Synthes VEPTR Quick start guide

VEPTR – Vertical Expandable
Prosthetic Titanium Rib. A new
treatment concept for paediatric
three-dimensional thoracic deformities.
Technique Guide

Synthes 1
Please note that specialised training is mandatory.
In order to perform procedures associated with the VEPTR
system, a wide range of additional basic spine surgery
instruments are required. For further details contact your
local Synthes representative.
Table of Contents
Image intensifier control
Treatment Concept 3
Indications 4
Contraindications 5
Construct Options 6
Implants 10
Instruments 15
Overview Surgical Technique 19
Primary Procedure 20
Expansion Procedure 38
Replacement Procedure 40
Introduction
Product Information
Surgical Technique

2Synthes VEPTR Technique Guide

Synthes 3
VEPTR – Vertical Expandable
Prosthetic Titanium Rib. A new
treatment concept for paediatric
three-dimensional thoracic deformities.
Concept
Three-dimensional thoracic approach to
treat patients with complex chest wall
and/or spinal deformities where the
thorax is unable to support normal res-
piration or lung growth (Thoracic Insuf-
ficiency Syndrome).
Designed to mechanically stabilize and
distract the thorax to improve respira-
tion and lung growth in infantile and
juvenile patients.
VEPTR devices control and may correct
scoliosis.
Devices are attached perpendicularly to
the patient’s natural ribs (superior at-
tachment point) and to more caudal
ribs, a lumbar vertebra or to the ilium
(inferior attachment point). This is done
through a standard thoracotomy inci-
sion by performing an opening wedge
thoracostomy.
Regular expansion, anatomic distrac-
tion, and replacement of components
through less invasive surgery.
Goals of treatment:
– Increase thoracic volume
– Scoliosis correction
– Thoracic symmetry by lengthening
the concave, restricted hemithorax
– Improve thoracic function
– Avoiding growth inhibition proce-
dures
– Maintain these improvements
throughout the growth of the child

4Synthes VEPTR Technique Guide
Indications
Primary Thoracic Insufficiency Syndrome (TIS) due to three-
dimensional deformity of the thorax
– Progressive thoracic congenital scoliosis with concave
fused ribs
– Progressive thoracic congenital scoliosis with flail chest due
to absent ribs
– Progressive thoracic congenital, neurogenic or idiopathic
scoliosis without rib abnormality
– Hypoplastic thorax syndromes
– Jeune’s Syndrome
– Jarcho-Levine Syndrome
– Cerebro costal mandibular syndrome
– Others
– Congenital chest wall defect, posterolateral
– Acquired chest wall defect, posterolateral
– Chest wall tumor resection
– Traumatic flail chest
– Surgical separation of conjoined twins
Secondary Thoracic Insufficiency due to lumbar kyphosis
(non gibbus)

Synthes 5
Contraindications
The VEPTR device should not be used under the following
conditions:
– Inadequate strength of bone (ribs/spine) for attachment of
the VEPTR
– Absence of proximal and distal ribs for attachment of the
VEPTR
– Absent diaphragmatic function
– Inadequate soft tissue for coverage of the VEPTR
– Age beyond skeletal maturity for use of the VEPTR
– Age below 6 months
– Known allergy to any of the device materials
– Infection at the operative site
Warnings and precautions
Patients implanted with the VEPTR should not be braced. The
VEPTR device is designed to allow for thoracic cavity growth
and the restrictive nature of a brace would not help the con-
dition, but defeat its purpose.
Patients may require additional wound protection to prevent
inadvertent rubbing or bumping of the wound.
Patients with a diagnosis of spina bifida should have an oc-
clusive dressing over the wound site to keep the site dry.

6Synthes VEPTR Technique Guide
Construct Options
The VEPTR set contains 220 mm and 70 mm radius
constructs.
220 mm radius constructs are used to treat most of the
VEPTR indications and are the standard VEPTR constructs.

Synthes 7
70 mm radius constructs are used to treat hypoplastic
thorax syndromes.
A hypoplastic low thorax volume (as seen with Jeune’s Syn-
drome) requires the use of a 70 mm rib-to-rib construct
(70 mm implants include: Cranial Rib Support, Caudal Rib
Support, Extension Bar). These constructs are placed bilater-
ally in separate procedures.
Surgical technique for 70 mm radius constructs
After inserting both the Cranial and Caudal Rib Support, free
the central segment of the selected hemithorax by making
transverse incisions in the periosteum to enable anterior and
posterior osteotomies.
Perform anterior and posterior osteotomies from ribs three
through eight. Distract the mobilized chest segment postero-
laterally.
Place retractors subperiosteally to protect the underlying
lung.
Choose 2–3 sites in the central portion of the mobilized seg-
ment to insert the 2.0 mm Titanium Rod which will hold
the ribs to the construct. Bend the rod to form a gentle curve
using the Wire Bending Pliers.
Assemble the construct as stated in the rib-to-rib construct
section.
After the construct has been completely assembled and
locked, use the Pliers to again grasp rods and contour
around implanted rib-to-rib construct, leaving space to re-
move the locks and expand the construct.

12
3
56
6
7
4
12
3
478
5
6
6
Construct Options
Rib-to-lumbar lamina
– Attaches to rib and to lumbar spine
– Components available in 220 mm radius
1 Cranial Rib Support
2 Closing Half-Ring
3 Lock for Rib Support
4 Lumbar Extension Rod
5 Extension Bar
6 Closure for Extension Bar
7 Lamina Hook
Rib-to-ilium
– Attaches from rib to ilium
– Components available in 220 mm radius
1 Cranial Rib Support
2 Closing Half-Ring
3 Lock for Rib Support
4 Lumbar Extension Rod
5 Extension Bar
6 Closure for Extension Bar
7 Extension connector
8 Ala Hook
8Synthes VEPTR Technique Guide

1
1
3
4
22
22
3
66 5
3
4
3
5
66
Rib-to-rib
– Attaches to the cranial and to the caudal rib
– Components available in 220 mm or 70 mm radius
Rib-to-rib 220 mm radius
1 Cranial Rib Support
2 Closing Half-Ring
3 Lock for Rib Support
4 Caudal Rib Support
5 Extension Bar
6 Closure for Extension Bar
Rib-to-rib 70 mm radius
1 Cranial Rib Support
2 Closing Half-Ring
3 Lock for Rib Support
4 Caudal Rib Support
5 Extension Bar
6 Closure for Extension Bar
Synthes 9

Cranial Rib Support, Titanium Alloy (TAN), gold
– Attaches to the Closing Half-Ring and Extension Bar to
support the cranial rib
In 220 mm radius, standard size, in neutral angulation
Art. No. Angulation
497.057 Neutral
In 70 mm radius, standard size, in neutral angulation
Art. No. Angulation
497.061 Neutral
Caudal Rib Support, Titanium Alloy (TAN), gold
– Attaches to the Closing Half-Ring and Extension Bar to
support the caudal rib
In 220 mm radius, available in sizes 4–13 in neutral,
right and left angulation
Art. No. Angulation Sizes
497.065–497.069 Neutral 4–8
497.225–497.229 Neutral 9–13
497.071–497.075 Right angled 4–8
497.230–497.234 Right angled 9–13
497.076–497.080 Left angled 4–8
497.235–497.239 Left angled 9–13
In 70 mm radius, available in sizes 4–11 in neutral,
right and left angulation
Art. No. Angulation Sizes
497.085–497.089 Neutral 4–8
497.241–497.243 Neutral 9–11
497.091–497.095 Right angled 4–8
497.244–497.246 Right angled 9–11
497.096–497.100 Left angled 4–8
497.247–497.249 Left angled 9–11
Implants
10 Synthes VEPTR Technique Guide

Synthes 11
Closing Half-Ring, Titanium Alloy (TAN), gold
– Attaches to the Cranial or Caudal Rib Support to encircle
the cranial or caudal rib(s)
Standard size
Art. No.
497.126 Closing Half-Ring for Rib Support
Extended
Art. No.
497.129 Closing Half-Ring for Rib Support, large
Locks, Titanium Alloy (TAN)
– Lock for Rib Support (blue) connects the Closing Half-Ring
to the Cranial Rib Support or the Caudal Rib Support
Art. No.
497.128 Lock for Rib Support, blue
– Closure for Extension Bar (gold) connects the Extension Bar
to the Cranial Rib Support, Caudal Rib Support or Lumbar
Extension Rod
Art. No.
497.125 Closure for Extension Bar, gold

12 Synthes VEPTR Technique Guide
Extension Bar, Titanium Alloy (TAN)
– Attaches the Cranial Rib Support to the Caudal Rib Sup-
port or Lumbar Extension Rod
In 220 mm radius, available in sizes 4–13
Art. No. Sizes
497.103–497.112 4–13
In 70 mm radius, available in sizes 4–11
Art. No. Sizes
497.115–497.122 4–11
Lumbar Extension Rod, Titanium Alloy (TAN)
– Attaches the Extension Bar to the Lamina Hook or the
Extension Connector
– Available in sizes 6–13 to correspond with 220 mm radius
Extension Bar
– Rod ⭋6.0 mm
Art. No. Sizes
497.131–497.134 6–9
497.251–497.254 10–13
Implants

Synthes 13
Lamina Hook, Titanium Alloy (TAN)
– Used with the Lumbar Extension Rod to connect to the
lumbar lamina
– Available as left and right angled
– 3.5 mm setscrew secures the placement
Art. No. Angulation
497.261 Left angled
497.262 Right angled
Ala Hook, Pure Titanium
– Used with the Lumbar Extension Rod and Extension
Connector to attach to the ilium
– Available in left and right contours
– Rod ⭋5.0 mm
Ala Hook, 45°
Art. No. Contours
497.257 left
497.258 right
Ala Hook, 90°
Art. No. Contours
04.601.001 left
04.601.000 right

14 Synthes VEPTR Technique Guide
Implants
Extension Connector ⭋5.0/6.0, Titanium Alloy (TAN)
– Connects the Ala Hook to the Lumbar Extension Rod
– Accepts ⭋5.0 mm and ⭋6.0 mm rods
Art. No.
498.167 Extension Connector ⭋5.0/6.0mm
Rod ⭋2.0mm, Pure Titanium
– Holds osteotomized ribs against the construct
Art. No.
497.127 Rod ⭋2.0 mm

Synthes 15
Below a description of all VEPTR specific instruments.
A detailed overview of all required instruments (standard or
new) for a VEPTR surgery can be found in the VEPTR setlist.
388.452 Lock Removal Pliers, for VEPTR
Used to remove the locks (497.125 and
497.128) from the constructs for expan-
sion procedures or removing constructs.
388.453 or Holding Forceps for Closing Half Ring for
388.465 VEPTR
For holding and placing the Closing Half
Ring around the ribs.
388.456 or Lock Crimper, for VEPTR
388.474
Attaches the locks around the construct
for proper closing.
388.457 Distraction Pin for VEPTR, temporary
Allows temporary distraction of the
constructs and is used during expansion
of a construct.
Instruments

16 Synthes VEPTR Technique Guide
388.458 Iron for Rib Support
Used to align/adjust the Extension Bar and
the Cranial Rib Support. Goes around
the Cranial Rib Support and is used with
the Iron for Extension Bar.
388.459 Iron for Extension Bar
Used to align/adjust the Extension Bar and
the Cranial Rib Support. Goes around the
Extension Bar and is used with the Iron for
Rib Support.
388.461 Holding Forceps for Rib Support
Holds the Cranial and the Caudal Rib
Supports.
388.462 Lock Removal Device, for VEPTR
Used to remove the locks (497.125 and
497.128) from the construct.
388.464 Spreader for Rib Support
Used for the expansion of the Extension
Bar from the Caudal Rib Support. Allows a
primary, limited expansion. The Large
Spreaders (388.471 or 388.472) can now
be placed to expand the construct further.
Instruments

Synthes 17
388.466 Positioner for Rib Support
Used to adjust the Cranial Rib Support and
the Extension Bar.
388.467 Rib Support Feeler
Prepares the ribs for the Cranial Rib
Support (or Caudal Rib Support
respectively). The Feeler has the same
shape as the rib support devices.
388.468 Holding Forceps for Extension Bar
For holding the Extension Bar and pushing
it over the Cranial Rib Support and Caudal
Rib Support.
388.471 Rib Distraction Pliers
Used to expand the Extension Bar from the
Caudal Rib Support or Lumbar Extension
Rod.
388.472 Distractor for Extension Bar, curved
Used to expand the Extension Bar from the
Caudal Rib Support or Lumbar Extension
Rod.

18 Synthes VEPTR Technique Guide
388.475 Lock Inserter, lateral
Attaches the locks around the construct to
close the construct.
388.486 Foot for Rib Retractor, for No. U22-64010
Fits in the Rib Retractor to distract the ribs.
388.493 Inserter for Rib Support Lock
Used to pick up and hold the locks
(497.125 and 497.128) and attach the
locks to the constructs.
388.495 Hook Holding Forceps for VEPTR
Used to bring the hooks in position at the
lamina.
Instruments