Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide

Cannulated Pediatric OsteotomySystem (CAPOS). A single system ofosteotomy blade plates and cannulatedinstrumentation.

Technique Guide

23361_J4287F_Tech Guide 9/13/10 3:04 AM Page C1

Introduction

Surgical Technique

Product Information

Table of Contents

Cannulated Pediatric Osteotomy System (CAPOS) 2

AO Principles 3

Indications 4

Preoperative Planning 5

Place Guide Wire 6

Insert Chisel 9

Perform Osteotomy 12

Insert Plate 13

Secure Plate 14

Postoperative Care and Cleaning Tip 15

Instruments 16

Set Lists 19

Image intensifier control

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23361_J4287F_Tech Guide 9/13/10 3:04 AM Page 1

Cannulated Pediatric Osteotomy System (CAPOS)

The Cannulated Pediatric Osteotomy System (CAPOS) combines implants and instruments in one convenient system. This system offers the advantages of the osteotomyblade plates and cannulated instrumentation. Osteotomyplates provide ease of reduction and good rotational stabilitywhile maintaining bone stock. Cannulated instruments workover a guide wire for precise placement and safety.

Features– Osteotomy plates are offered in a variety of sizes:

infant, toddler, child, and adolescent

– Cannulated chisels and guide wires simplify surgical technique

– Saw guides improve the accuracy of the osteotomy and reduce surgical time

– Two graphic cases provide organization and storage for the complete system

2 Synthes Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide


AO Principles

The fundamental aim of long bone osteotomy is to alteranatomy, including axial and rotational alignment. Throughvarus, valgus and/or rotational osteotomy, limb function, patient mobility, and comfort can be improved, while subluxation, dislocation and eventual degeneration of thehip are prevented.

The Cannulated Pediatric Osteotomy System (CAPOS) adheres to the basic principles of internal fixation developedby the AO.1 Osteotomy plates and screws allow reduction ofthe osteotomy, provide stable internal fixation, preserve theblood supply, and in certain cases permit early mobilization.

1. T.P. Rüedi and W.M. Murphy, ed. AO Principles of Fracture Management. New York: Thieme, 2000.

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The CAPOS System is intended for use in infants, toddlers,children, adolescents, and small-stature adult patients.

Specific indications include:– Intertrochanteric derotation and varus osteotomies

(Osteotomy Plates—Infant, Toddler, Child, Adolescent, and Bifurcated)

– Intertrochanteric valgus osteotomies(95° Condylar Plates—Adolescent and Small Stature Adult)

– Femoral neck and pertrochanteric fractures(130° Angled Blade Plates—Adolescent and Small Stature Adult)


Indications

4 Synthes Cannulated Pediatric Osteotomy System (CAPOS)

Please see the package insert for a complete list of contraindications, warnings, precautions, and adverse effects.


1Preoperative planning

Preoperatively evaluate and plan the surgical procedure. Determine the appropriate osteotomy plate by blade length,angle, and displacement. Note the corresponding guide wirediameter. The AO Preoperative Planner (6000) assists in selection of the appropriate osteotomy plate; it contains Müller’s classic description2 of osteotomy surgical technique. The osteotomy plates are available with various offsets. Theplate offset is designed to create “medialization” of the distal fragment to restore the proper mechanical axis of thelong bone. In a valgus or purely derotational osteotomy, a smaller offset is typically best. In a large, angled varus osteotomy, a larger offset is often best.

Note: The technique described in this guide is for a varusderotational osteotomy of the proximal femur, utilizing a 90° osteotomy blade plate. Steps may differ for alternativeosteotomy techniques or fracture repair.

2Position the patient

Surgery is typically performed on a radiolucent operatingtable. Position the patient for AP views of the hip underimage intensification. Obtain lateral views of the hip by flexing and abducting the leg.

3Surgical approach

Use a standard lateral approach to the proximal femur.3

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Preoperative Planning


3. Raymond T. Morrissy. Atlas of Pediatric Orthopaedic Surgery.Philadelphia: J. B. Lippincott Company, 1992.


Place Guide Wire


4Place guide wire

Instruments

314.070 Small Hexagonal Screwdriver

333.683 Adjustable Wire Guide

A guide wire may be held on the anterior side of the femoral neck to assist in determination of the direction that the definitive guide wire will take.

Set the adjustable wire guide to the angle determined in thepreoperative plan, using the small hexagonal screwdriver. Forexample, if a 30° varus osteotomy is planned, using a 90° osteotomy plate, then the adjustable wire guide should beset at 120° (= 30°+90°).


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Choose the guide wire that correspondswith the cannulated chisel and osteotomyplate selected.

Load the guide wire through the adjustable wire guide. Insert the wireinto the femoral neck (Figures 1, 2 and3a). Optimal placement of the guidewire is inferior in the neck, above thecalcar region as seen in the AP view. Inthe lateral view, the guide wire shouldbe located centrally in the femoral neck.

Verify final placement of the guide wire in both views, under image intensification (Figure 3b).

Note: Be aware that marginal placementof the guide wire could cause the chiseland osteotomy plate to penetrate themedial, anterior or posterior cortex.

Direct Cannulated Saw Implant Size Guide Wire Measuring Chisel Guide Device

Infant 292.722 (1.6 mm) 319.17 332.173 332.356

Toddler 292.652 (2.0 mm) 319.21 332.174 332.355

Child/Adolescent 292.652 (2.0 mm) 319.21 332.175 332.354

Figure 1 Figure 2

Figure 3a Figure 3b


Place Guide Wire continued

4Place guide wire continued

Instrument

319.17 Cannulated Screw (Direct) Measuring Device or 319.21

Slide the appropriate direct measuring device over the guide wire. Determine and record the insertion depth of the guide wire. This measurement is critical in determiningappropriate chisel insertion in the next step. The properblade length of the osteotomy plate will typically be the next size smaller than the measurement taken with the direct measuring device.



Insert Chisel

5Insert chisel

Instruments

332.09 Chisel Guide

332.173– Cannulated Chisels332.175

Place the cannulated chisel in the chisel guide and over the guide wire. The chisel and chisel guide assembly can be rotated in the anterior or posterior direction to achieve flexionor extension, respectively. Should a neutral position be desired,the chisel guide should align with the femoral shaft.

Anterior angulation = flexion at the osteotomy sitePosterior angulation = extension at the osteotomy site

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Neutral

Flexion

Extension


Insert Chisel continued

5Insert chisel continued

Instrument

319.17 Cannulated Screw (Direct) Measuring Device or 319.21

399.42 Hammer

Correct insertion depth can be calculated by taking themeasurement obtained with the direct measuring device andsubtracting the osteotomy plate blade length. This figureshould correspond with the appropriate chisel insertiondepth as measured by the calibrated window of the chisel.

Note: Direct measuring device (DMD) measurement (see Step 4) minus implant blade length equals insertionmeasurement on chisel window (see example).

Use the hammer to drive the cannulated chisel along theguide wire and into the femoral neck. During hammering of the chisel, take care to keep the chisel properly trackingover the guide wire and avoid any bending force on the wire.It is often advantageous to intermittently withdraw the chisel during insertion.


Example:44 mm (DMD measurement)

–38 mm (implant blade length) 6 mm


During chisel insertion, verify proper tracking over the guide wireby periodically checking progress with image intensification.

Monitor insertion depth by observing the position of the guidewire in the calibrated window of the chisel. Stop insertiononce the predetermined insertion measure ment is achieved.

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Perform Osteotomy

6Perform osteotomy

Instruments

332.173– Cannulated Chisels332.175

332.20 Slotted Hammer

332.354, Saw Guides332.355 or 332.356

Before beginning the osteotomy, ensure that the chisel isloosened slightly, with a reverse impact with the slotted hammer.

Insert rotation guide wires above and below the osteotomysite in a manner that will not interfere with plate placement.Protect the medial soft tissues with retractors.

Slide the appropriate saw guide on the inferior side of thecannulated chisel. With image intensification, check that thesuperior cut will be below the level of the femoral neck. Using appropriate power equipment and saw, perform thefirst osteotomy cut parallel to the saw guide (Figure 1).

Using the cannulated chisel as a lever, carefully tilt the proximalbone fragment to the desired position. Make the second cutstarting at the same point on the lateral cortex, but directedperpendicular to the femoral shaft (Figure 2). Remove thewedge of bone from the distal segment of the femur.

Note: In some cases, particularly of neuromuscular disease,the bone may be extremely soft.

Alternative techniqueThe first osteotomy cut may be made at a right angle (perpendicular) to the femoral shaft, at the level determinedfrom the preoperative plan. The second cut is then made tothe distal bone fragment and the wedge of bone is removed.4

If this technique is chosen, the saw guide may still be used,exercising the proper degree of caution to prevent sawincursion into the femoral neck.



Figure 1

Figure 2


Insert Plate

7Insert plate

Instruments

321.20 Ratchet Wrench

332.21 Impactor

332.352 or Inserter /Extractors332.353

333.060, Triangular Positioning Plates333.070 or 333.080

398.811*, Plate Holding Forceps with swivel foot398.812* or (size 0, 1 or 2)398.813*

Carefully remove the cannulated chisel, saw guide, andguide wire.

Insert the selected osteotomy plate by hand, ensuring thatthe plate follows the path created by the chisel. It is best toavoid using a hammer during initial insertion, so that onecan feel the plate tracking properly along the chisel path.Verify with image intensification that the plate is followingthe chisel track.

After the plate has been inserted sufficiently, affix the properinserter/extractor and tighten with the ratchet wrench. Thiswill provide control of the proximal fragment. Continue insertion using the hammer (Figure 3).

Reduce the proximal and distal segments. Provisionally clampthe distal segment to the plate, using plate holding forceps.Check varus, flexion, and extension alignment. Remove theinserter/extractor. Use the impactor to completely insert theplate into the femoral neck (Figure 4).

Use the previously placed guide wires to adjust rotation. Normalanteversion is approx imately 20°, but other anteversion valuesmay be appropriate. The triangular positioning plates can beused to measure rotation.

Examine osteotomy alignment with image intensification.

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Figure 3

Figure 4

*Also available


Secure Plate

8Secure plate

Instrument

332.352 or Inserter /Extractors332.353

Secure the plate to the femoral shaft using standard DCP screw insertion technique, selecting the appropriate size cortex screws.

The final result should be verified with AP and lateral views.


332.352 and plate

332.353 and plate


Postoperative Care and Cleaning Tip

Postoperative care

Postoperative care depends on many factors and needs to be individualized by the surgeon. Bed rest, spica casting, ormobilization with partial weight bearing is dependent uponpatient age, compliance, and diagnosis.

Cleaning tip

Instruments

319.26 or Cleaning Brushes (1.75 mm or 2.1 mm)319.27

319.35 or Cleaning Stylets (1.6 mm or 2.0 mm)319.36

Cleaning the cannulation of the chisels is imperative to prevent accumulation of debris. Instruments can be cleanedintraoperatively using the cleaning stylets and postoperativelyusing the cleaning brushes.

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Selected Instruments from CAPOS Instrument Set (105.364)

319.26 1.75 mm Cleaning Brush319.27 2.1 mm Cleaning Brush

319.35 1.6 mm Cleaning Stylet319.36 2.0 mm Cleaning Stylet

332.09 Chisel Guide, with adjustable angle

332.173 Cannulated Chisel, for use with Infant Osteotomy Plates

332.174 Cannulated Chisel, for use with Toddler Osteotomy Plates

332.175 Cannulated Chisel, for use with Child and Adolescent Osteotomy Plates



332.352 Inserter/Extractor, for bifurcated, infant, and toddler osteotomy plates

332.353 Inserter/Extractor, for Child and Adolescent Osteotomy Plates

332.354 Saw Guide, for Child/Adolescent Osteotomy Plates

332.355 Saw Guide, for Toddler Osteotomy Plates

332.356 Saw Guide, for Infant Osteotomy Plates

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332.21 Impactor

Bottom Side

Bottom Side

Bottom Side


Selected Instruments from CAPOS Instrument Set (105.364) continued

333.060 90° /50° /40° Triangular Positioning Plate

333.070 80° /70° /30° Triangular Positioning Plate

333.080 100°/60° /20° Triangular Positioning Plate

333.683 Adjustable Wire Guide, for 1.6 mm to 2.0 mm Guide Wires



Cannulated Pediatric Osteotomy System (CAPOS) Instrument Set (105.364)

Graphic Case690.364 Cannulated Pediatric Osteotomy System

Instrument Set Graphic Case

Instruments292.20 2.0 mm Kirschner Wire, 150 mm, trocar

point, 1 pkg. of 10

292.652 2.0 mm Non-Colored Threaded Guide Wire, 230 mm, spade point, 4 ea.

292.722 1.6 mm Non-Colored Threaded Guide Wire, 150 mm, spade point, 4 ea.

310.25 2.5 mm Drill Bit, quick coupling, gold, 110 mm, 2 ea.

310.31 3.2 mm Drill Bit, quick coupling, 145 mm, 2 ea.

311.32 Tap for 3.5 mm Cortex Screws, gold, 110 mm

311.44 T-Handle, with quick coupling

311.46 Tap for 4.5 mm Cortex and 4.5 mm Shaft Screws, 130 mm, 57 mm tap depth

312.20 2.0 mm Parallel Drill Guide and Drill Sleeve

314.03 Small Hexagonal Screwdriver Shaft, quick coupling

314.070 Small Hexagonal Screwdriver, 2.5 mm width across flats

314.09 Holding Sleeve (for small hexagonalscrewdrivers)

314.11 Holding Sleeve (for large hexagonalscrewdrivers)

314.15 Large Hexagonal Screwdriver Shaft, quick coupling

314.27 Large Hexagonal Screwdriver

319.04 Depth Gauge, for 2.7 mm and small screws

319.10 Depth Gauge, for large screws

319.17 Cannulated Screw (Direct) Measuring Device, for use with 4.5 mm Cannulated Screws

319.21 Cannulated Screw (Direct) Measuring Device, for use with 7.0 mm Cannulated Screws

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Note: For additional information, please refer to package insert.

For detailed cleaning and sterilization instructions, please refer tohttp://us.synthes.com/Medical+Community/Cleaning+and+Sterilization.htmor to the below listed inserts, which will be included in the shipping container:—Processing Synthes Reusable Medical Devices—Instruments, Instrument Trays

and Graphic Cases—DJ1305—Processing Non-sterile Synthes Implants—DJ1304


Cannulated Pediatric Osteotomy System (CAPOS) Instrument Set (105.364) continued


Instruments continued

319.26 1.75 mm Cleaning Brush

319.27 2.1 mm Cleaning Brush

319.35 1.6 mm Cleaning Stylet

319.36 2.0 mm Cleaning Stylet

321.12 Articulated Tension Device, with gauge, span 20 mm

321.20 Ratchet Wrench, 11 mm width across flats

323.36 3.5 mm Universal Drill Guide

323.46 4.5 mm Universal Drill Guide

332.09 Chisel Guide, with adjustable angle

332.173 Cannulated Chisel, for use with Infant Osteotomy Plates

332.174 Cannulated Chisel, for use with Toddler Osteotomy Plates

332.175 Cannulated Chisel, for use with Child and Adolescent Osteotomy Plates

332.20 Slotted Hammer

332.21 Impactor

332.352 Inserter/Extractor, for bifurcated, infant, andtoddler osteotomy plates

332.353 Inserter /Extractor, for Child and AdolescentOsteotomy Plates

332.354 Saw Guide, for Child /Adolescent Osteotomy Plates

332.355 Saw Guide, for Toddler Osteotomy Plates

332.356 Saw Guide, for Infant Osteotomy Plates

333.060 90°/50°/40° Triangular Positioning Plate



333.683 Adjustable Wire Guide, for 1.6 mm to 2.0 mm Guide Wires

359.204 Locking Pliers

399.42 Hammer, 500 grams


Cannulated Pediatric Osteotomy System (CAPOS) Implant Set (105.365)

Graphic Cases and Trays60.108.010 Cannulated Pediatric Osteotomy System

Implant Graphic Case

Implants (in 60.108.010)3.5 mm Cortex Screws, self-tapping, 8 ea.

Length (mm) Length (mm)

204.814 14 204.824 24204.816 16 204.826 26204.818 18 204.828 28204.820 20 204.830 30204.822 22

115° Bifurcated Plates, 2 holes, 2 ea.

Blade Length (mm) Displacement (mm)

236.400 30 5236.430 35 5

90° Infant Osteotomy Plates, 2 ea. Blade Length (mm) Displacement (mm)

236.250 25 7236.260 32 7236.350 25 12236.360 32 12

90° Toddler Osteotomy Plates, 2 ea.


236.001 26 4236.002 32 4236.011 26 8236.012 32 8236.013 38 8

100° Toddler Osteotomy Plates, 2 ea.


236.101 26 4236.102 32 4236.103 38 4236.104 44 4236.111 26 8236.112 32 8236.113 38 8236.114 44 8

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Cannulated Pediatric Osteotomy System (CAPOS) Implant Set (105.365) continued


Implants (in 60.108.010)4.5 mm Cortex Screw, self-tapping, 8 ea.

Length (mm) Length (mm)

214.816 16 214.826 26214.818 18 214.828 28214.820 20 214.830 30214.822 22 214.832 32214.824 24

80° Child Osteotomy Plates, 2 ea.


235.170 35 8235.190 45 8



235.270 35 8235.290 45 8



235.370 35 8235.390 45 8

90° Adolescent Osteotomy Plates, 2 ea.


235.600 50 10235.680 40 10235.700 50 15235.720 60 15235.780 40 15

100° Adolescent Osteotomy Plates, 2 ea.


235.601 50 10235.681 40 10235.701 50 15235.721 60 15235.781 40 15

Instrument319.97 Screw Forceps


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Also Available

90° Infant Osteotomy Plates Blade Length (mm) Displacement (mm)

236.352 37 12236.354 42 12

90° Toddler Osteotomy Plate


236.003 38 4

95° Condylar Plates, 5 holes

Blade Length (mm) Shaft Length (mm)

282.50 50 92282.52 60 92282.54 70 92282.58 40 92



282.70 50 124282.72 60 124282.74 70 124282.78 40 124



282.90 50 156282.92 60 156282.94 70 156282.98 40 156

*Note: Seating Chisel (332.19) is needed for use with these plates.

130° Angled Blade Plates, 4 holes*


283.40 50 60283.42 60 60283.44 70 60283.46 80 60



283.60 50 104283.62 60 104283.64 70 104283.66 80 104



283.90 50 152283.92 60 152283.94 70 152283.96 80 152

332.19 Seating Chisel

398.811 Plate Holding Forceps with swivel foot, size 0




Synthes (USA)1302 Wrights Lane EastWest Chester, PA 19380Telephone: (610) 719-5000To order: (800) 523-0322Fax: (610) 251-9056

Synthes (Canada) Ltd.2566 Meadowpine BoulevardMississauga, Ontario L5N 6P9Telephone: (905) 567-0440To order: (800) 668-1119Fax: (905) 567-3185

© 2003 Synthes, Inc. or its affiliates. All rights reserved. DCP and Synthes are trademarks of Synthes, Inc. or its affiliates. Printed in U.S.A. 8/10 J4287-F

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Cannulated Pediatric Osteotomy System (CAPOS) Technique Guide

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