Synthes USS Small Stature/Paediatric Spine System User manual

Thoracolumbar fixation with dual opening pedicle screws and hooks
USS™Small Stature /
Paediatric 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™ Small Stature/Paediatric Spine System DePuy Synthes 1
Table of Contents
Introduction AO Spine Principles 2
Surgical Technique Handling the Implants with a Stick 3
Insert Pedicle Screws (Posterior Approach) 4
Insert Pedicle Screws with Washers
(Only for Anterior Approach) 6
Position Pedicle Hook 8
Position Lamina Hook 11
Angled Lamina Hook Positioning 12
Rod Contouring 13
Locking Implants to Rods 14
Introducing Rods into Dual-Opening Implants 15
Distraction or Compression of Adjacent Implants 18
Connecting a Rod to an Implant with
Rod Connectors 19
Connecting Two Rods with Cross-Link
Connectors 20
Indications and Contraindications 22
Bibliography 23
For product catalog contact your local DePuy Synthes representative.

2 DePuy Synthes USS™ Small Stature/Paediatric 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™ Small Stature/Paediatric Spine System DePuy Synthes 3
The dual-opening pedicle screws have the same head as
the pedicle, lamina and angled hooks. The following
handling instructions hence refer to both the pedicle
screws and all three hook types (termed “implants” in
the following).
1. Attach handle to stick
Press the knurled release button on the upper end of the
handle (388.622), and simultaneously attach the hook
and screw holder with hexagonal 4.0 mm (388.612)
(also termed the ”stick”) to the handle.
2. Pick up implant
Pick up the dual-opening implant with the stick and
handle by rotating the release button on the handle.
3. Release handle from stick
Insert the implant. To release the handle from the stick,
press the release button on the handle.
Handling the Implants with a Stick
05_02 USS Paediatric
05_01 USS Paediatric –
von 06_01 Ped.Hooks
05_03 USS Paediatric

4 DePuy Synthes USS™ Small Stature/Paediatric Spine System Surgical Technique
1. Open pedicle and determine screw
length
Use one of the pedicle awls (1) (388.551 for screws
Ø 4.2 mm, 388.550 for larger screws) to open the cortex
of the pedicle to a depth of 10 mm. Continue opening
the pedicle using one of the pedicle probes (2) with
markings at 30, 40 and 50 mm.
• 388.538 for Ø 4.2 mm screws;
• 388.540 for Ø 5.0 and 6.0 mm screws;
• 388.539 for Ø 7.0 mm screws.
Determine the length of the pedicle screws with the
depth gauge for pedicle screws (357.789).
2. Probe pedicle channel
Using the straight feeler Ø 2.3 mm (388.545) or the
curved feeler Ø 2.3 mm (388.546), probe the pedicle
screw channel in order to check for perforations in the
walls.
Insert Pedicle Screws
(Posterior Approach)
Pedicle 8
30
40
50
09_02 USS II von 07_02 USS Paediatric –
von 08_02 Ped.Hooks
12
09_03 USS II von 07_03 USS Paediatric

Surgical Technique USS™ Small Stature/Paediatric Spine System DePuy Synthes 5
3. Insert pedicle screw into pedicle
Pick up the pedicle screw as described on page 3.
Insert the pedicle screw into the prepared pedicle until
the screw head is well seated and one of the openings
points towards the rod that is to be subsequently
inserted (1). To disconnect the stick from the handle,
press the release button on the handle (2).
Note: If using a rod connector, align the screw head
such that one of the openings is perpendicular to the
rod.
Insert Pedicle Screws
(Posterior Approach)
10_04 USS II von 08_04 USS Paediatric
1
2

6 DePuy Synthes USS™ Small Stature/Paediatric Spine System Surgical Technique
Flat (1) and angled (2) washers can be used with anterior
fixation constructs to distribute the force of the screw
over the bone. The angled washers form a fixed angle
with the screw.
1. Prepare screw hole and determine
screw length
Determine the entry point for the screw, preferably at
the junction of the pedicle and the vertebral body.
Align the pedicle awl (1) (388.550 or 388.551) perpen-
dicular to the contralateral side, and prepare the screw
hole. Enlarge the screw hole using the pedicle probe (2)
(388.538, 388.539 or 388.540) until it penetrates the
contralateral cortex.
Determine the length of the pedicle screw using the
depth gauge for pedicle screw (357.789) (3).
2a. Insert flat washer and screw
Place a flat washer with the convex side facing down
onto the concavity of the vertebral body.
Pick up a dual-opening pedicle screw as described on
page 3. Insert the pedicle screw into the prepared verte-
bral body until the screw head is well seated. To release
the stick from the handle, press the release button on
the handle.
Insert Pedicle Screws with Washers
(Only for Anterior Approach)
09_02a USS Paediatric
1 2 3
1 2

Surgical Technique USS™ Small Stature/Paediatric Spine System DePuy Synthes 7
2b. Insert angled washer and screw
While pressing the release button, load an angled
washer in the inserter (385.807) (1). Anchor the washer
in the bone by gently tapping the inserter (2).
Once the washer is firmly seated, remove the inserter by
pressing the release button (3). Pick up a dual-opening
pedicle screw as described on page 4. Insert the pedicle
screw into the prepared vertebral body until the screw
head is well seated (4). To disconnect the stick from the
handle, press the release button on the handle.
Insert Pedicle Screws with Washers
(Only for Anterior Approach)
10_02b_1 USS Paediatric
1
10_02b_2 USS Paediatric
2
10_02b_3 USS Paediatric
3
10_04 USS Paediatrics
4

8 DePuy Synthes USS™ Small Stature/Paediatric Spine System Surgical Technique
The USS Small Stature/Paediatric 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 pedicle feeler (388.511)
(1). Place the pedicle feeler between the inferior and
superior facet joints.
Precaution: Ensure that the feeler is placed in the
articular space and not in the bone of the inferior
facet.
To facilitate the insertion of the pedicle hook, remove a
small portion of the inferior facet with an osteotome (2).
The pedicle feeler has a mark. As soon as the mark is
reached, sufficient bone has been removed to accommo-
date the hook around the pedicle.
Check the optimal position of the pedicle feeler by mov-
ing it laterally and cranially (3).
Precaution: Do not push medially.
Remove the pedicle feeler.
Position Pedicle Hook
Haken 03 S11
13_01 USS II = 11_01b Ped.Hooks
3
3
Haken 02 S11s
13_01a USS II = 11_01a Ped.Hooks
2
1
3 mm

Surgical Technique USS™ Small Stature/Paediatric Spine System DePuy Synthes 9
2. Position pedicle hook
Using the stick, pick up a pedicle hook from the set, as
described on page 4.
Note: Use a front-opening hook if a rod connector is
needed.
Insert the hook positioner (388.631) into the positioning
hole of the hook, and ease the pedicle hook into the
previously prepared seat. Ensure that the pedicle hook is
snug around the pedicle by pushing the hook positioner
axially and 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 handle. The stick
remains attached to the hook.
3. Drill hole for screw Ø 3.2 mm
To anchor the pedicle hook to the pedicle, a screw Ø 3.2
mm can be inserted through the hole at the back of the
hook.
Use a three-fluted drill bit Ø 2.0 mm (315.190) together
with the USS drill sleeve 2.0 and an oscillating drill to
drill the screw hole. The drill sleeve consists of two com-
ponents, the drill sleeve (388.581) and the handle
(387.060). These two components 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.
Position Pedicle Hook
Haken 06 S11
11_02 USS Paediatric
Haken 08 S12
12_03 USS Paediatric

10 DePuy Synthes USS™ Small Stature/Paediatric Spine System Surgical Technique
4. Determine screw length
Remove the drill sleeve and determine the depth with
the depth gauge (319.060).
5. Insert Ø 3.2 mm screw
Pick up an appropriate length USS Screw for Pedicle
Hook using the holding sleeve (388.381) and the hexag-
onal screwdriver (314.070), and insert the screw into the
previously prepared drill hole. The pedicle hook is now
attached to the pedicle.
Position Pedicle Hook
Haken 11b
12_05 USS Paediatric
Haken 5b S12
14_05b USS II = 12_05b USS Paediatric

Surgical Technique USS™ Small Stature/Paediatric Spine System DePuy Synthes 11
1. Prepare seat for lamina hook
The lamina hook can be placed around either the supe-
rior or inferior portion of the lamina. Prepare the seat for
the lamina hook using the lamina feeler (388.521) (1
and 2). To ensure good seating of the hook, carefully
remove the ligamentum flavum and a small portion of
the lamina with a rongeur.
Remove the lamina feeler.
2. Position lamina hook
Using the stick, pick up an appropriate lamina hook
from the set, as described on page 3.
Note: Use a front-opening hook if a rod connector is
needed.
Insert the hook positioner (388.631) into the positioning
hole of the hook, and ease the lamina hook into the
previously prepared seat. The inferior part of the lamina
hook must fit snugly with the lamina.
Precaution: Ensure that the lamina hook does not lie
too deep or press upon the bone marrow.
Remove the hook positioner and the handle. The stick
remains attached to the hook.
Position Lamina Hook
Haken 01a S13
15_02b USS II
von 13_02b USS Paediatric
13_02a USS Paediatric
Haken 01a S13a
1
13_01b USS Paediatric
2

12 DePuy Synthes USS™ Small Stature/Paediatric Spine System Surgical Technique
1. Prepare seat for angled lamina
hook
Remove the soft tissue from the transverse process.
Place the lamina feeler (388.521) around the transverse
process, elevating the soft tissue attachments from the
anterior portion of the transverse process.
Remove the lamina feeler.
2. Angled lamina hook positioning
Using the stick, pick up an appropriate angled lamina
hook from the set, as described on page 3.
Note: Use a front-opening hook if a rod connector is
needed.
Insert the hook positioner (388.631) into the positioning
hole of the hook, and ease the angled lamina hook into
the previously prepared seat.
Remove the hook positioner and the handle. The stick
remains attached to the hook.
Angled Lamina Hook Positioning
Haken 01a S13dHaken 01a S13d
14_01/02 USS Paediatric
Haken 01a S13dHaken 01a S13d
14_01/02 USS Paediatric

Surgical Technique USS™ Small Stature/Paediatric Spine System DePuy Synthes 13
Use the bending template Ø 5.0 mm (388.906/907) to
determine the proper rod contour and length.
Contour the rod using either the bending pliers with
rolls for rods Ø 5.0 mm, with bending radius adjustment
(1) (388.961), or the bending iron (2) (388.911, left,
388.922 right).
Warning: Once bent, the titanium rods should not be
bent back again. Do not bend titanium rods more
than 45°.
Note: Hook/screw offset
Anatomical conditions sometimes result in the implants
not being aligned in a straight line. The screws and
hooks have a 7.6mm offset and the dual opening allows
for insertion of the rod to either side of the pedicle
screws and hooks.
Rod Contouring
Pedicle 07/2
15_02 USS Paediatric
2
Pedicle 07/1
15_01 USS Paediatric
S
m
a
l
l
M
e
d
i
u
m
L
a
r
g
e
1
Perdicle 06c S15
7.6mm
15_03 USS Paediatric
7,6 mm

14 DePuy Synthes USS™ Small Stature/Paediatric Spine System Surgical Technique
The rod Ø 5.0 mm is secured with a sleeve and nut.
1. Pick up and locate sleeve with
sleeve positioner
Fit the sleeve pusher (388.582) to the sleeve positioner
(388.583). Pick up a sleeve, ensuring that the shorter leg
of the sleeve pusher stands above the narrow-fluted side
of the sleeve. Slide the sleeve positioner over the stick
and place it on the implant.
Press down on the sleeve pusher to place the sleeve on
the implant/rod (1). Retract the sleeve pusher (2). The
sleeve remains on the implant/rod.
2. Place nut on implant
Pick up the nut from the loading station using the socket
wrench for 12-point nut, with L-handle (388.584).
Introduce the socket wrench 5.0 mm with T-handle
(388.143) into the socket wrench for 12-point nut and
slide together over the stick. The socket wrench 5.0 mm
must engage in the hexagon of the stick, which is used
to apply counter torque.
If the stick has already been removed, insert the screw-
driver 4.0 mm with T-Handle (388.338) into the socket
wrench for 12-point nut and apply counter torque.
3. Tighten nut
Tighten the nut with the socket wrench for 12-point nut
with L-handle. The instruments used for applying coun-
ter torque are spring-loaded and can be kept under con-
stant pressure by means of the T-handle. To tighten the
nut further, lift off the L-handle and place it on again.
Locking Implants to Rods
Pedicle 14
16_03 (20_03) USS Paediatric
Pedicle 10
16_01 (20_02a) USS Paediatric
1 2

Surgical Technique USS™ Small Stature/Paediatric Spine System DePuy Synthes 15
Using the USS small stature/paediatric rod introduction
pliers (the “persuader”)
Occasionally, a rod cannot easily be introduced into a dual-
opening implant because of the distance between the
rod and the implant. When using the rod introduction
pliers (388.503) (the persuader), the dual-opening
implant can be lifted and pulled towards the rod.
1. Mount sleeve pusher onto
persuader
Place the sleeve pusher (388.582) onto the cylinder of
the persuader (1). Pick up a sleeve from the loading sta-
tion using the sleeve pusher (2). The handle of the sleeve
pusher must be located on the side of the persuader
with the arrow.
2. Place persuader on implants
Slide the cylinder of the persuader on the stick and the
leg of the pliers on the rod.
Introducing Rods into Dual-Opening Implants
Haken 14a S17
16_02 USS Paediatric
16_01a USS Paediatric
Pedicle 13 S16a
Pedicle 13
Pedicle 13 S16a
16_01b USS Paediatric
1 2

16 DePuy Synthes USS™ Small Stature/Paediatric Spine System Surgical Technique
3. Attach support for rod introduction
pliers
Slide the support for rod introduction pliers (388.615)
over the protruding end of the stick, and simultaneously
pull the lever (1). The forked opening of the support
must face upwards (TOP). Release the lever so that the
support engages in the hexagon of the stick (2). The
support for rod introduction pliers serves as a locking
device when lifting the implants and allows the implants
to be rotated.
4. Bring rod towards dual-opening
implant
Place the spreader forceps (388.413) on the stick
between the support and the persuader. Slowly open
the spreader to bring the implant up towards the rod.
When the opening of the implant is at the height of the
rod, close the persuader to engage the rod.
Precaution: Carefully close the persuader since this
instrument can exert considerable force. If neces-
sary, the catch can be ipped up so that the per-
suader does not remain in the closed position.
Remove the support for rod introduction pliers.
Warning: Do not apply too much force on the anchor-
age of the implant or it will tear out of the bone.
Introducing Rods into Dual-Opening Implants
Haken 14a S17
18(17)_03 USS Paediatric
TOP
1
Haken 14a S17
18(17)_03 USS Paediatric
TOP
2
Pedicle Reposition S18
18(17)_05 USS Paediatric

Surgical Technique USS™ Small Stature/Paediatric Spine System DePuy Synthes 17
5. Place sleeve over implant and rod
Push the sleeve pusher down the cylinder to place the
sleeve over the rod and implant (1). Retract the sleeve
pusher (2). The sleeve remains on the implant/rod.
If the sleeve cannot be readily placed in position, tap the
sleeve pusher gently to position the sleeve on the
implant.
6. Attach implant to rod
Remove the persuader. Pick up a nut using the socket
wrench for 12-point nut (as described on page 14), drop
it over the stick and screw it loosely onto the implant.
Introducing Rods into Dual-Opening Implants
19_05 (18_06) USS Paediatric
1
2

18 DePuy Synthes USS™ Small Stature/Paediatric Spine System Surgical Technique
Distraction or compression with corresponding
forceps
Once the rod has been introduced and loosely attached
to the implant, distraction or compression can be
performed.
Before tightening the nut of the implant, use the
spreader forceps (388.413) for distraction, or the com-
pression forceps (388.424) for compression.
a. Option
Additional use of fixation ring
If the two implants are placed too far from each other,
use the fixation ring for rods Ø 5.0 mm (498.909). Place
the small hexagonal screwdriver (314.070) with the
holding sleeve (388.360) onto the fixation ring, and
place it next to the implant. Carry out distraction or
compression. The implant-rod connection must be loose
during this procedure.
Remove the fixation ring, and tighten the nut of the
implant.
b. Option
Additional use of holding forceps for rods
Instead of using the fixation ring, secure the holding for-
ceps for rods (388.441) next to an implant and carry out
the distraction or compression.
Distraction or Compression of Adjacent Implants
Pedicle 13 S19
20(19)_01 USS Paediatric