai
ls

 Pr
oxi
mall
ocki
ngscr
ewswhi
char
eondi
ff
erentdi
rect
ionspr
ovi
dest
abi
li
tyonmul
ti
-pl
ane
 Becauseoft
hatt
her
eisn’
tanydi
stall
ocki
ngscr
ewhol
eont
henai
l
,thesol
i
dnai
l
swhi
chhavel
ess
diamet er scanbeusedasunr eamedf ortibi aswhi chhavenar row medul la.Evenf ul
lloadingar e
delayedasmaki ngt hem i nter nalathelf unct i
on,ear l
ykneeandankl emovement scanbeper formed
 Be caus eof that t
hereisn’tanydi st
allocki
ngs crewhol eont henai l
swhi chhav es malldiamet ers
,nailbr
eak age
compl icationont hesi deoft hescr ewhol ewhi chcanbeseenont hecl assicnai lsdoesn’ thappen.
 Duet o'Di stalSuppor t
iveBol tLocki ngScr ew ( DSBLS) ;
 Di stall ockingscr ewbr eakageandmi grat ionofi nteriorofthej oi ntdon’ texistevenont henai l
s
whi chhav es mal ldiamet er s
 Th enail canals obeus eds afel
yforthebr eak st il
l2.5cmpr oxi
mal f
romt hedi st
aljoi
nt s
urface
 Di stallocki ngi spr ovidedonal lplanes,wi thDSBLSwhi chi spl acedf r
om asi nglehol e.
 Ma ximum r esi
s t
anc etoax ial l
oading, r
otation, transl
ationandangul ationfor c
esi sprov i
dedwi t
hDSBLS
(withoutbr eak ageofnai l ands crew)
 Non eedf ors copyandgui def orlockingwi thDSBLS. Forthef r
actureswhi chrepos i
ti
onhasbeen
prov ided,whent henai l i
smov edf orwar df rom prox i
mal towar dsdi stal,itplacest oDSBLSeas i
ly
 Pr ov i
dingl ocki
ngwi t
hDSBLSc anbec hec kedwi t
hthes etscrewins i
dei t
I fus ageof scopyi spreferred, I
t’
sex pos edt otheX- Ray st
hel eastti
meac cordi
ngt otheot hernai
l s
y s
tems

6
Sur
gicalTechni
que

l
NaiLenght

25mm
20mm

 Twosidedgraphyoft
heheal
thyt
ibi
aistakenf
rom 1meterdist
ancepre-oper
ati
on.
 Thediameterofthenar
rowestmedull
arregi
onismeasur ed,theenlargementr
ati
othati
sappr
oxi
mat
ely10% i
s
subt
ract
edandsot hedi
amet
erofthenaili
sdet
ermined.
 Tibi
abonel engt
hismeas uredbet
weenthejoi
nts urf
aces
.Thelengt
hofthenail
isdeterminedass ubt
r act
i
ngtheenlargement
rati
othati
sapproximat
el
y10% andex t
ra2cm( Thelengt
hofthenail
isals
odeterminedwhent hedistancebetweenthemos t
proj
ectedpartof
themedialmall
eol
arof
theheal
thytibi
aandthemostproj
ect
edpartof
thetuberos
itasti
bi
ai smeasur
edex ter
nal
l
y).
 Medial
-l
at
eral
int
erc
ort
i
caldi
stanc
ef ort
hel
engt
hof
DSBLSi
smeas
uredf
rom2c
mpr
oxi
mal
oft
hedi
st
alt
i
biaj
oi
nt
sur
faceont
heantero-
pos
ter
iorgraphy.
 Thenai
l
swhi chhav
ethenex tsmal
l
erandthenextbi
ggerdi
ameter
sandt hel
engt
hsthanthedi
ameterandthelengt
h
oft
hemeasurednai
lareprepar
ed.I
fther
eisnosc
opyoritwon’
tbeused;DSBLSisfi
rstpl
acedt
othefr
act
uredti
biadi
stal
oft
hepati
enttobeoperat
ed.
 Ashol
dingt
hef
ootatneut
ral(
theankl
eisneut
ralat90degr
eeandi
nthewayt
hebi
gtoewi
l
llookt
othecei
l
ing.

3mmk i
r
schnerwi
reisenteredtransverstot
heanklej
oi
nton
Thelat
eraloftheguidewit
hChandl eisplac
edtothe themi ddleli
nefrom 2.5c m proximal medi
alofthemost
f
ibul
aat4c m proxi
mal f
rom l
ater
almall
eol
arend,and extrudedpartofthemedi almalleolar(I
fdes
ir
edDSBLSi s
medi
alofit
isplacedtothet
ibi
amedialatt
hemiddl
eli
ne determinedwit
hthedist
als cr
ewl engthmeasuri
nggaugevi
a
att
he2.5cm proxofthemed. mal
. kir
sc hnerwir
eanddi st
al ki
rschnerwi r
eguide).

7
Bot
hcor
texisdri
l
ledwi
t
hadri
l
lbi
tof
5mmv
iaK.
.
wir
e.(
Car
eis Dr
il
l
ingismade,
wit
has peci
algr
adedl
engt
hjus
ti
fi
erdr
il
lbit
via
t
akenf
orthefi
bul
anott
obehol
ed) K.
wire,
int
hewaythat
later
alcor
texwi
l
lbe5mm,medialcor
tex
wi
l
lbe8.5mm

DSBLS(Dis
tal
Support
i
vBolt
Locki
ngScr
ew)inmeasured St
andar
dmedpar
apat
el
larorant
eri
or5c
mlongi
t
udi
nal
inc
isi
on
l
engt
hispl
acedint
hewaythatt
henai
lpl
aci
ngsl
ot’
swider i
sper
for
medonpr
oxi
mal
.
si
dewil
ll
ookatt
heproxi
mal
. It’
sr eachedtotibi
amedul l
afrom themiddleoft heant eri
or
i
nt
er condyl
arr
egion( Univ
ersalent
rypoint
)withanawl or3mm
K.wire.It
’
smovedaheadasex pandi
ngthemedullaentryholewit
h
ac annulat
eddr
il
lbit
viathewir
e.
P.
s.
:Ifthenaili
sdesi r
edt obeusedwi ththereamersyst em, t
he
diameteroft
hemedul lacanbeexpandedwi t
ht her eamers

8
Previ
ouslypreparednaili
smovedaheadi
ntot
hedistal Ifther educt i
onhasbeenabl etobepr ovidedbyhand,
partbypart
ialrot
ationsbymeansofi
t
shol
der-
inser
ter- whent henai lismovedahead,i t’
smovedt othedi stal
dri
ver-ext
ernalguide. f
r agment .Ifthereduc t
ionhasn’tbeenpr ovided,t henail
i
si nsertedt othemos tpossi
bledistal bymeansofs c opy
control;if
itdoesn’thappenagain,it
’sdonebymi nii
ncisi
on
f
ol l
owingr educti
on.Int
hemeant i
me, it’
sf eltors eenthat t
he
nailwaspl acedi ntheDSBLS.
Ifdesi red,it’
scheckedwi thaset scr ew t hati fl
ocking
happenedornot .
P.s:DSBLSi nserterisnotusedf ortr action.

Thenai
lendhasbeenex
act
l
ypl
acedt
otheDSBLS. Di
st
all
ockingispr
ovi
dedwit
has etsc
rewinsui
t
abl
e
l
engt
h(thel engt
hofthesetscrew=thel
engt
hof
DSBLS-18mm)

9
Prox
imall
oc k
ingcanbemadeeas i
lyinanydesi
redway.I
fpri
mer Aft
erext
remi
tyal
ignmentcont
rol,pr
oxi
mallocki
ng
compress
ion,dynamizati
onoraut
o-compres
sionarer
equi
red,t
he scr
ewsarepl
acedinanydesir
edwayandnumber s
oval
holeisused;if
stati
cloc
kingi
srequi
red,r
oundhol
esareus ed (
Inser
ti
ngscr
ewtothedynamiclocki
nghol
e)

I
nsert
ingscr
ewasobl
i
que(
fr
om ant
ero-
medi
alt
o Sui
tabl
etopscrew(neutr
al
,l
engtheni
ngorc
ompres
sion
post
ero-
lat
eral
e) scr
ew)isplaced(pl
acingthetops c
rewwhic
hmak es
compres
sion)

10
Viewwhic
hc ompr
ess
ionhas T
ran
sve
rsean
dob
li
ques
tat
i
clo
cki
ngh
as L
ock
inghasb
eenc
omp
let
edo
npr
oxi
mal
beenappl
ied b
eenpr
ovi
ded a
nddi
sta
l

PostOper
ati
on;

 Ever
ykindofbedexer
ci
sesi
sst
art
edbegi
nni
ngf
rom t
het
i
met
hatt
hepat
i
enthasr
egai
nedhi
s/
herc
ons
cious
nes
s
af
teranest
hesia.
 Thepati
entgetsall
owedtowalkassuggest
edthemostpossi
bleloadi
ng(forthepati
entswhot henai
lwit
h
8mmdiameterandwi
tht
hos
eoverthat
areus
edon)at
thes
hor
tes
tti
methathi
s/
hergener
alheal
t
hc ondi
t
ional
l
owsthi
s.

I
fscopyusagei
sdesi
red;

 Aft
erreduct
ion,thenai
linsuit
ablediameterandl
engthi
si nser
tedt
il
l2cm fr
om proxi
mal.
 Dis
tal
endisseenbyscopyonlat
eralpl
an,Ki
rc
hnerwi
r
eisent
eredto1cmdist
alf
romthenai
lendandpar
al
lel
tot
hej
oi
nt
.
 DSBLSi spl
acedvi aK.wir
e.
 I
t’
senteredintheDSBLSasdr ivi
ngt henai
l.
 Locki
ngisprovidedwit
haset screw.

CAUTI
ON!
!!

I
mpor
tantnot
esabouts
urgi
cal
tec
hni
quewhi
chi
sneededt
obek
eepti
nmi
nd;

Duringprepar ati
onbef oreoper at
ion,Ap- Latgraphyofheal thytibi
ai sdefinit
elytakenand;
 B onean atomy m ust beca r
eful
lyinspect
ed .Ifextr
em el
y narr
ow m edull
a rc
a nalorex t
remel yanter
iorbowingexi
stsor
notmus tbec hec ked.
 Thedi amet erandt helengt hofthenai lplannedt obepl acedmus tbedet ermi ned.
C ar
e mu stbe taken for t
he cho i
ce of ent
ry poi
n t
.
Nailmus tbemov edaheadbyhandt il
lenteri
ngt ot hecorti
calregionf r
om met aphy seal region.
Its
ho ul
dn’tbeforgott
en forfragm entsthatm edul
l
a ro peni
ng oft
he dist
alm ainfragm entcouldb e cl
osedwi t
hpiecesorcould
benar r
owed.
Duringthenail i
sdirectedt othedi st
al,t
hehol dermus tbechec kedast hinkingthatsc r
ewl oos eni
ngc ouldbehappened.
C ar
e mu stbe taken as placing the DSB LS ,f
i
bu la mu st
n’
tbe dril
led.
Ift
henai lendi s;
 D i
rected tothemedi al oftheDSBLSgr oov e,DSBLSi st akenbac k2- 3mm.
 D i
rected t
o thela t
eral ofthe DS BL Sgroo ve, DSBLS ismo v ed ahea d2-3mm.
 D i
rect
ed t
o t
he an t
erioror post
eri
or oft
he D S BLS gr
oov e,
a sd i
rect
ing DSB LSr eamerf romt hesamemedi al
entryto
anteri
orandpos ter
ior,ands oa5mmnewhol eisopenedonl at
eralandDSBLSi splac edinthere.(Nail
dir
ecti
onc an
bec hangedbymani pulati
onf orthedistal metaphysealfracturesasneedednonewhol e

11
Oper
ati
onX-
Ray

pr
eop post
op 45.day 90.day

I
I

pr
eop post
op 45.day 90.day

12
I
II

pr
eop post
op 45.day 90.day

I
V

pr
eop post
op 45.day 90.day

13
TheAnal
ysi
soft
heTi
bia

Model
:Lef
tTi
bi
a Model
:Lef
tTi
bi
a
Ty
pe:St
ati
cNodal
Str
ess Ty
pe:St
ati
cNodal
Str
ess

(
Hasar
)

Max183.
3 Max7.
569

DSBLS Socket DSBLS Socket

Mat
eri
al
:Bone(
Tibi
a) Loadi
ng:250k
g(2500N)
Mat
eri
alYi
el
dSt
rengt
h:i
stak
enas
189.
8kgf
/cm2 Numberofc
ycl
es:1.
000.
000
Max
.Loadi
ng:170k
g(1700N) Whent
hist
estwasappl
i
ed,r
egi
onwi
t
hst
res
shas
n’tex
ist
edatt
heDSBLS
Bec
aus
eoft
hatt
hey
iel
dst
rengt
hatt
hemax
.poi
nti
s184.
3kgf
/cm2,t
hebonei
ssaf
e. appl
i
ngpl
aceondi
st
alt
i
bia.
Agai
n,di
aphy
sehasbeendet
ermi
nedasr
egi
on
Ther
egi
onwi
t
hthemos
tst
res
sist
hedy
aphy
seal
regi
onof
theboneasi
t
’ss
eenont
hef
i
gur
e. wi
t
hthemos
tst
res
s

TheAnal
ysi
sofTheTI
N Nai
l

Model
:Nail
ofTi
bi
a11x11x
320mm Model
:Nailof
Tibi
a11x
11x
320mm Model
:Nail
ofTi
bi
a10x7x280mm Model
:Nailof
Tibi
a10x
7x280mm
Ty
pe:Stat
i
cNodalStr
ess Ty
pe:Fat
igue Ty
pe:Stat
i
cNodalSt
ress Ty
pe:Fat
igue

(
Hasar
)
(
Hasar
)

Max10000.
000 Max15681.
0
Max9897.
2 Max10000.
000

Mat
eri
al
:T16AI
4V Mat
eri
al
:Ti
6AI
4V Mat
eri
al
:Ti
6AI
4V Mat
eri
al
:T16AI
4V
Mat
eri
alYi
el
dSt
res
s:i
stak
enas
10707k
gf/
cm2 Loadi
ng:
170k
g(1700N) Mat
eri
alYi
el
dSt
res
s:i
stak
enas Loadi
ng:102k
g
Max
.Loadi
ng:170k
g NumberofCy
cles
:1.
000.
000 10707k
gf/
cm2 NumberofCy
cles
:1.
000.
000
Bec
aus
eoft
hatt
hey
iel
dst
rengt
hatt
he Whent
hi
stes
twasappl
i
ed,damagedar
ea Max
.Loadi
ng:
102k
g
max
.poi
nti
s9897.
2kgf
/
cm2,
theTI
Nnai
li
ssaf
e has
n’t
exi
st
edat
theDSBLSappl
i
ngpl
aceon
di
st
alt
i
bia

14
Li
ter
atur
e

Gi
riSK.Achi
evi
ngdi
stall
ocki
ngwi
thoutani
magei
ntensi
fi
er.NepalMedCol
lJ.2007Dec;
9(4)
:275-
7.
Babi
sGCBenet osIS,ZoubosAB,SoucacosPNTheef f
ecti
venessoft
heext
ernaldi
stalaimingdevi
ce
i
nint
ramedul
laryf
ixat
ionofti
bialshaf
tfr
act
ures.Ar
chOrt
hopTraumaSurg.2007Dec; 127(10)
:905-
8.
Epub2007Jul20.
Babi
sGC,Benet osIS,Kar achal
i
osT,SoucacosPN
Ei
ghtyears
'cl
i
nic
al experi
encewit
htheOrt
hofi
xti
bi
alnai
l
ings
yst
em i
nthet
reat
mentoft
i
bial
shaf
tfr
act
ures
.
I
niur
y.2007Feb;38(2):
227-34.Epub2006Oct18.
Karachali
osT,BabisG,Tsar
ouchasJ.SapkasG.PantazopoulosT
.
Thec li
ni
calper
for
manceofas mall
diamet
erti
bi
alnai
l
ings yst
em wit
hamec
hani
cal
dis
tal
aimi
ngdev
ice.
I
niury.2000Jul
;31(
6):
451-9.
RzesaczEH,KönnekerW,Rei l
mannH.CulemannU.
[
Combinat
ionofint
ramedul
l
arynai
landcover
edsc
rewost
eosynt
hesi
sformanagi
ngdi
st
alt
i
bial
frac
tur
ewi
t
h
ankl
ejoi
ntinvol
vement]Unf
all
chi
rur
g.1998Dec;
101(
12):
907-13.
I
m GI,TaeSK.Distal
metaphys
eal f
ractur
esofti
bi
a:apr
ospect
i
verandomi
zedt
ri
alofcl
osedreduct
ionand
i
nt
ramedull
arynai
lver
susopenreducti
onandplat
eandscr
evvsf
bcat
i
on.JTr
auma.2005Nov;59(
5):
1219-
23;
di
scussi
on1223.

EgolKA.
WeiszR.Hieber
tR.Tej
waniNC. KovalKJ.
SandersRWDoesfi
bul
arpl
at
ingimpr
oveali
gnmentaf
ter
i
ntr
amedull
arynai
l
ingofdist
almetaphysealti
biaf
ract
ures?JOr
thopTrauma.2006Feb;20(
2):
94-103.

Ric
ci WM.O'
BovleM.Bor
rel
l
iJ.Bel
l
abar
baC,SandersRFrac
tur
esoft
heprox
imalt
hir
dofthet
i
bial
shaf
t
t
reatedwi
thi
ntr
amedul
lar
ynail
sandbl
ocki
ngscr
ews.Ort
hopTrauma2001May;
15(4):
264-
70.
Kr
ett
ekC.StephanC,Schandelmai
erP.Ri
cht
erM.PapeHC.Micl
auTTheus eofPol
l
ers
c r
ewsasbl
ocki
ng
sc
rewsi
nstabi
li
si
ngti
bi
alf
ract
urestr
eat
edwit
hsmal
ldi
ameteri
nt
ramedul
l
arynai
ls
.JBoneJoi
ntSur
gBr
.1999
Nov;
81(
6):
963-8.

Ri
cci
WM, O'
Boy
leM,Borr
ell
iJ,
Bell
abar
baC,Sander
sRFrac
tur
esoft
hepr
oxi
mal t
hir
doftheti
bi
als
haf
tt
reat
ed
wi
thi
ntr
amedul
l
arynai
lsandblocki
ngscr
ews.JOr t
hopTr
anma.2001May;15(4)
:264-70

BenmansourMB.Gott
inM,Rouvill
ain.İ
L,LarosaG.DibC.Dint
imi
ll
eH.Cat onneY
[
Elast
i
cint
ramedul
l
arynail
i
ngoftheti
biawitht
heMarchet
ti
-Vi
cenz
inai
l.43t
reatedcas
es]RevChi
rOr
thop
Repaı
-at
ri
ceApparMot.1999Jun;85(3)
:267-
76.
Fi
nkemeierCG.SchmidtAH.KvleRF.Templ emanDC.Var eckaTF.
Apros
pecti
ve,r
andomi
zedstudyofi
ntramedull
arynai
lsi
nser
tedwithandwi
t
houtreamingfort
het
reat
mentof
openandclosedfr
act
uresoftheti
bialshaf
t.JOr t
hopTrauma.2000Mar-Apr;14(3):187-
93.

15