Synthes Hybrid Fixator User manual

Hybrid Fixator—Distal Tibia Frame.
Using rings with clamps.
Technique Guide
Part of the
External
Fixation
System

1
6
7
8
9
3
11
2
A
B
4, 5
Hybrid Fixator—Distal Tibia Frame
1
Insert wires
2
Attach wires to ring using adjustable wire/pin clamps
3
Wrench-tighten clamp-locking nuts
4
Tighten wire-locking nuts
Wrench-tighten the wire-locking nut on the far side of the
ring (A). Finger-tighten on the side to be tensioned (B).
5
Tension wires
Typically, wires are tensioned to 100 kg. Tighten wire-locking
nuts (B) and remove tensioner. To obtain maximum wire
tension, it is recommended after tensioning the second wire,
to retension both wires in the same sequence to obtain the
best frame stability. An alternative method would be to use
two tensioners simultaneously.
6
Insert Schanz screw into distal fragment
Insert through wire/pin clamp.
Note: A third wire can be inserted if the fracture pattern
does not permit Schanz screw placement.
Technique Overview
SynthesSynthes Hybrid Fixator— Distal Tibia Frame Technique Guide

7
Trim, bend and cap wires
Leave 3 cm–4 cm in case retensioning becomes necessary.
8
Construct anterior half-frame
9
Connect ring to half-frame with ring-to-rod clamp
10
Reduce extra-articular component of fracture
Use ring and anterior rod as handles to manipulate fracture.
Tighten ring-to-rod clamp.
11
Add second rod
Connect ring-to-rod clamp and large combination clamp.
Add carbon fiber rod.
Note: Operating instructions for the Wire Tensioner
(393.742) can be found in Wire Tensioners for Hybrid Fixator
(The AO ASIF Hybrid Fixator Technique Guide).
Synthes
10
Synthes

Recommended Components for Hybrid Fixator
Synthes Hybrid Fixator— Distal Tibia Frame Technique Guide
Product Item Quantity
Number Needed
390.005 Large Combination Clamp 3
393.464 Adjustable Wire/Pin Clamp 5
393.436 Ring-to-Rod Clamp 2
294.785 5.0 mm Self-Drilling 3
Schanz Screw, 175 mm
292.38 – Spade-Point Reduction Wire 2
292.41 (or Spade-Point Wire)
Notes: Additional components are required for optional
frame configurations.
Additionally available lengths of stainless steel self-drilling
Schanz screws, stainless steel non–self-drilling Schanz screws
and titanium self-drilling Schanz screws may also be used.
Although some components are MR Conditional, the
standard hybrid frame is not safe to be utilized in an
MR environment.

Synthes
Product Item Quantity
Number Needed
394.8x 11.0 mm Carbon Fiber Rod 2
393.7xx 3/4 Ring (size chosen should 1
allow two finger breadths of
soft tissue clearance)
394.97 Protective Cap, for 11.0 mm rods 4
394.99x Protective Cap, for Fixation Pins 3
392.18 Protective Cap, for 1.8 mm and 4
2.0 mm wires

Hybrid Fixator—Distal Tibia Frame
Synthes Hybrid Fixator— Distal Tibia Frame Technique Guide
When to use
The hybrid frame is used for the stabilization of complex
distal tibial fractures, particularly those involving the joint.
Wire positioning
Proper wire positioning follows these basic guidelines:
– Use a minimum of two wires with a separating angle of
at least 60° and approaching 90° when possible.1Ideally,
the wires should intersect in the center of the bone.
– Wires may be positioned at different levels using the
adjustable wire/pin clamp.
– An adequate incision should be made at wire and Schanz
screw insertion points to avoid skin tenting and soft tissue
irritation. Wires should be straight for the same reason.
– Place an additional Schanz screw or third wire in the distal
fragment for stability. If a Schanz screw is used, it should
be placed above the ring and angled distally to maximize
thread purchase in the bone.
– The anatomy surrounding the distal portion of the tibia
should be taken into consideration for wire placement
(Figure 1).
– Place wires within the distal fragment and proximal to
interfragmentary screws (Figure 2).
Wire
A1
A2B
Figure 1
Typical wire positions, as noted on diagram:
A. Wire can be placed either lateral to medial (A1) or
posterolateral to anteromedial through the fibula (A2)
B. Posteromedial to anterolateral tibia
Figure 2
1. F.J. Kummer. “Biomechanics of the Ilizarov External Fixator.”
Clinical Orthopaedics and Related Research. 1992;280. 11–14.

Synthes
Basic principles
– Many of these fractures are due to high energy injuries and
may require provisional stabilization by reduction and fixation
of an associated fibula fracture and use of a large external
fixator across the ankle joint. When the soft tissues are stable,
definitive fixation with a hybrid fixator will follow.
– Apply distraction, if required. The Large Distractor (394.35)
may be placed across the ankle joint to provide ligamento-
taxis and to aid in fracture reduction.
– Restore the articular surface. Screw fixation must be used
to provide interfragmentary compression after anatomic
reduction of the articular surface. Bone graft may be
necessary for any metaphyseal defect.2
– Opposing spade-point reduction wires may be used.3,4
They prevent frame movement and are helpful in the
reduction of small fragments. When using spade-point
reduction wires, insert the wire until the “olive” contacts
the bone surface. Washers can be used in osteopenic
bone (see Figure 3).
– To increase frame stability, the distal pin on the anterior
rod should be 2 cm proximal to the fracture, and the
second pin should be as far proximal as possible. To
accommodate pins placed in differing planes, modular
frame technique, using more than one carbon fiber rod,
can be used in place of the anterior frame. (See the Basic
Modular Frame Technique Guide.)
– A second carbon fiber rod must be placed either laterally
or medially for optimal stability. When ORIF is performed
on the fibula, the rod must be placed medially in order to
prevent varus deformity. A third rod can be added on the
opposite side.
– Preoperative planning of clamp and ring placement should
take future x-ray visibility of both the joint line and the
fracture site into consideration.
– To achieve fine distraction, Open Compressors (393.76)
can be used (Figure 4). For more information, consult the
Open Compressor Technique Guide.
Figure 4
Figure 3
2. R. Barbieri, R. Schenk, K. Koval, K. Aurori, and B. Aurori. “Hybrid External
Fixation in the treatment of tibial plafond fractures.” Clinical Orthopaedics and
Related Research. 1996;332. 16–22.
3. G.L. Orbay, V.H. Frankel and F.J. Kummer. “The Effect of Wire Configuration
in the Stability of the Ilizarov External Fixator.” Clinical Orthopaedics and Related
Research. 1992;279. 299–302.
4. Kummer. op cit..

Using the Adjustable Wire/Pin Clamp (393.464)
Synthes Hybrid Fixator— Distal Tibia Frame Technique Guide
1
Hold clamp in hand as with a
syringe.
2
Pull vise plates apart with thumb
and fingers.
3
Hook top vise plate over ring and
release.
The wire/pin connection provides up to 15 mm
of excursion for versatile wire or pin placement.
15 mm
Clamp-locking
nut
Wire-locking
nut

Optional Frame Configurations
Synthes
Large multi-pin clamp frame with an
additional Schanz screw in the first
metatarsal to prevent equinus contracture
Frame with anterior, medial and
lateral carbon fiber rods
Large multi-pin clamp frame with anterior
and medial carbon fiber rods
Additional reading
D.L. Helfet, K. Koval, J. Pappas, R.W. Sanders, and T. DiPasquale. “Intra-articular
‘Pilon’ Fracture of the Tibia.” Clinical Orthopaedics and Related Research.
1994;298. 221–228.
P. Tornetta III, L. Weiner, M. Bergman, N. Watnik, J. Steuer, M. Kelley, and E.Yang.
“Pilon Fractures: Treatment with Combined Internal and External Fixation.”
Journal of Orthopaedic Trauma. 1993;7,6. 489–496.
J.T. Watson, D.E. Karges, K.E. Cramer, and B.R. Moed. “Analysis of Failure of
Hybrid Fixation Techniques for the Treatment of Distal Tibial Pilon Fractures.”
paper #60, Orthopaedic Trauma Association 16th Annual Meeting, October 12–14,
2000. San Antonio, TX.

Hybrid Fixator Universal Set (115.940)
Synthes Hybrid Fixator— Distal Tibia Frame Technique Guide
Graphic Case
304.340 Hybrid Fixator Set Graphic Case
Implants.
219.98 Washer, 7.0 mm, 6 ea.
292.38 1.8 mm Spade-Point Wire, 350 mm, 6 ea.
292.39 1.8 mm Spade-Point Reduction Wire,
400 mm, 4 ea.
292.40 2.0 mm Spade-Point Wire, 350 mm, 6 ea.
292.41 2.0 mm Spade-Point Reduction Wire,
400 mm, 4 ea.
294.785 5.0 mm Self-Drilling Schanz Screw,
175 mm, 6 ea.
Instruments
310.37 3.5 mm Drill Bit, quick coupling,195 mm, 2 ea.
321.20 Ratchet Wrench, 11 mm width across flats
391.962 Bending/Cutting Pliers
393.10 Universal Chuck with T-Handle
393.103 Drive Adaptor with quick coupling, for 5.0 mm
Schanz Screws
393.742 Wire Tensioner
393.743 Backup Wire Tensioner
393.745 Split Tissue Protection Sleeve, for wires
up to 2.5 mm
393.746 Split Tissue Protection Sleeve, for wires
and pins up to 5.0 mm
394.182 3.5 mm Trocar, 118 mm (long)
395.913 5.0 mm/ 3.5 mm Drill Sleeve, 107 mm (long)
Fixation Material
390.005 Large Combination Clamp, 6 ea.
392.18 Protective Caps, for 1.8 mm and 2.0 wires,
1 pkg. of 10
393.436 Ring-to-Rod Clamp, 4 ea.
393.464 Adjustable Wire/Pin Clamp, 10 ea.
393.722 3/4 Ring, 205 mm ID
393.732 3/4 Ring, 115 mm ID
393.734 3/4 Ring, 140 mm ID, 2 ea.
393.736 3/4 Ring, 165 mm ID, 2 ea.
394.85 11.0 mm Carbon Fiber Rod, 300 mm, 2 ea.
394.86 11.0 mm Carbon Fiber Rod, 350 mm, 2 ea.
394.97 Protective Caps, for 11.0 mm Rods, 1 pkg. of 10
394.993 Protective Caps, for 5.0 mm Fixation Pins,
1 pkg. of 10
Note: For additional information, please refer to package insert.
For detailed cleaning and sterilization instructions, please refer to
http://us.synthes.com/Medical+Community/Cleaning+and+
Sterilization.htm or 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