Modular Rod Systems

Large and Medium

­External Fixators
Surgical Technique
Image intensifier control

This description alone does not provide sufficient background for direct use
of DePuy Synthes products. Instruction by a surgeon experienced in handling
these products is highly recommended.
Please refer to the IFU for product information including but not limited to
indications, contraindications, warnings, precautions and adverse effects.

Processing, Reprocessing, Care and Maintenance

For general guidelines, function control and dismantling of m ­ ulti-part
instruments, as well as processing guidelines for i­mplants, please contact your
local sales representative or refer to:
http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance
For general information about reprocessing, care and maintenance of
DePuy Synthes reusable devices, instrument trays and cases, as well as
processing of DePuy Synthes non-sterile implants, please consult the Important
Information leaflet (SE_023827) or refer to:
http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance
Table of Contents

Introduction Large External Fixator 2

AO Principles 5

Indications, Contraindications and Warnings 6

MRI Information 7

Surgical Technique Surgical Approaches 9

Setting the Schanz Screws 12

Modular Frame Using the

Rod-to-Rod Technique 20

Additional Treatment Options Using the

Rod-to-Rod Technique  23

Unilateral Frame with Single- or Double-Rod

Construction 28

Pelvic Use – Supraacetabular Assembly 30

Bilateral Frame for Arthrodesis and Osteotomies 37

Product Information Implants 39

Fixation Components for

the Large External Fixator 40

Fixation Cmponents for

the Medium External Fixator 41

Instruments 42

Large and Medium ­E xternal Fixators Surgical Technique DePuy Synthes 1

Large External Fixator
Allows Modularity in all Three Planes

User-oriented handling
• Clamps with a clip-on self-holding m
­ echanism
• Color-coded for identification

Free frame design

• Frames can be freely assembled
• Free pin placement
• Radiolucent carbon fibre rods ensure
fracture visualization

2 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Treatment of the pelvis

Bridging of ankle Triangular (for symmetric, balanced ligamentotaxis)

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 3

Large External Fixator

Overview of available Fixator systems

Rod Fixators Supplements to the Monolateral Systems

External Fixation Family External Fixation Family MEFiSTO Systems
(clip-on)
Large rod  11 mm

Large External Fixator Hybrid Ring Fixator Carbon fibre tube

Medium rod  8 mm

External Distal Radius Fixator

Medium External Fixator (DRF)

Small rod  4 mm

Small External Fixator

Mini rod  3 mm

External Mini-Fixator

* MEFiSTO central body, MEFiSTO angulator,

and MEFiSTO segment transport are also available

MEFiSTO Central Body MEFiSTO Angulator MEFiSTO Segment Transport

4 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

The AO Principles of
Fracture Management

Mission
The AO’s mission is promoting excellence
in patient care and outcomes in trauma
and musculoskeletal disorders.

AO Principles 1,2
1 2 3 4

Fracture reduction and Fracture fixation provid- Preservation of the blood Early and safe mobiliza-
fixation to restore ing absolute or relative supply to soft-tissues and tion and rehabilitation
anatomical relationships. stability, as required by bone by gentle reduction of the injured part and
the “personality” of the techniques and careful the patient as a whole.
fracture, the patient, ­ handling.
and the injury.

1 M üllerME, M Allgöwer, R Schneider, H Willenegger. Manual of Internal Fixation.

3rd ed. Berlin, Heidelberg, New York: Springer. 1991
2 Rüedi TP, RE Buckley, CG Moran. AO Principles of Fracture Management. 2nd ed.

Stuttgart, New York: Thieme. 2007

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 5

Indications, Contraindications and Warnings

Indications
The Large External Fixator (rod diameter: 11 mm) is
­particularly suitable for treating the lower extremities.
The Medium External Fixator (rod diameter: 8 mm) is
particularly appropriate for the extremities of adults,
and the upper and lower extrem­ities of children and
small adults.

The most important indications for Large and Medium

­E xternal Fixators are:
• Second and third-degree open fractures
• Infected pseudoarthrosis
• Rapid, initial immobilization of soft tissue injuries and
­fractures in severely injured patients
• Immobilization of closed fractures with severe soft
­tissue trauma (bruising of the soft tissue mantle,
burns, skin ­diseases)
• Extensive shaft and periarticular fractures
• Transient joint-bridging immobilization in severe soft
­tissue and ligament injuries
• Certain injuries to the pelvic ring, and selected
­fractures in children
• Arthrodeses and osteotomies

Contraindications
No specific contraindications.

Warning: The treating physician should make

­patient specific clinical judgment and decision to
use External Fixation System in patients with the
following conditions:
• Patients who for social and physical reasons are
not suitable for an External Fixator.
• Patients in whom no screws can be inserted due
to a bone or soft tissue disease.

6 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

MRI Information

Large External Fixator The above field conditions should be compared with
Large External Fixator devices used in a typical construct those of the user’s MR system in order to determine
include clamps, rods and various attachments. A patient if the item can safely be brought into the user’s MR
with a DePuy Synthes Large External Fixator frame may environment.
be scanned safely after placement of the frame under
the following conditions: If placed in the bore of the MR scanner during scan-
ning, DePuy Synthes Large External Fixator devices
• Static magnetic field of 1.5 Tesla or 3.0 Tesla when the may have the potential to cause artifact in the diag-
fixator frame is positioned outside the MRI Bore at nostic ima­ging.
Normal Operator or in First Level Control Mode
• Highest spatial gradient magnetic field of 720 Gauss/cm Warnings:
or less • Only use frame components stated in the surgical
• Maximum MR system reported whole body averaged technique of the Large External Fixator System
­specific absorption rate (SAR) of 2 W/kg for the Normal • Potential complications of putting a part in the MR
Operating Mode and 4 W/kg for the First Level Con- field are:
trolled Mode for 15 minutes of scanning –– Torsional forces can cause the device to twist
• Use only whole body RF transmit coil, no other trans- in MR field
mit coils are allowed, local receive only coils are al- –– Displacement forces can pull the device into
lowed the MR field
• Specialty coils, such as knee or head coils, should not –– Induced currents can cause peripheral nerve
be used as they have not been evaluated for RF heat- stimulation
ing and may result in higher localized heating –– Radio Frequency (RF) induced currents can
cause heating of the device that is implanted
Note: In nonclinical testing, the Large External Fix- in the patient
ator frame was tested in several different configura- • Do not place any radio frequency (RF) transmit
tions. This testing was conducted with the construct coils over the Large External Fixator frame
position 7 cm from within the outside edge of the
MRI bore. Artifact Information
The results showed a maximum observed heating MR image quality may be compromised if the area of in-
for a pelvic frame of less than 1 °C for 1.5 T and terest is in the same area or relatively close to the position
3.0 T with a machine reported whole body averaged of the DePuy Synthes Large External Fixator frame. It may
SAR of 2 W/kg. be necessary to optimize MR imaging parameters in order
to compensate for the presence of the fixator frame.
Precautions: Patients may be safely scanned in the
MRI chamber under the above conditions. Under Representative devices used to assemble a typical Large
such conditions, the maximum expected tempera- External Fixator frame have been evaluated in the MRI
ture rise is less than 6 °C. Because higher in vivo chamber and worst-case artifact information is provided
heating cannot be excluded, close patient monitor- below. Overall, artifacts created by DePuy Synthes Large
ing and communication with the patient during the External Fixator System devices may present issues if the
scan are required. Immediately abort the scan if the MR imaging area of interest is in or near the area where
patient reports burning sensation or pain. To mini- the fixator frame is located.
mize heating, the scan time should be as short as • For FFE sequence: scan duration 3 minutes, TR 100 ms,
possible, the SAR as low as possible and the device TE 15 ms, flip angle 15° and SE sequence: scan dura-
should be as far as possible from the edge of the tion 4 minutes, TR 500 ms, TE 20 ms, flip angle 70°
bore. Temperature rise values obtained were based ­radio echo sequence, worst-case artifact will extend
upon a scan time of 15 minutes. approximately 10 cm from the device.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 7

MRI Information

Medium External Fixator The above field conditions should be compared with
Medium External Fixator devices used in a typical con- those of the user’s MR system in order to determine
struct include clamps, rods and various attachments. if the item can safely be brought into the user’s MR
A patient with a DePuy Synthes Medium External Fixator environment.
frame may be scanned safely after placement of the
frame under the following conditions: If placed in the bore of the MR scanner during scan-
ning, DePuy Synthes Medium External Fixator de-
• Static magnetic field of 1.5 Tesla or 3.0 Tesla when the vices may have the potential to cause artifact in the
fixator frame is positioned: diagnostic imaging.
–– 7 cm or less from within the outside edge of the
bore of the MRI at Normal Operating Mode or Warnings:
–– Completely outside of the MRI Bore in First Level • Only use frame components stated in the surgical
­Control Mode technique of the Medium External Fixator System
• Highest spatial gradient magnetic field of 900 Gauss/cm • Potential complications of putting a part in the MR
or less field are:
• Maximum MR system reported whole body averaged –– Torsional forces can cause the device to twist
specific absorption rate (SAR) of 2 W/kg for the Normal in MR field
Operating Mode and 4 W/kg for the First Level Con- –– Displacement forces can pull the device into
trolled Mode for 15 minutes of scanning the MR field
• Use only whole body RF transmit coil, no other trans- –– Induced currents can cause peripheral nerve
mit coils are allowed, local receive only coils are al- stimulation
lowed –– Radio Frequency (RF) induced currents can
cause heating of the device that is implanted
Note: In nonclinical testing, the Medium External in the patient
Fixator frame was tested in several different config- • Do not place any radio frequency (RF) transmit
urations. This testing was conducted with the con- coils over the Medium External Fixator frame
struct position 7 cm from within the outside edge of
the MRI bore. Artifact Information
The results showed a maximum observed heating MR image quality may be compromised if the area of in-
for a wrist fixator frame of 6 °C for 1.5 T and less terest is in the same area or relatively close to the position
than 1 °C for 3.0 T with a machine reported whole of the DePuy Synthes Medium External Fixator frame. It
body averaged SAR of 2 W/kg. may be necessary to optimize MR imaging parameters in
order to compensate for the presence of the fixator frame.
Precautions: Patients may be safely scanned in the
MRI chamber under the above conditions. Under Representative devices used to assemble a typical Medium
such conditions, the maximum expected tempera- External Fixator frame have been evaluated in the MRI
ture rise is less than 6 °C. Because higher in vivo chamber and worst-case artifact information is provided
heating cannot be excluded, close patient monitor- below. Overall, artifacts created by DePuy Synthes
ing and communication with the patient during the ­Medium External Fixator System devices may present
scan are required. Immediately abort the scan if the ­issues if the MR imaging area of interest is in or near the
patient reports burning sensation or pain. To mini- area where the fixator frame is located.
mize heating, the scan time should be as short as • For FFE sequence: scan duration 3 minutes, TR 100 ms,
possible, the SAR as low as possible and the device TE 15 ms, flip angle 15° and SE sequence: scan dura-
should be as far as possible from the edge of the tion 4 minutes, TR 500 ms, TE 20 ms, flip angle 70°
bore. Temperature rise values obtained were based ­radio echo sequence, worst-case artifact will extend
upon a scan time of 15 minutes. approximately 10 cm from the device.

8 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Surgical Approaches

The Large and Medium External Fixators must be affixed

within the recommended zones described below.

The construction may not hinder the approach for a

­primary wound debridement or for a secondary opera-
tion. Skin transplants, sequestrectomies, bone grafting
or a later osteosynthesis must be performable without
restriction.

Note: For a detailed handling description of the

Schanz screws and the Steinmann pins, refer to the
Surgical Technique Schanz Screws and Steinmann
Pins (DSEM/TRM/0516/0677).

Surgical approach to the tibia

The soft tissue zone through which Schanz screws can
be inserted without damaging important structures
­(vessels, nerves, muscles and tendons) is anteromedial to
the tibia. The angles of this safe zone vary.

If the lateral surface of the distal third of the tibia is

avoided, damage to the anterior tibial artery can be
avoided.

When the ventral zone of the distal tibia is avoided,

interference with the tendons can also be avoided.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 9

Surgical Approaches

Surgical approach to the femur

A lateral approach to the femur within a 30° angle is
recommended. A medial approach is also possible from
a distal d
­ irection.

Surgical approach to the pelvis

There are two recommended options for pin placement
of the external fixation assembly in the pelvis.

Supraacetabular pin placement

Given the pronounced bone structure, the more techni-
cally difficult supraacetabular pin placement is preferred
over that of the iliac crest. Proceeding from the superior
anterior crest, the site of entry is approximately 4–6 cm
in a caudal direction, and 3–4 cm in a medial direction.
When the patient is in a supine position, the alignment
for drilling the screws is angled approximately 20° in a
cranial direction and 30° inward.

Iliac crest pin placement

Precaution: To keep from damaging the femoral cu-

taneous nerve, avoid insertion up to 15 mm in a dor-
sal direction from the superior anterior iliac spine.

The orientation of the os ilium can be determined by

palpation with a finger or an additional instrument. The
screws are then inserted delicately between the two
laminae of the os ilium.

11 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Approach to the humerus
Distally, a dorsal approach to the humerus is appropriate.

Precautions:
• When dealing with the humerus, primary consid-
eration should be given to the radial and axillary
nerves.
• Proximally, it is recommendable to introduce the
Schanz screws from a ventrolateral direction, cau-
dal to the path of the axillary nerve.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 11

Setting the Schanz Screws

The following steps will be explained with reference to a

B 5.0 mm self-drilling, self-tapping (SELDRILL™) Schanz
screw, and a conventional B 5.0 mm Schanz screw in-
serted in the diaphyseal region of the tibia.

Precaution: Select the appropriate Schanz screw or

Steinmann pin for the patient’s bony anatomy.

SELDRILL™ Schanz Screw

The SELDRILL Schanz screw is a self-drilling, self-tapping
Schanz screw.

Note: When the new adaptors for Schanz screws are

used, the SELDRILL Schanz screws do not have to
be clamped in the drill chuck. The adapters are
compatible with the universal chuck and AO/ASIF
Quick Coupling.

11 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

1. Set the drill sleeves on the bone

Required instruments
Handle for Drill Sleeve 395.911
Drill Sleeve 6.0/5.0 short, with thread 395.921
Drill Sleeve 5.0/3.5, short 395.912
Trocar B 3.5 mm, short 394.181

Insert the drill sleeve assembly through a stab incision

and set it directly on the bone surface. Then remove the
trocar B 3.5 mm and the drill sleeve 5.0/3.5.

Precautions:
• Instruments and screws may have sharp edges or
moving joints that may pinch or tear user’s glove
or skin.
• Handle devices with care and dispose worn bone
cutting instruments in an approved sharps con-
tainer.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 11

Setting the Schanz Screws
SELDRILL Schanz Screw

2. Insert SELDRILL Schanz Screws

Required instruments
SELDRILL Schanz Screws B 5.0 mm X94.782–788*
Handle for Drill Sleeve 395.911
Drill Sleeve 6.0/5.0 short, with thread 395.921
Adapter for SELDRILL Schanz Screws B 5.0 mm 393.103
Drill with attachment for AO/ASIF
Quick Coupling type-dependent

Insert the SELDRILL Schanz screw in the B 5.0 mm

adapter, and use the drill to screw it through the drill
sleeve 6.0/5.0 until the drill tip is anchored in the distant
cortical bone.

If it is difficult to determine whether the screw has en-

tered the opposite side of the cortical bone, it is recom-
mendable to check the screw’s penetration depth and
position with the image intensifier.

After screwing in the SELDRILL Schanz screw, remove

the drill sleeve and the drill with the adapter.

Precautions:
• The SELDRILL Schanz screw has been developed
to minimise heat ­development. Nevertheless, slow
insertion and additional cooling (for example with
a Ringer solution) are recommended.
• The tip of the SELDRILL Schanz screw should be
embedded in the far cortex to effectively resist
cantilever forces and to provide sufficient stability.

Note: Less experienced users are advised to use a

hand drill when placing the SELDRILL Schanz
screw in the far cortex. The SELDRILL Schanz screw should be embedded in the far cortex.

* X=2 Stainless Steel

X=4 Titanium (TiCP)

11 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Alternative technique:
Required instruments
SELDRILL Schanz Screws B 5.0 mm X94.782–788*
Handle for Drill Sleeve 395.911
Drill Sleeve 6.0/5.0, short, with thread 395.921
Drill Sleeve 5.0/3.5, short 395.912
Trocar B 3.5 mm, short 394.181
Adapter for SELDRILL Schanz Screws B 5.0 mm  393.103
Universal Chuck with T-Handle  393.100
Drill with attachment for AO/ASIF
Quick Coupling type-dependent

Insert the SELDRILL Schanz screw B 5.0 mm in the

adapter, and use the drill to screw it through the drill
sleeve 6.0/5.0 into the near cortical bone.

Remove the drill and replace it with the universal drill

chuck with the T-handle (393.100). The screw can now
be delicately screwed manually into the middle of the
distant c­ ortical bone. It is not necessary to completely
penetrate the distant cortical bone since anchoring the
thread in the near cortical bone and sinking the drill tip
in the distant cortical bone effectively absorbs bending
force.

Remove the drill sleeve and the universal chuck with

T-handle.

Precaution: Only when bones are osteoporotic does

the SELDRILL Schanz screw have to be screwed a
bit further into the ­distant cortical bone, and it may
even slightly penetrate through it since this can in-
crease anchoring stability.

Note: A SELDRILL Schanz screw can be turned

back without loosening as the thread is not conical.

Use in the metaphyseal region

The individual surgical steps are the same as when the
screws are used in the shaft area.

* X=2 Stainless Steel

X=4 Titanium (TiCP)

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 11

Setting the Schanz Screws
Self-tapping Schanz Screw

Self-tapping Schanz Screw

Instead of self-drilling Schanz screws (SELDRILL), self-­
tapping screws can also be used. In contrast to the
­SELDRILL Schanz screws, self-tapping screws must be
predrilled.

1. S
 et the drill sleeve assembly
on the bone

Required instruments
Handle for Drill Sleeve 395.911
Drill Sleeve 6.0/5.0 short, with thread 395.921
Drill Sleeve 5.0/3.5, short 395.912
Trocar B 3.5 mm, short 394.181

Insert the drill sleeve assembly through a stab incision

and set it directly on the bone surface and remove the
trocar B 3.5 mm.

2. Predrilling

Required instruments
Drill Bit B 3.5 mm, length 195/170 mm, 2-flute,
for Quick Coupling 310.370
Drill with attachment for AO/ASIF
Quick Coupling type-dependent

Drill through both sides of the cortical bone with the

B 3.5 mm drill bit, then remove the drill sleeve 5.0/3.5.

11 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

3. Insert the Self-tapping
Schanz screw

Required instruments
Self-tapping Schanz Screw X94.520–570*
Handle for Drill Sleeve 395.911
Drill Sleeve 6.0/5.0 short, with thread 395.921
Universal Chuck with T-Handle  393.100

The Schanz screw can now be screwed in through the

drill sleeve 6.0/5.0. The tip must be anchored in the dis-
tant cortical bone to effectively absorb bending force.

Precaution: The tip of the self-tapping Schanz screw

should be embedded in the far cortex to effectively
resist cantilever forces and to provide sufficient
­stability.

* X=2 Stainless Steel

X=4 Titanium Alloy (TAN)

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 11

Setting the Schanz Screws
Self-tapping Schanz Screw

Alternative technique using the length gauge

Alternately, the length of the required Schanz screw can
also be precisely checked using the length gauge.

Required instruments
Handle for Drill Sleeve 395.911
Drill Sleeve 6.0/5.0 short, with thread 395.921
Depth Gauge for Schanz Screws 393.780
Universal Chuck with T-Handle  393.100

After predrilling as described in step 2 on page 16, the

length gauge is guided through the drill sleeve 6.0/5.0
and hooked in the distant cortical bone.

Then move the retaining disk to the height of the drill

sleeve and lock it with the locking screw.

11 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Remove the length gauge, and insert the tip of the
Schanz screw into the recess of the retaining disk. Slide
the universal chuck over the smooth shaft of the Schanz
screw to the height of the tip of the length gauge, and
tighten the chuck on the Schanz screw. Determining the
length in this manner will ensure that the screw will be
firmly anchored in the distant cortical bone.

The Schanz screw can now be screwed in through the

drill sleeve 6.0/5.0 until the drill chuck stops on the drill
sleeve.

Note: If the Schanz screw is screwed in beyond this

point, it will strip the thread due to the resistance of
the drill sleeve.

Precautions:
• Implant sites should be meticulously cared to
avoid pin-tract infection. Schanz screws and
Steinmann pins may be surrounded with antisep-
tic coated foam sponges in an effort to avoid infec-
tion. An implant-site care procedure should be
­reviewed with the patient.
• To minimize the risk of pin track infection, the
­following points should be observed:
a. Placement of Schanz screws and Steinmann pins
taking anatomy into consideration (ligaments,
nerves, arteries).
b. Slow insertion and/or cooling, particularly in
dense, hard bone to avoid heat necrosis.
c. Release of skin tension at soft tissue entry point
of implant.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 11

Modular Frame Using the Rod-to-Rod Technique

You can choose between a unilateral or modular frame

construction. If a modular frame is chosen, you can
freely choose how to set the Schanz screws. This
method is recommended by the AO as a standard
­technique for fractures that require reduction.
Schanz screws, clamps and carbon fibre rods are re-
quired to construct the different frames. Instead of ra-
diolucent carbon fibre rods, stainless steel rods can be
used for all constructions with Large External Fixators.

1. Set the Schanz screws

Set two Schanz screws per main fragment using the drill
sleeve assembly.

Freely select their position appropriate for the fracture,

soft tissue, and anatomical situation. The greater the dis-
tance b­ etween the Schanz screws, the greater the stabil-
ity of the frame.

2. C
 onnect the Schanz screws with
carbon fibre rods

Required instruments
Carbon Fibre Rod B 11.0 mm  394.800–394.870
Clamp, clip-on, self-holding 390.008
Combination Wrench B 11.0 mm 321.160

The two Schanz screws per main fragment are con-

nected with a rod. Clip-on, self-holding clamps are used.
Make sure that the rods project a bit beyond the fracture
zone so that sufficient length remains for the combina-
tion clamp.

Tighten all the clamp nuts.

22 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

3. Connect the carbon fibre rods

Required instruments
Carbon Fibre Rod B 11.0 mm  394.800–394.870
Combination Clamp, clip-on, self-holding 390.005

Connect the two ends of the rods near the fracture to a

third rod using two self-holding combination clamps.
Do not yet tighten the nuts for the combination clamps.

4. Reduce the fracture

Use the two partial frames as handles to reduce the
­fracture.

After checking the reduction, alternately tighten the

nuts of the combination clamps in the image intensifier
while manually holding the reduction.

Alternative technique:
Required instruments
Clamp, clip-on, self-holding 390.008
Combination Wrench B 11.0 mm 321.160
Carbon Fibre Rod B 11.0 mm 394.800–870

For each fragment, additionally affix one long rod

that can be used as a temporary lever for reduction.
The l­everage can be used for controlled reduction that
­requires less force (particularly recommended for the
­femur). In addition, your hands will remain safely outside
the X-rays when this technique is applied.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 22

Modular Frame Using the Rod-to-Rod Technique

5. Tighten nuts

Required instruments
Combination Wrench B 11.0 mm 321.160

Finally, recheck all the nuts with the wrench to ensure

they are all tight.

Retighten all the nuts after 24 hours.

6. Secondary reduction
A secondary correction of the reduction can be per-
formed within the first few days after surgery. Only the
two combination clamps are released. The correction
can then be made using the partial frames that move
relative to each other.

After the correction, retighten the two combination

clamps.

Precautions:
• Implant sites should be meticulously cared to
avoid pin-tract infection. Schanz screws and
Steinmann pins may be surrounded with antisep-
tic coated foam sponges in an effort to avoid infec-
tion. An implant-site care procedure should be
­reviewed with the patient.
• To minimize the risk of pin track infection, the
­following points should be observed:
a. Placement of Schanz screws and Steinmann pins
taking anatomy into consideration (ligaments,
nerves, arteries).
b. Slow insertion and/or cooling, particularly in
dense, hard bone to avoid heat necrosis.
c. Release of skin tension at soft tissue entry point
of implant.

22 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Additional Treatment Options Using the
Rod-to-Rod Technique

B 11.0 mm system

Adult femur
Insert 2–3 Schanz screws into the proximal and distal
main fragment from a lateral direction. With adipose
patients, it is recommendable to use 6.0 mm screws.
The stability of the rod-to-rod assembly can be increased
with an additional neutralization rod.

Bridging the ankle

Unilateral
Insert the screws into the calcaneus and talus from
a medial direction. In the tibia, set the screws at an
a­nteromedial to medial angle, and connect them using
the rod-to-rod technique.

Triangular
Insert the first screw from an anteromedial direction
into the tibial shaft. Insert the Steinmann pin through
the calcaneus, and affix the rods in the form of a tent
between the first screw and Steinmann pin. Then reduce
the fracture by pulling lengthwise with balanced liga-
mentotaxis. Then insert two screws into the tibia start-
ing from the medial rod. For prophylaxis of pes equines,
insert an ­additional Schanz screw at an angle from
above into the first and fifth metatarsal bone.

Bridging the knee joint

Insert two Schanz screws into the distal femur from a
lateral or ventral direction, and into the proximal tibia
from an anterome-dial direction. Connect them using
the rod-to-rod technique.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 22

Additional Treatment Options Using the Rod-to-Rod Technique

B 8.0 mm system

Humerus
Insert the Schanz screws in the proximal humerus from
a ­lateral direction and into the distal humerus from a
dorsal direction, avoiding injury to the radial nerve. Con-
nect the Schanz screws using the rod-to-rod technique.

Bridging the elbow

Insert Schanz screws into the distal humerus from a dor-
sal direction. The screws can be introduced into the fore-
arm from a dorsal direction into the ulna. Connect the
Schanz screws using the rod-to-rod technique.

It is only recommendable to insert an additional screw in

the radius to stabilize the radio-ulnar joint.

Child femur
Insert 2–3 Schanz screws into the proximal and distal
main fragment from a lateral direction. The stability of
the rod-to-rod assembly can be increased with an addi-
tional neutralization rod.

22 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Using multi pin clamps
The advantage of multi pin clamps is that reduction can
be carried out using the above-described rod-to-rod
technique. The Schanz screws with clamps serve as an
external reduction instrument system. Additional reduc-
tion levers may be used to lengthen the lever arm (see
alternative technique).

1. S
 et the Schanz screws for
multi pin clamps

Required instruments
SELDRILL Schanz Screws X94.782–788*
Drill Guide Handle, 6 positions 392.963
Drill Sleeve 6.0/5.0, short, with thread 395.921
Drill Sleeve 5.0/3.5, short 395.912
Trocar B 3.5 mm, short 394.181
Drill Sleeve 6.0/5.0 long, with thread 395.923
Drill Sleeve 5.0/3.5, long 395.913
Trocar B 3.5 mm, long 394.182
Adapter for SELDRILL Schanz Screws B 5.0 mm 393.103
Universal Chuck with T-Handle  393.100
Drill with attachment for AO/ASIF
Quick coupling type-dependent

Insert two Schanz screws into the distal and proximal

fragments using a parallel drill sleeve.

2. Assembling the Fixator

Required instruments
Multi Pin Clamp, 6 positions, large 390.002
Carbon Fibre Rod B 11.0 mm 394.800–870
Combination Wrench B 11.0 mm 321.160

Guide the clamps of the premounted clamp-rod con-

struction over the Schanz screws, and tighten the clamps
on the screws with the B 11.0 mm combination wrench.

* X=2 Stainless Steel

X=4 Titanium (TiCP)

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 22

Additional Treatment Options Using the Rod-to-Rod Technique

3. Reduction
Due to the clamps that enable the Schanz screws and
carbon-fibre rod to be independently fixed, the fracture
can be ­optimally reduced using the modular technique
with the double Schanz screws as levers.

Alternative technique:
Required instruments
Reduction Handle for Large Multi Pin Clamp 392.966
Combination Wrench B 11.0 mm 321.160
Wrench, hexagonal B 5.0 mm, long, angled 392.919

In certain cases, it is recommendable to use additional

reduction levers. Greater force can be applied from the
increased leverage. In addition, the levers enable free
image intensifier control.

4a. U
 nilateral single frame with
multi pin clamps

Required instruments
Combination Wrench B 11.0 mm 321.160

After reduction, tighten all the screws of the clamps.

22 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

4b. Unilateral double frame
construction with Multi Pin
clamps

Required instruments
Rod Attachment for large Multi Pin Clamp 390.003
Combination Wrench B 11.0 mm 321.160

If additional rod connectors are attached to the frame,

a double-frame construction can be created to increase
the stability of the frame.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 22

Unilateral Frame with Single- or Double-Rod
Construction

1. P
 rovisionally reduce the fracture,
and set the first Schanz screw
Provisionally reduce the fracture, and insert the first
Schanz screw in a main fragment. From a ventrolateral
direction, locate the first screw as distally as possible.

2. M
 ount the carbon fibre rod
and clamp

Required instruments
Carbon Fibre Rod B 11.0 mm  394.800–394.870
Clamp, clip-on, self-holding 390.008
Combination Wrench B 11.0 mm 321.160

Mount the rod with the assistance of a clip-on, self-

holding clamp.

3. Definitively reduce the fracture,

and set the second Schanz screw
After reducing the fracture, set the second Schanz screw
as proximally as possible. Secure the reduction by tight-
ening the ­proximal and distal clamp, yet continue to hold
the reduction ­until the fracture is definitively fixed (see
following pages).

22 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

4a. U
 nilateral frame with single-rod
construction

Required instruments
Clamp, clip-on, self-holding 390.008
Combination Wrench B 11.0 mm 321.160

Insert the remaining Schanz screws, and place the

­required clip-on, self-holding clamps on the rod to the
side of the screws. Tighten all the clamp nuts.

4b. Unilateral frame with double-rod

construction

Required instruments
Clamp, clip-on, self-holding 390.008
Carbon Fibre Rod B 11.0 mm  394.800–394.870
Combination Wrench B 11.0 mm 321.160

Use the same procedure as for single-rod construction;

however, after setting the first two Schanz screws, place
the second rod over the first.

The double-rod construction should be standard for the

femur.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 22

Pelvic Use – Supraacetabular Assembly

Particular care is required with external fixation assem-

blies in the pelvis. Indications for stabilizing the anterior
pelvic ring with a large external fixator are: Unstable
fractures in the anterior pelvic ring, or symphysis frac-
tures with or without participation of the posterior pelvic
ring. This type of stabilization is also possible in emer-
gencies such as polytrauma, open wounds and, where
appropriate, as an alternative to internal osteosynthesis.

The pelvis can be stabilized with an external fixator both

at the iliac crest and the supraacetabular region.
­Although the point of entry for the Schanz screw is eas-
ier to find on the iliac crest, it is frequently difficult or
impossible to attain a permanent and secure seat for the
Schanz screws in the curved ala of the ilium. For this rea-
son, the treatment of t­ he pelvis will be illustrated first
with reference to supraacetabular fixation in the follow-
ing surgical instructions.

33 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Supraacetabular pin placement

1. Setting the first two Schanz screws

Anatomical landmarks for the supraacetabular place-
ment of the Schanz screws are the superior anterior iliac
crest and inferior ­anterior iliac crest.

Set a self-drilling/self-tapping Schanz screw (SELDRILL)

on the right and left between the inferior anterior iliac
spine, and the ventral labrum of the acetabulum. Pro-
ceeding from the superior anterior iliac crest, this site of
entry is 4 to 6 cm in a caudal direction, and 3 to 4 cm in
a medial direction. When inserting the screw, make sure
that the lateral femoral cutaneous nerve is not damaged.

To prevent the screws from penetrating the acetabulum,

make sure that the screw is aligned 20–30° medially and
10–20° ­cranially. When the screws are mechanically in-
serted, concentrate on feeling if the screw is properly
screwing into the bone ­substance. Monitor the site of
entry and the advance of the self-drilling screws with the
image intensifier.

The final turns and fine adjustment of the Schanz screw

should be done manually with the universal handle.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 33

Pelvic Use – Supraacetabular Assembly

2. S
 etting the second two
Schanz screws
The second Schanz screws to be set on both sides are
­introduced somewhat cranially to the first set of screws.
The two tips can slightly converge.

3. Ventral connection

Required instruments
Carbon Fibre Rod B 11.0 mm 394.800–394.870
Clamp, clip-on, self-holding 390.008
Combination Clamp, clip-on, self-holding 390.005
Combination Wrench B 11.0 mm 321.160

Initially, the two caudal screws of the bilaterally set

Schanz screws are connected with two carbon fibre rods
and a self-holding combination clamp. It is important for
the assembly to be large enough to allow a sufficient
­degree of freedom to accommodate swelling of the
­abdomen.

The rods are held with a combination clamp but are not
tightened.

33 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

4. Reduction

Required instruments
Combination Wrench B 11.0 mm 321.160

Manually reduce the pelvic ring by pressure, stretching,

or using the Schanz screws as levers. In certain cases,
distraction by pulling on a leg can be advantageous.
­After reduction, tighten the combination clamp.

5. Connect the second pair of screws

Required instruments
Carbon Fibre Rod B 11.0 mm  394.800–394.870
Clamp, clip-on, self-holding 390.008
Combination Clamp, clip-on, self-holding 390.005
Combination Wrench B 11.0 mm 321.160

If the reduction of the pelvis has been correctly carried

out, the two top Schanz screws can be connected with
each other.

Note: Instead of the rods and combination clamps,

a curved carbon fibre rod 394.790 can be used for
both the first and second pair of screws.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 33

Pelvic Use – Supraacetabular Assembly

6. Connecting the partial frames

Required instruments
Connecting Rod B 5.0 mm, Stainless Steel393.900–393.940
Self-tapping Schanz Screw  X94.520–570*
Protective Cap, for Schanz Screws and
Steinmann Pins B 5.0 mm 393.420

To increase the stability of the construction, the two

­partial frames are connected with additional 4.0 mm
cross-braces (such as 4.0 mm carbon fibre rods or Schanz
screws with a protective cap). The clip-on, self-holding
clamps are particularly suitable for mounting an addi-
tional cross-brace.

* X=2 Stainless Steel

X=4 Titanium Alloy (TAN)

33 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Placing pins in the Iliac crest

1. Setting the first two Schanz screws

The iliac crests serve as landmarks for introducing the
Schanz screws. Marking the inner and outer surfaces of
the ala of the ilium with Kirschner wires can help estab-
lish the alignment for placing the first Schanz screw.

Note: It is advantageous to place at least one screw

in the ­margin of the os ilium on both sides.

2. S
 etting the second two
Schanz screws
The second screw is set slightly posterior (approximately
2 cm) to the first Schanz screw.

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 33

Pelvic Use – Supraacetabular Assembly

3. Reduction and definitive assembly

Required instruments
Carbon Fibre Rod B 11.0 mm 394.800–394.870
Clamp, clip-on, self-holding 390.008
Combination Clamp, clip-on, self-holding 390.005
Combination Wrench B 11.0 mm 321.160
Self-tapping Schanz Screw  X94.520–570*
Protective Cap, for Schanz Screws and
Steinmann Pins B 5.0 mm 393.420

The additional steps for fixing the pelvis are analogous

to points 3–6 on pages 32 to 34.

Note: In individual cases, the supraacetabular

­assembly and crest assembly can be combined.

* X=2 Stainless Steel

X=4 Titanium Alloy (TAN)

33 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Bilateral Frame for Arthrodesis and Osteotomies

Arthrodesis and osteotomies generally require symmetri-

cal ­compression that is best generated using a bilateral
frame construction.

Bilateral frames for arthrodesis

Required instruments
Steinmann Pin B 5.0 mm with trocar tip X93.500–X93.590*
Carbon Fibre Rod B 11.0 mm 394.800–394.870
Clamp, clip-on, self-holding 390.008
Combination Wrench B 11.0 mm 321.160
Protective Cap, for Schanz Screws and
Steinmann Pins B 5.0 mm 393.420
Compressor, open 393.760
Drill Bit B 3.5 mm, length 195/170 mm, 2-flute,
for Quick Coupling 310.370

The large external fixator enables effective compression

by pretensioning the Steinmann pins in relation to each
other. Maximum stability is attained by first untightening
the relevant clamp nuts, then generating the desired
compression using the open compressor, and then re-
tightening the nuts.

Knee arthrodesis Ankle arthrodesis

* X=2 Stainless Steel

X=4 Titanium Alloy (TAN)

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 33

Bilateral Frame for Arthrodesis and Osteotomies

Bilateral frames for Osteotomies

Required instruments
Steinmann Pin B 5 mm with trocar tip X93.500–X93.590*
Carbon Fibre Rod B 11.0 mm 394.800–394.870
Clamp, clip-on, self-holding 390.008
Combination Wrench B 11.0 mm 321.160
Protective Cap, for Schanz Screws and
Steinmann Pins B 5.0 mm 393.420
Compressor, open 393.760
Drill Bit B 3.5 mm, length 195/170 mm, 2-flute,
for Quick Coupling 310.370

In the case of osteotomies of the proximal and distal

tibia, inner fixation is generally preferred if there are no
associated soft-­tissue problems.

Compression osteotomies with a bilateral frame con-

struction are supportive of the metaphysis of rapid bone
healing.

Proximal tibia osteotomy Distal tibia osteotomy

* X=2 Stainless Steel

X=4 Titanium Alloy (TAN)

33 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Implants

Note: For detailed information of the Schanz screws

and the Steinmann pins, refer to the Surgical Tech-
nique Schanz Screws and Steinmann Pins (DSEM/
TRM/0516/0677).

For the Large External Fixator

SELDRILL Schanz Screws

Titanium* Stainless Steel Diameter Length
(mm) (mm)
494.782–788 294.782–788 5.0 100–250
494.792–798 294.792–798 6.0 100–250

Self-Tapping Schanz Screws

Titanium Stainless Steel Diameter Length
alloy ** (mm) (mm)
494.520–570 294.520–570 5.0 100–190
494.650–680 294.650–680 6.0 100–190

For the Medium External Fixator

SELDRILL Schanz Screws

Titanium* Stainless Steel Diameter Length
(mm) (mm)
494.769 294.769 4.0/2.5 80
494.771 294.771 4.0/3.0 80
494.772 294.772 4.0/3.0 100
494.774–779 294.774–779 4.0 60–175

Self-Tapping Schanz Screws

Titanium Stainless Steel Diameter Length
alloy ** (mm) (mm)
494.445 294.445 4.0/2.5 80
494.300 294.300 4w.0/3.0 80
494.430–460 294.430–460 4.0 60–125

** (TiCP)
** (TAN)

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 33

Fixation Components for the Large External Fixator

390.008 Clamp, clip-on, self-holding

390.005 Combination Clamp, clip-on, ­

self-holding

390.002 Multi Pin Clamp, 6 positions, large

390.004 Multi Pin Clamp, 4 positions, large

390.007 Rod-to-rod Clamp

390.003 Rod Attachment for large Multi Pin

Clamp

394.800–870 Carbon Fibre Rod, B 11.0 mm,

lengths 100–400 mm

44 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Fixation Components for the Medium External Fixator

390.035 Clamp, medium, clip-on, self-holding

390.031 Combination Clamp, medium, clip-on,

self-holding

390.037 Combination Clamp 8.0/11.0, clip-on,

self-holding

390.033 Multi Pin Clamp, 4 positions, medium

390.036 Multi Pin Clamp, 6 positions, medium

390.034 Rod Attachment for medium Multi Pin

Clamp

390.051 Clamp for External Fixator for Distal

Radius

395.779–797 Carbon Fibre Rod, B 8.0 mm,

length 160–400 mm

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 44

Instruments

Adapters

393.101 Adapter for SELDRILL Schanz Screw

B 4.0 mm

393.103 Adapter for SELDRILL Schanz Screw

B 5.0 mm

393.104 Adapter for SELDRILL Schanz Screw

B 6.0 mm

Protective caps

393.400 Protective Cap for Schanz Screws and

Steinmann Pins B 4.0 mm

393.420 Protective Cap for Schanz Screws and

Steinmann Pins B 5.0 mm

Combination wrenches

321.160 Combination Wrench B 11.0 mm

321.158 Combination Wrench B 8.0 mm

44 DePuy Synthes Surgical Technique Large and Medium ­External Fixators

Handles for drill sleeves

392.963 Drill Guide Handle, 6 positions

395.911 Handle for Drill Sleeve

Drill sleeves
Drill sleeves 6.0 mm (for use with 5.0 mm system)

392.951 Drill Sleeve 8.0/6.0, short, with thread

392.952 Drill Sleeve 8.0/6.0, long, with thread

Drill sleeves 5.0 mm

395.921 Drill Sleeve 6.0/5.0, short, with thread

395.912 Drill Sleeve 5.0/3.5, short

394.181 Trocar B 3.5 mm, short

395.923 Drill Sleeve 6.0/5.0, long, with thread

395.913 Drill Sleeve 5.0/3.5, long

394.182 Trocar B 3.5 mm, long

Large and Medium ­External Fixators Surgical Technique DePuy Synthes 44

Instruments

Drill sleeves 4.0 mm

395.922 Drill Sleeve 4.0, with thread

392.955 Drill Sleeve 4.0/2.5

394.183 Trocar B 2.5 mm

44 DePuy Synthes Surgical Technique Large and Medium ­E xternal Fixators

 All rights reserved. DSEM/TRM/0416/0651 SE_ 808402 AA 05/20
© DePuy Synthes Trauma, a division of Synthes GmbH. 2020.

Synthes GmbH Not all products are currently available in all markets.
Eimattstrasse 3
4436 Oberdorf This publication is not intended for distribution in the USA.
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Tel: +41 61 965 61 11 All surgical techniques are available as PDF files at
www.jnjmedicaldevices.com www.depuysynthes.com/ifu 0123