Synthes USS Universal User manual

Side-opening screws and hooks for thoracolumbar spine
USS™Universal
Spine System
Surgical Technique

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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™ Universal Spine System DePuy Synthes 1
Table of Contents
Introdution AO Spine Principles 2
Surgical Technique Picking up implants 3
Pedicle screw positioning (posterior instrumentation) 4
Pedicle screw positioning with washers
(anterior instrumentation only) 5
Pedicle hook positioning 7
Lamina hook positioning 9
Angled lamina hook positioning 10
Rod contouring 11
Introducing rods into side-opening implants 12
Distraction or compression of adjacent implants 15
Locking side-opening implants to a rod 16
Connecting a rod to an implant with closed rod
connectors 17
Connecting two rods with cross-link clamps 18
Indications and Contraindications 20
Bibliography 21
For product catalog contact your local DePuy Synthes representative.

2 DePuy Synthes USS™ Universal 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
specic 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™ Universal Spine System DePuy Synthes 3
Picking up implants
The side-opening pedicle screws have the same head as
the hooks. Therefore, the following handling instructions
apply to both pedicle screws and hooks (called side-
opening implants in the following).
1. Attach handle to stick
Attach the USS Handle (388.640) to the Hook and Screw
Holder, the “stick” (388.610).
2. Pick up implant
Connect the side-opening implant to the stick by rotat-
ing the cog-wheel of the handle.
3. Release handle from stick
Insert the implant. To release the handle from the stick,
press the release mechanism on top of the handle.

4 DePuy Synthes USS™ Universal Spine System Surgical Technique
Pedicle screw positioning
(posterior instrumentation)
1. Open pedicle and determine screw
length
Use the Pedicle Awl (1) (388.550) to open the cortex of
the pedicle to a depth of 10 mm. Continue opening the
pedicle using the USS Pedicle Probe Ø 3.8 mm (2)
(388.540) with markings at 30, 40 and 50 mm.
Determine the length of the pedicle screw using the
Depth Gauge for Screws (319.100).
Note: For Ø4.0 mm or Ø5.0 mm pedicle screws use
the Pedicle Probe Ø2.8 mm (388.538).
2. Insert pedicle screw into pedicle
Pick up a side-opening pedicle screw as described on
page 3.
Note: If a rod connector is needed, align the screw
head by turning it 90°. The opening has to be perpen-
dicular to the rod.
Insert the pedicle screw into the prepared pedicle until
the screw head is well seated (1). To disassemble the
stick from the handle press the button on the handle (2).
1 2
1
2

Surgical Technique USS™ Universal Spine System DePuy Synthes 5
Pedicle screw positioning with washers
(anterior instrumentation only)
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. Open pedicle and determine screw
length
Determine the entry point for the screw, preferably at
the junction of the pedicle and the vertebral body.
Use the Pedicle Awl (1) (388.550) to prepare the screw
hole, directing it perpendicularly to the contralateral
side. Enlarge the screw hole using the USS Pedicle Probe
(2) (388.540), until it penetrates the contralateral cortex.
Determine the length of the pedicle screw using the
Depth Gauge for Screws (3) (319.100). The actual length
of the screw is chosen 5 mm longer than measured in
order to enable the positioning of a washer.
2a. Insert screw and flat washer
Place at washers with the convex side down onto the
concavity of the vertebral body.
Pick up a side-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 disas-
semble the stick from the handle press the button on
the handle.
1
1
2
3
2

6 DePuy Synthes USS™ Universal Spine System Surgical Technique
Pedicle screw positioning with washers
(anterior instrumentation only)
2b. Insert angled washer
a. Pick up screw and washer
Slide an appropriate-size pedicle screw into a washer
and pick it up with a stick. Insert the screw until the
washer slightly touches the bone surface.
Leave a space of 8–10 mm between the angled washer
and the screw for the USS Pusher (388.691).
b. Place pusher onto stick
Pull the cannulated guide of the pusher backwards until
the ringmark appears (1). Place the tip of the pusher
onto the washer and the cannulation of the pusher over
the stick (2). Push down the cannulated guide to lock
the stick in place (3).
c. Insert screw and washer
Tap onto the end of the pusher to introduce the angled
washer into the bone. When tapping the pusher, the
force is transmitted to the angled washer and not to the
screw (4). Once the washer is firmly seated, remove the
pusher. Using the USS Handle (388.640), insert the
screw further until the screw head is well seated (5).
1
2
8–10 mm
3
4

Surgical Technique USS™ Universal Spine System DePuy Synthes 7
Pedicle hook positioning
The USS 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 (1)
(388.510). Place the pedicle feeler between the inferior
and superior facet joints.
Precaution: Make sure to place it in the articular
space and not into the bone of the inferior facet.
To facilitate the insertion of the pedicle feeler, a small
portion of the inferior facet is removed with an osteo-
tome (2). The pedicle feeler has six lines on the blade.
When the last line is reached, sufficient bone has been
removed to accommodate the hook around the pedicle.
Check the optimal position of the pedicle feeler by mov-
ing it laterally and cranially (3).
Precation: Do not push medially.
Remove the pedicle feeler.
2. Position pedicle hook
Pick up a pedicle hook from the tray with the hook and
screw holder as described on page 3.
Note: Use a front-opening hook if a rod connector is
needed.
Insert the USS Hook Positioner (388.630) into the screw
hole of the hook and ease the pedicle hook into the pre-
viously prepared seat. Check if the pedicle hook is snug
around the pedicle by axial loading of the hook posi-
tioner 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 USS handle. The
stick remains attached to the hook.
1
2
3
3
3– 4 mm

8 DePuy Synthes USS™ Universal Spine System Surgical Technique
Pedicle hook positioning
3. Drill hole for Ø 3.2 mm screw
To anchor the pedicle hook to the pedicle screw, a
Ø 3.2 mm cortical screw can be inserted through the
hole at the back of the pedicle hook.
Use a three-uted 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. Advance the tip of the drill until it
passes through the vertebral endplate.
Warning: Do not start the power drill if the drill 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 for Screws Ø 1.5 to 2.0 mm (319.060).
5. Insert Ø 3.2 mm screw
Pick up an appropriate length USS Screw for Pedicle
Hooks using the Holding Sleeve (314.060) using the
Holding Sleeve (314.060) and Screwdriver (314.070) and
insert it into the previously prepared drill hole. The pedi-
cle hook is now attached to the pedicle and the
endplate.

Surgical Technique USS™ Universal Spine System DePuy Synthes 9
Lamina hook positioning
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 (388.520). To
ensure a good seating of the hook, carefully remove the
ligamentum avum and a small portion of the lamina
with a rongeur.
Remove the lamina feeler.
2. Position lamina hook
Pick up an appropriate-size lamina hook from the tray
with the hook and screw holder as described on page 6.
Note: Use a front-opening hook if a rod connector is
needed.
Insert the Hook Positioner (388.630) into the screw hole
of the hook and ease the lamina hook into the previ-
ously prepared seat. The inferior part of the lamina hook
must fit snugly to the lamina.
Warning: Make sure the foot of the lamina hook does
not lie too deep or presses upon the spinal cord.
Remove the hook positioner and the handle. The stick
remains attached to the hook.

10 DePuy Synthes USS™ Universal Spine System Surgical Technique
Angled lamina hook positioning
1. Prepare seat for angled lamina
hook
Remove the soft tissue of the transverse process. Place
the lamina feeler (388.520) around the transverse pro-
cess elevating the soft tissue attachment from the ante-
rior portion of the transverse process.
Remove the lamina feeler.
2. Position angled lamina hook
Pick up an appropriate-size angled lamina hook from the
tray with the hook and screw holder as described on
page 3.
Note: Use a front-opening hook if a rod connector is
needed.
Insert the Hook Positioner (388.630) into the screw 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.

Surgical Technique USS™ Universal Spine System DePuy Synthes 11
Rod contouring
Use the Rod Template for USS Rods Ø 6.0 mm
(388.870/880) to determine the proper rod contour and
length.
Contour the rod using either the Bending Pliers with
Rolls (1) (388.960) or the USS Bending Irons (2) (388.910
left, and 388.920 right).
Warning: Do not bend titanium rods backwards and
do not bend rods more than 45°.
If necessary, the construct can be extended by connect-
ing two rods with a parallel or extension connector.
Note: Hook/screw offset.
Anatomical conditions sometimes result in the implants
not being aligned in a straight line. The screws and
hooks have a 4-mm offset. If the implants are not
aligned during rod insertion it may be necessary to
rotate the screw by 180 degrees or choose a different
hook (i.e. left or right side opening).
1
4 mm
2

12 DePuy Synthes USS™ Universal Spine System Surgical Technique
Introducing rods into side-opening implants
Using USS rod introduction pliers, “persuader”
It is sometimes not possible to easily introduce a rod into
a side-opening implant as a result of the distance
between the rod and the side-opening implant. When
using the Rod Introduction Pliers (388.500), the per-
suader, the side-opening implant can be lifted and
pulled towards the rod.
1. Mount sleeve pusher onto
persuader
Place the Sleeve Pusher (388.502) onto the cylinder of
the persuader (1). Place a sleeve onto the cylinder so
that the short leg of the sleeve faces in direction of the
rod (2).
2. Place persuader onto implants
Slide the cylinder of the persuader over the hook and
screw holder and the limb of the pliers on the rod.
1
2

Surgical Technique USS™ Universal Spine System DePuy Synthes 13
Introducing rods into side-opening implants
3. Attach support for rod introduction
pliers
Slide the Support for Rod Introduction Pliers (388.501)
over the protruding end of the stick (1) and click the
stopping lever into place (2). The support for rod intro-
duction pliers is used to prevent rotation of the side-
opening implant.
Note: Alternatively, the Holding Forceps (388.440)
can be used.
4. Bring rod towards side-opening
implant
Gently close the persuader to bring the side-opening
implant towards the rod.
Precaution: Do not completely close the persuader,
as this is a very powerful instrument.
5. Lift implant up towards rod
Place the Spreader Forceps (388.410) between the sup-
port for rod introduction pliers and the cylinder. Slowly
open the spreader to bring the implant up towards the
rod. When the opening of the implant is opposite the
rod, close the persuader to engage the rod.
Warning: Do not apply too much force on the anchor-
age, it will tear out of the bone.
Remove the support for rod introduction pliers.
1
2

14 DePuy Synthes USS™ Universal Spine System Surgical Technique
Introducing rods into side-opening implants
6. Place sleeve over implant and rod
Push the sleeve pusher down the cylinder and place the
sleeve over the rod and implant.
7. Place sleeve using rod pusher
(optional)
If the sleeve cannot be engaged, place the Rod Pusher
(388.940) onto the sleeve and gently tap the sleeve into
place.
8. Attach rod to implant
Remove the persuader. Pick up a nut, drop it over the
stick and attach it loosely to the implant.
Alternative
Using rod crimping pliers
Use the Rod Crimping Pliers (380.490) to ease the rod
into the side-opening implants.
Pick up a sleeve and nut with the USS Handle (388.640)
as described on page 16 and drop them over the
construct.

Surgical Technique USS™ Universal Spine System DePuy Synthes 15
Distraction or compression of adjacent implants
Using the spreader or compression forceps
Once the rod has been introduced and loosely attached
to the implant, carry out distraction or compression if
necessary.
Before tightening the nut of the implant, use the
Spreader Forceps (388.410) for distraction or the
Compression Forceps (388.422) for compression.
Using the fixation ring (optional)
If the two implants are placed too far from each other,
use the Fixation Ring (498.911). Place the small hexago-
nal screwdriver (314.070) with the Holding Sleeve
(388.363) onto the fixation ring and place it next to the
screw. During this procedure, the screw-to-rod connec-
tion has to be loose. Carry out distraction or
compression.
Remove the fixation ring and tighten the nut of the
implant.
Alternative
Using the holding forceps for rods
Instead of using the fixation ring, place the Holding
Forceps for Rods (388.440) next to a screw and carry out
distraction or compression.

16 DePuy Synthes USS™ Universal Spine System Surgical Technique
Locking side-opening implants to a rod
The Ø 6.0 mm rod is held in place with a sleeve and nut.
If the sleeve has not been placed while introducing the
rod into the implant using the persuader as described on
page 14, proceed as follows:
1. Pick up sleeve and nut
Pick up a sleeve and a nut with the USS Handle
(388.640).
2. Place sleeve and nut over implant
Place the handle over the stick and press the top of the
handle to release the sleeve and nut.
The sleeve has a long and a short leg. The short leg
slides over the open side of the implant and has a small
mark on the top for identification (1).
3. Tighten nut
Tighten the construction with the nut using the Socket
Wrench 11.0 mm with L-Handle (388.130). Use the
Socket Wrench 6.0 mm (388.140) mounted on the stick
to counteract torque.
1
1

Surgical Technique USS™ Universal Spine System DePuy Synthes 17
Connecting a rod to an implant
with closed rod connectors
Rod connectors can be used to bridge distances
between rod and implant. When using rod connectors,
frontal opening hooks must be used or the pedicle screw
turned by 90°. Rod connector bars are introduced into
the implant at a right angle to the rod.
Closed rod connectors can be used at either end of the
USS construct. They can be added at the end of a
procedure.
1. Select closed rod connector
Select the appropriate length of the closed rod connec-
tor bar. Introduce the small Hexagonal Screwdriver
(314.070) and the USS Holding Sleeve (388.360) into
the set screw of the rod connector clamp.
2. Place rod connector onto rod and
into implant
Slide the closed rod connector onto the rod and intro-
duce the rod connector bar into the front-opening hook
or screw. If necessary, use the Rod Crimping Pliers
(388.490) or the persuader (Rod Introduction Pliers,
388.500) as described on pages 12–14.
3. Secure rod connector
Tighten the set screw of the rod connector clamp. Place
the sleeve and nut onto the side-opening implant and
tighten it using the Socket Wrench 11.0 mm with
L-Handle (388.130) and the Socket Wrench 6.0 mm
(388.140) mounted on the stick to counteract torque.

18 DePuy Synthes USS™ Universal Spine System Surgical Technique
Connecting two rods with cross-link clamps
Cross-link clamps are designed to connect the two longi-
tudinal rods.
1. Mount first cross-link clamp
Assemble the small Hexagonal Screwdriver (314.070)
and the Holding Sleeve with Catches (388.363). Pull
back the holding sleeve. To pick up the Pre-assembled
Cross-link Clamp, insert the hexagonal screwdriver into
the set screw of the clamp, push down the holding
sleeve and clip the catches onto the sleeve of the pre-
assembled clamp. Pull the holding sleeve back slightly,
place the clamp onto the rod and release the holding
sleeve.
2. Introduce cross-link rod
The design of the cross-link sleeve with its two recesses
on top allows the cross-link rod to be angled up to ±20°
as necessary.
Determine the appropriate length of the Ø 3.5 mm
cross-link rod. If necessary, cut to length using the USS
Rod Cutting and Bending Device (388.750).
Hold the clamp with the small hexagonal screwdriver
and introduce the Ø 3.5 mm cross-link rod through the
hole in the cross-link clamp (1). If necessary, use the
Holding Forceps (388.450) to introduce the cross-link
rod. Tighten the set screw of the cross-link clamp with
the small hexagonal screwdriver (2).
1
2