Synthes USS Low Profile User manual

Thoracolumbar posterior fixation system with side-opening
screws and hooks
USS™Low Profile
Spine System
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.
Processing, Reprocessing, Care and Maintenance
For general guidelines, function control and dismantling of multi-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 Synthes
reusable devices, instrument trays and cases, as well as processing of Synthes
non-sterile implants, please consult the Important Information leaflet
(SE_023827) or refer to:
http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance

Surgical Technique USS™ Low Profile Spine System DePuy Synthes 1
Table of Contents
Introduction AO Spine Principles 2
Surgical Technique Handling Implants with the Stick 3
Insert Pedicle Screws 4
Pedicle Hook Positioning 7
Lamina Hook Positioning 10
Angled Lamina Hook Positioning at
the Transverse Process 11
Rod Contouring 12
Tightening of Construct 13
Introduction of Rods Into Side Openings 15
Distraction or Compression of Adjacent Implants 19
Connecting a Rod to an Implant With a
Rod Connector 20
Indications and Contraindications 22
Bibliography 23
For product catalog contact your local DePuy Synthes representative.

2 DePuy Synthes USS™ Low Profile Spine System Surgical Technique
The four principles to be considered as the foundation
for proper spine patient management underpin the
design and delivery of the Curriculum: Stability –
Alignment – Biology – Function.1,2
AO Spine Principles
Stability
Stabilization to achieve a
specific therapeutic
outcome
Alignment
Balancing the spine in
three dimensions
Biology
Etiology, pathogenesis,
neural protection,
and tissue healing
Function
Preservations and resto-
ration of function to pre-
vent disability
Copyright © 2012 by AOSpine

Surgical Technique USS™ Low Profile Spine System DePuy Synthes 3
Required instruments
388.640 USS Universal Handle
388.641 Sleeve for USS LP
388.616 USS LP Hook and Screw Holder
314.070 Screwdriver, hexagonal, small, length
200 mm
Attaching handle to Stick
Press the button on top of the USS Universal Handle (1)
and simultaneously insert the Stick from below into the
handle (2).
Picking-up of implants
Insert the tip of the Stick into the head of the implant
(1). Tighten the Stick to the implant by rotating the
knurled knob of the USS Universal Handle (2).
Release of Stick
After implant insertion, simultaneously press the button
and remove the handle to release the Stick.
Precaution: If the Stick is required for subsequent
manipulations, make sure that the Stick is rmly
tightened to the implant. To do this, use the small hex-
agonal screwdriver to tighten the stick-implant-thread
connection.
Handling Implants with the Stick
1
2
1
2

4 DePuy Synthes USS™ Low Profile Spine System Surgical Technique
Required instruments
388.551 USS pedicle awl, Ø3.0 mm, length 230
mm, for Ø4.2 mm screws
388.550 USS pedicle awl, length 230 mm, for
Ø5.0, 6.0 and 7.0 mm screws
388.538 Pedicle probe, Ø2.8 mm, length 230
mm, for Ø4.2 mm screws
388.540 Pedicle probe, Ø3.8 mm, length 230
mm, for Ø5.0 and Ø6.0 mm screws
388.539 Pedicle probe, Ø4.8 mm, length 230
mm, for Ø7.0 mm screws
357.789 Length indicator for Pedicle Screws
388.545 Feeler for screw channel, straight,
Ø2.3 mm, length 275 mm
388.546 Feeler for screw channel, curved,
Ø2.3 mm, length 275 mm
Insert Pedicle Screws

Surgical Technique USS™ Low Profile Spine System DePuy Synthes 5
1. Open pedicle
Use the awl that corresponds to the selected screw
diameter and perforate the cortex of the pedicle.
Continue opening the pedicle canal using one of the
USS Pedicle Probes.
Precaution: If the probe resists advancement, use
image intensier control to check the position and
orientation.
2. Probe pedicle channel
Palpate the inner walls of the pedicle screw channel
using the straight or curved Feeler in order to check the
wall for perforations.
Insert Pedicle Screws

2
1
6 DePuy Synthes USS™ Low Profile Spine System Surgical Technique
Insert Pedicle Screws
3. Insert pedicle screw into pedicle
Determine the length of the pedicle screws using the
length indicator. Confirm the position and orientation
with image intensifier control. Pick up the appropriate
pedicle screw from the tray as described on page 3.
Insert the screw into the prepared pedicle until the screw
head is well seated, i.e., the side opening of the implant
head should point in the desired direction and the hori-
zontal position should be aligned with the rod trajectory
(1). In order to disconnect the handle from the Stick,
press the release button (2).
Note: If a rod connector is used, the opening of the
screw must be oriented perpendicular to the rod tra-
jectory.

Surgical Technique USS™ Low Profile Spine System DePuy Synthes 7
Required instruments
388.510 USS Pedicle Feeler, length 260 mm
388.642 USS LP Hook Positioner, length 273 mm
310.190 Drill Bit, Ø2.0 mm, length 102/75 mm
319.060 Depth Gauge for 1.5 to 2 mm screws
314.070 Screwdriver, hexagonal, small, length
200mm
388.381 Holding Sleeve for Fillister Head Screws
388.581 USS Drill Sleeve 2.0
The USS Low Profile Pedicle Hooks can be anchored in
the pedicle with a single Ø 3.2 mm USS Screw for
Pedicle Hook.
1. Prepare seat for pedicle hook
Prepare the pedicle using the USS Pedicle Feeler. Place
the pedicle feeler between the inferior and superior
facet joints.
Precaution: Carefully check that the instrument is
placed in the articular joint space and not in the
bone of the inferior facet.
To facilitate insertion of the pedicle hook, remove a small
portion of the inferior facet with an osteotome (1). The
pedicle feeler has marks. When the last mark in direction
of the tip is reached, sufficient bone has been removed to
accommodate the hook around the pedicle (2).
Check the position of the pedicle feeler by moving it lat-
erally and cranially. The feeler should not move.
Precaution: Do not push medially.
Remove the pedicle feeler.
Pedicle Hook Positioning
1
2

8 DePuy Synthes USS™ Low Profile Spine System Surgical Technique
Pedicle Hook Positioning
2. Position pedicle hook
Pick up a pedicle hook from the tray with the stick as
described on page 3.
Note: Use a front-opening hook if a rod connector is
mounted on the hook.
Insert the hook positioner into the screw hole of the
pedicle hook and move the hook into the previously pre-
pared seat. Check that the pedicle hook is snug around
the pedicle by axial loading of the hook positioner and
also by pushing laterally. The pedicle hook should not
move.
Gently tap the hook positioner with a hammer to firmly
seat the hook. Remove the hook positioner and the han-
dle. The Stick remains attached to the hook.
3. Drill hole for screw Ø3.2 mm
Drill the screw hole with the three-fluted drill bit
together with the USS Drill Sleeve and an oscillating
device. The two components of the drill sleeve (sleeve
and handle) must be screwed together before use.
Warning: Do not start the power drill if the bit does
not hit bone after passing through the drill sleeve.
4. Determine screw length
Remove the drill sleeve and determine the depth with
the Depth Gauge.

Surgical Technique USS™ Low Profile Spine System DePuy Synthes 9
Pedicle Hook Positioning
5. Insert screw Ø3.2 mm
Select a suitable length USS Screw for Pedicle Hook and
insert it into the previously prepared drill hole using the
hexagonal screwdriver and the holding sleeve.
The pedicle hook is now attached to the pedicle.

10 DePuy Synthes USS™ Low Profile Spine System Surgical Technique
Required instruments
388.520 USS Lamina Feeler, length 260 mm
388.642 USS LP Hook Positioner, length 273 mm
1. Prepare seat for lamina hook
The lamina hook can be placed around the superior or
inferior portion of the lamina. Carefully remove the liga-
mentum flavum with a rongeur to ensure a snug fit of
the hook on the lamina. Remove a small portion of the
lamina with a bone rongeur. Check the seat for the lam-
ina hook using the USS Lamina Feeler.
Remove the lamina feeler.
2. Position lamina hook
Pick up an appropriate lamina hook from the tray with
the Stick as described on page 3.
The inferior part of the lamina hook must fit snugly with
the lamina.
Note: Use a front-opening hook if a rod connector is
mounted on the hook.
Insert the hook positioner into the positioning hole of
the hook and move the lamina hook into the previously
prepared seat.
Remove the hook positioner. The Stick remains attached
to the hook until the hook is connected to the rod.
Lamina Hook Positioning

Surgical Technique USS™ Low Profile Spine System DePuy Synthes 11
Required instruments
388.520 USS Lamina Feeler, length 260 mm
388.521 USS SmStature/Paediatric Lamina Feeler
388.642 USS LP Hook Positioner, length 273 mm
1. Prepare seat for angled lamina
hook
Remove the soft tissue from the transverse process.
Place the USS Lamina Feeler around the transverse pro-
cess in order to elevate the soft tissue attachments from
the anterior portion of the transverse process.
Remove the lamina feeler.
Warning: Aim for a hook position as medially as
possible in order to limit stress on transverse pro-
cess.
2. Position angled lamina hook
Pick up an appropriate angled lamina hook from the tray
with the Stick as described on page 3.
Note: Use a front-opening hook if a rod connector is
mounted on the hook.
Insert the hook positioner into the positioning hole of
the hook and ease the angled lamina hook into the pre-
viously prepared seat. Remove the hook positioner. The
Stick remains attached to the hook until the hook is con-
nected to the rod.
Angled Lamina Hook Positioning
at the Transverse Process

12 DePuy Synthes USS™ Low Profile Spine System Surgical Technique
Required instruments
388.870/ Trial Rod for USS Rods, length 150 or
388.880 400 mm
388.960 Bending Pliers with Rolls for USS Rods
388.910/ USS Bending Irons, left/right
388.920
Use a trial rod to determine the shape and length of the
rod to be inserted. Contour the rod using either the
bending pliers with rolls (1) or the USS Bending Irons.
Warning: Once bent, titanium rods should not be
bent back again. Do not bend titanium rods more
than 45°.
Rod Contouring
1

1
2
Surgical Technique USS™ Low Profile Spine System DePuy Synthes 13
Required instruments
388.616 USS LP Screw and Hook Holder
388.640 USS Universal Handle
388.641 Sleeve for USS LP
388.663 USS LP Socket Wrench 12 point, 11 mm, straight
388.130 USS Socket Wrench 11 mm, with L-handle
388.140 USS Socket Wrench 6 mm
Optional instruments
388.643 USS LP Counter torque instrument with L-handle
1. Pick up and place Sleeve with the
universal handle
The Sleeve and Nut are picked up with the universal
handle from the tray. Make sure that the upper side of
the Nut is correctly oriented; i.e., the crank of the Nut
faces downward and fits the Sleeve correctly (1). Release
the Sleeve and Nut from the Stick by pushing on the
release button (2).
Precaution: Be sure to use USS Low Prole Sleeves
and Nuts only. Do not use Sleeves and Nuts from
other USS systems.
2. Loosely tighten the Nut
Use the straight socket wrench to loosely tighten the
Nut. The screw-rod connection is now loosely fixed and
allows for further manipulations along the construct.
Tightening of Construct

14 DePuy Synthes USS™ Low Profile Spine System Surgical Technique
Tightening of Construct
3. Firmly tighten the Nut
Use the Counter torque instrument with L-handle, which
acts directly on the rod. As before, the Socket Wrench
with L-Handle is used to tighten the Nuts.
Warnings:
• At the end of the surgery, it is necessary to check
with the Socket Wrench with L-handle if every sin-
gle implant is rmly tightened to the rod. The coun-
ter torque instrument is used simultaneously.
• Also check that the rods overlap the screws at the
respective ends (min. 5 mm).
Options:
• Use the Straight Socket Wrench to tighten the nut
and provide counter torque with the USS LP Coun-
ter Torque Instrument with L-handle.
• Use the Socket Wrench 11 mm with L-handle to
rmly tighten the Nut while providing counter
torque with the USS Socket Wrench 6 mm applied
on the Stick.

Surgical Technique USS™ Low Profile Spine System DePuy Synthes 15
Required instruments
388.500 USS Rod Introduction Pliers (Persuader),
length 250 mm
388.502 USS Sleeve Pusher for 388.500
388.501 Support for No. 388.500
388.410 USS Spreader Forceps, length 330 mm
388.642 USS LP Hook Positioner, length 273 mm
388.140 USS Socket Wrench6 mm
Optional Instruments
388.490 Rod Crimping Pliers for USS Implants
Using the Rod Introduction Pliers (Persuader)
The Persuader is used in situations when the distance
between implant and rod is significant. The Persuader
permits introduction of the 6 mm rod into the side
opening of the implant.
The Persuader is also used when applying the segmental
derotation technique for scoliosis correction.
Option:
Alternative method without Persuader
If the rod is aligned horizontally to the side opening, the
rod crimping pliers can be used to push the rod into the
implant opening.
Introduction of Rods Into Side Openings

1
2
16 DePuy Synthes USS™ Low Profile Spine System Surgical Technique
1. Mount Sleeve Pusher onto
Persuader
Place the USS Sleeve Pusher onto the cylinder of the
Persuader. The handle of the Sleeve Pusher must be
located on the side of the Persuader with the arrow
pointing to the outer side (1). Pick up a Sleeve from the
tray (2).
2. Locate Persuader on implants
Slide the cylinder of the Persuader over the Stick and ori-
ent the leg of the pliers towards the rod. Engage the rod
with the opposite jaw of the Persuader and lightly
squeeze the handle to push the rod towards the
implant.
Introduction of Rods Into Side Openings

Surgical Technique USS™ Low Profile Spine System DePuy Synthes 17
3. Attach support for rod introduction
pliers
The support serves as a locking device when lifting the
implant towards the rod.
Slide the support over the protruding end of the Stick in
the configuration with the persuader mounted over the
Stick (1). The forked opening of the support must face
upwards. The lever must be pulled and then released so
that the fork of the support engages in the hexagon of
the Stick.
4. Bring rod towards side opening of
implant
Place the spreader forceps on the Stick between the
Distraction Clip and the Persuader (1). Slowly open the
spreader to bring the implant up towards the rod (2).
When the opening is opposite to the rod, close the
Persuader to fully engage the rod (3).
Warning: Carefully apply force to the anchorage to
prevent pull-out from the bone.
Introduction of Rods Into Side Openings
1
1
2
3

2
1
18 DePuy Synthes USS™ Low Profile Spine System Surgical Technique
5. Place Sleeve over implant and rod
Push the Sleeve Pusher down the cylinder to place the
Sleeve over the rod and implant (1). When retracting the
Sleeve Pusher (2) it is important to leave the Sleeve on
the implant and rod
If the Sleeve cannot be readily placed in position:
a. either try to align the screw to the rod by slightly
turning the Stick using the USS Socket Wrench 6 mm
b. or gently tap the sleeve pusher to position the Sleeve
on the implant using the USS Low Profile Hook
Positioner by placing it in the round dent on the han-
dle of the sleeve pusher.
6. Attach implant to rod
Remove the Persuader. The implant is now loosely fixed
by the Sleeve. In order to secure the assembly, add a Nut
over the implant and tighten it as described on page
13/14.
Introduction of Rods Into Side Openings