P r o d u c t R a t i o n a l e S u r g i c a l T e c h n i q u e - Biomet

P r o d u c t
S u r g i c a l
R a t i o n a l e
T e c h n i q u e
ELASTIC STABLE
INTRAMEDULLARY
NAILING

The Nancy and ECMES Nails Philosophy
Elastic Stable Intramedullary Nailing (ESIN) is an established philosophy for treatment of long bone
fractures in children. Pioneered at the Hopital des Enfants in Nancy, France, ESIN relies on the
flexibility of Titanium to provide a stable reduction and dynamisation of long bone fractures in
children. ESIN uses Two Small Diameter Titanium Nails which are pre-bent and inserted in
either a retrograde or antegrade fashion into the fractured bone.
M/L Stability (Figure 1)
The Bend in the nails causes the nails to act as springs which
stabilise the two bone fragments in the medio-lateral plane.
Axial and Rotational Stability (Figure 2)
Figure 1
The Sharp Flattened Extremities penetrate the distal or proximal
cancellous bone to provide both axial and rotational stability to the
bone fragments.
Figure 2
Minimally Invasive Approach (Figure 3)
The Small Diameter of the nails (maximum 4 mm) allows for a
minimally invasive approach (2 cm incision).
Figure 3
Continuous Dynamisation (Figure 4)
Titanium provides flexibility to the nails, thus allowing continuous
dynamic loading of the fracture site.
The Results
These design and biomechanical factors combine to benefit the
child by enabling:
• Early Weight Bearing
• Rapid Return to Normal Activities
Figure 4
2

Clinical Results
Case 1 Case 2 Case 3
Femoral Spiral Comminuted Fracture
Retrograde Nailing
Femoral Transverse Fracture
Antegrade Nailing
Ulna and Radial Diaphyseal Fracture
Bifocal Nailing
Case 4 Case 5 Case 6
Radial Head Fracture
Retrograde Nailing
Spiral Tibial Fracture
Antegrade Nailing
Proximal Humeral Fracture
Retrograde Nailing
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Design
ESIN can be achieved very effectively with either the Nancy
or ECMES Nails. Both Nails present specific advantages
(Table 1) and the selection of nail type is at the physician’s
discretion.
Indications
The Nancy and ECMES Nails are indicated for the treatment
of diaphyseal fractures of long bones where:
• Minimal growth plate disturbance is paramount
• Dynamisation is required
• The medullary cavity is narrow
Nancy Nail
ECMES Nail
5 diameters
(2.0, 2.5, 3.0, 3.5 and 4.0 mm)
Ti6Al4V Alloy
Curved, Flattened Tip
Atraumatic End
5 diameters
(2.0, 2.5, 3.0, 3.5 and 4.0 mm)
Ti6Al4V Alloy
Curved, Flattened Tip
Atraumatic Cap
Various Pre-cut Lengths Cut to Length Intra-operatively
Table 1. The main features of the Nancy and ECMES nails.
Both paediatric and adult indications are therefore included,
although limited to:
• Paediatric diaphyseal femoral fractures
• Paediatric diaphyseal tibial fractures
• Paediatric diaphyseal humeral fractures
• Paediatric proximal humeral fractures
• Paediatric and adult diaphyseal forearm fractures
• Paediatric radial head fractures
• Adult stable diaphyseal humeral fractures
Contra-Indications
The Nancy and ECMES Nails may not be used for the
treatment of unstable fractures such as long oblique or long
spiral fractures. Comminuted fractures should also be
adequately reduced prior to inserting the nails.
The Nancy and ECMES Nails are not indicated for the
treatment of lower extremity fractures in the adult.
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Nail Selection
Nail diameter and length are critical in achieving effective
fracture stabilisation.
Length
The length of the nail is equal to the distance separating the
proximal and distal growth plates (Figure 5).
Always ensure that the length of the nail is such that it will
protude one or two centimetres outside the entry portal area.
Diameter
The nail diameter can be chosen either by calculation
Nail Length
Calculation
Nail Diameter = Minimum Canal Diameter x 0.4
1 - 2 cm
or by adopting a typical size as illustrated in Table 2.
Always select the largest diameter nail possible.
Figure 5.
Typical Sizes
Bone Age Nail Diameter
Femur 6 -8 years 3.0 mm
9 - 11 years 3.5 mm
12 - 14 years 4.0 mm
Tibia 8 - 14 years 2.5 to 4.0 mm
Humerus 8 - 14 years 2.5 to 3.5 mm
Forearm 8 - 14 years 2.0 to 2.5 mm
Table 2.
5

Pre-Bending the Nail
Pre-bend each nail to an angle of 30˚, ensuring that
the tip lies in the same plane as the plane formed by the
bend. The pre-bend can be achieved by hand or by using the
Cannulated T-Handle (M21897) as a lever arm.
Caution 1
Ensure that the apex of curvature lies at the level of the fracture site.
✔ ✖ ✖ ✔
Caution 2
In order to achieve optimum reduction, stabilisation and alignment of the fracture, the curvature must be identical in both nails.
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Surgical Technique
Femoral Fractures
Paediatric femoral fractures are typically treated with two nails inserted in a retrograde
fashion from medial and lateral entry portals located above the epiphysis. Very distal
fractures should be treated with an antegrade approach.
Positioning and Fracture Reduction
The patient is positioned on an orthopaedic traction table (Figure 6). An image
intensifier is positioned so that it can be rotated to obtain AP and lateral views. It
should also be possible to visualise the whole femur from the knee to the hip joint.
The entire thigh including the knee is prepared as an operative field. External
manipulation is conducted until adequate reduction is obtained and confirmed by
flouroscopy.
Figure 6
Approach
Make a 2 cm skin incision distally to the required entry hole to provide access for the
instruments, and to prevent any trauma to the skin (Figure 7). You may start either
on the medial or the lateral side. An oblique drill hole is made 2 - 4 cm above the
growth plate by applying a careful angulation movement of the drill bit until the
entry hole is at an angle of at least 60˚ with the axis of the medullary canal (Figure 8).
Make the the entry hole slightly larger than the diameter of the chosen nail.
Figure 7
Figure 8
7

Figure 9 Figure 10 Figure 11
Nail Insertion
The nail is held in a Cannulated T-Handle Inserter (M21897). Align the horizontal
bar of the T-Handle and the curved tip of the nail in the same plane. This will enable
you to identify the position of the curved tip as it is passed along the medullary canal.
Pass the nail through the entry hole with the curved tip pointing downwards.
Once in the medullary canal rotate the curved tip so that it is pointing in the
direction in which the nail is to be passed (Figure 9). Drive the nail up the
canal by rotating the the T-Handle Inserter back and forth. Avoid using a
mallet to force the passage of a nail which has become stuck as a secondary
fracture may occur.
Advance the nail to the fracture site (Figure 10). With a mallet, lightly
tap the nail across the fracture taking care not to rotate the tip as this
may cause the nail to slip behind or in front of the opposite
fragment. Advance the nail towards the metaphysis and anchor it
into the cancellous bone (Figure 11). Advance the second nail
using the same backward and forward movements. Do not rotate
the second nail through a full 360˚ as this may result in the
second nail wrapping itself round the first nail. Again tap the
nail across the fracture site and advance it towards the
metaphysis and anchor it into the cancellous bone.
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Figure 12 Figure 13 Figure 14
Final Impaction and Cutting
It is at this stage of surgery that the Nancy and ECMES Nails
must be differentiated. The Nancy Nail is already the
correct length and should now be impacted in its final
position. The ECMES Nail must be cut to length prior to
being impacted in its final position.
ECMES Nail
Once the ECMES Nail is located in the cancellous bone,
impact it in its final position by lightly tapping the
Cannulated T-Handle. Remove the Cannulated T-Handle
and cut the nail using the cutter (M21840), ensuring that
1 to 2 cm of the nail remains outside the entry hole, as for
the Nancy Nail, the tip of the nail can be moderately
Nancy Nail
curved using surgical forceps.
The Impactor/Extractor (M21898) is used to impact the nail
in its final position. By lightly tapping the hammer pad of
the Impactor/Extractor with a mallet the tip of the nail
inserted medially should finally rest against the cortex above
Optional: In order to minimise the risks of soft tissue irritation
caused by the cut tip of the nail, Polyethylene End Caps
(M21941 to M21946) are provided to cover the tip.
the medial femoral condyle (Figure 12).
Post Operative Care
Caution: Do not make unnecessary rotational movements whilst
the Impactor/Extractor holds the nail as it may cause the rounded
tip to snap off.
No immobilisation is required. Once the patient can
straighten the leg, partial weight bearing may commence. As
soon as the patient feels ready, full weight bearing is allowed.
Physiotherapy should reinforce the quadriceps muscle and the
At this stage the atraumatic rounded tip of the nail can be
moderately curved to facilitate its future retrieval (Figure 13).
extension of the knee. Do not force the knee into flexion as
the extremities of the nail may cause some discomfort.
If distraction of the fracture is evident this may be overcome
by exerting pressure on the knee. If the nail is too long, it
may be shortened by using the Nail Cutter (M21840).
Nail Retrieval
The removal of the nails should be undertaken at around
4 - 6 months depending upon the appearance of the X-rays.
For the Nancy Nail, use the Impactor/Extractor (M21898).
For the ECMES Nails, use the Extraction Clamp (M21900).
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Tibial Fractures
Paediatric tibial fractures are typically treated with two nails inserted in an antegrade
fashion from anteromedial and anterolateral entry portals below the physis. The
recommended age for treating fractures is over 8 years in children or in younger
patients when conservative treatment has failed.
Positioning
The patient is positioned supine on a standard table.
Approach
Make the skin incision proximally to the entry hole to provide better access for the
instruments, and to prevent trauma to the skin. You may start either on the medial or
lateral side. An oblique drill hole is prepared in the proximal metaphysis anteromedial
and anterolateral faces. During the approach the tibialis anterior muscle is pushed
backwards. The nails are passed as per the instructions for the femur. The nails
should not be impacted into the cancellous bone of the distal tibia until any residual
deformity has been corrected.
Insertion and Impaction
As per femoral technique.
Post Operative Care
A simple dressing is put in place for 48 hours after which walking is allowed using
crutches. Plaster immobilisation is not required unless there is a persistent deformity
that requires correction, in which case a below the knee cast should be worn for 3
weeks. Weight bearing can commence between the 4 th and 6 th post operative week
depending upon the appearance of X-rays.
Nail Retrieval
The removal of the nails should be undertaken at around 4-6 months, depending
upon the appearance of the X-rays.
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Forearm Fractures
Paediatric forearm fractures typically
require only a single nail inserted in
Positioning
The patient is positioned supine with the affected arm on a radiolucent arm table.
each bone, either in an antegrade or
retrograde fashion depending on fracture
location. The recommended age for
treating forearm fractures is over 8 years
in children and adolescents and when
conservative treatment has failed.
Approach and Insertion - Radius
The entry hole is made at the distal metaphysis of the radius. The incision can be
either a stab wound or a larger incision with blunt dissection to avoid the radial nerve
and extensor tendons. An awl is used to make the entry hole which is enlarged by
circular movements. The nail is passed up the medullary canal to the fracture site.
Once the fracture has been reduced, the nail can be passed into the proximal
fragment. Once into the proximal fragment, rotate the nail by 180˚ thus reducing the
pronation of the curve of radius.
Approach and Insertion - Ulna
The entry hole is made on the medial surface of the proximal ulna through the
muscle. Pass the nail as described above and secure it in the distal metaphysis.
Note: The concavity of the two nails must face each other.
Impaction
As per the femoral technique.
Post Operative Care
Plaster immobilisation is unnecessary. Forearm movements can be started early. Skin
irritation by the nail may occur but can be minimised if the patient is informed
before hand.
Nail Retrieval
In some cases the fracture can be slow to reunite and some cases of recurrent fractures
have been observed. It is therefore recommended that removal of the nail is
undertaken at around 8 months.
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Humeral Fractures
Paediatric humeral fractures are typically
treated with 2 nails inserted in a
retrograde fashion from a posterior entry
portal. The recommended age for
Positioning and Fracture Reduction
The patient is positioned supine without a tourniquet, with the arm supported by a
radiolucent arm table. An image intensifier is required and is positioned so that the
long axis of the humerus is in view.
treating humeral fractures is over 8 years
in children and adolescents and when
conservative treatment has failed.
Approach
A 3 cm skin incision is prepared on the lateral border of the humerus and distally to
the entry hole in order to provide better access for the instruments and to prevent
any trauma to the skin.
Two retrograde oblique drill holes are created on the lateral supracondylar ridge, one
above the other. Make the entry holes slightly larger than the diameter of the chosen
nail.
Insertion and Impaction
The first nail is introduced through the inferior hole and passed upwards, towards
and beyond the fracture site. Rotate the nail through 180˚ so that the curved tip is
anchored in the medial metaphysis. The second nail is introduced through the
superior hole and passed upwards, and anchored in the lateral metaphysis. Impaction
is conducted as per the femoral technique.
Post Operative Care
A sling is used for 3 weeks at which time the patient can begin to mobilise their
shoulder and elbow on their own.
Nail Retrieval
The removal of the nails should be undertaken at 3 months.
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Ordering Details
Nancy Nail
Instruments
Implants
M21897
Cannulated T-Handle Inserter
M21850
2.0 mm Diameter, 130 mm Length
M21898
Impactor-Extractor
M21851
2.0 mm Diameter, 150 mm Length
M21899
Sliding Hammer
M21852
2.0 mm Diameter, 170 mm Length
M21853
2.0 mm Diameter, 190 mm Length
Delivery Systems
M21860
2.5 mm Diameter, 150 mm Length
M21845
Nancy Nail Tray
M21861
2.5 mm Diameter, 170 mm Length
M21862
M21863
2.5 mm Diameter, 190 mm Length
2.5 mm Diameter, 210 mm Length
ECMES Nail
Implants
M21864
2.5 mm Diameter, 230 mm Length
M21922
2.0 mm Diameter, 400 mm Length
M21870
3.0 mm Diameter, 210 mm Length
M21925
2.5 mm Diameter, 400 mm Length
M21871
3.0 mm Diameter, 230 mm Length
M21930
3.0 mm Diameter, 400 mm Length
M21872
3.0 mm Diameter, 250 mm Length
M21935
3.5 mm Diameter, 400 mm Length
M21873
3.0 mm Diameter, 270 mm Length
M21937
4.0 mm Diameter, 400 mm Length
M21874
3.0 mm Diameter, 290 mm Length
M21880
3.5 mm Diameter, 270 mm Length
Polyethylene End Caps
M21881
3.5 mm Diameter, 290 mm Length
4M21941
2.0 mm Diameter
M21882
3.5 mm Diameter, 310 mm Length
4M21943
2.5 mm Diameter
M21883
3.5 mm Diameter, 330 mm Length
4M21944
3.0 mm Diameter
M21884
3.5 mm Diameter, 350 mm Length
4M21945
3.5 mm Diameter
M21890
4.0 mm Diameter, 330 mm Length
4M21946
4.0 mm Diameter
M21891
4.0 mm Diameter, 350 mm Length
M21892
4.0 mm Diameter, 370 mm Length
Instruments
M21893
4.0 mm Diameter, 390 mm Length
M21897
Cannulated T-Handle Inserter
M21894
4.0 mm Diameter, 410 mm Length
M21840
Nail Cutter
M21895
4.0 mm Diameter, 430 mm Length
M21900
Extraction Clamp
M21896
4.0 mm Diameter, 450 mm Length
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This publication is not intended for distribution in the USA.
Nancy Nail is a trademark of DePuy Orthopaedics, Inc.
© 2011 DePuy International Limited. All rights reserved.
Registered Office: St. Anthony’s Road, Leeds LS11 8DT, England.
Registered in England No. 3319712
Cat No: 9066-70-000 version 1
DePuy International Ltd
St. Anthony’s Road
Leeds LS11 8DT
England
Tel: +44 (0)113 387 7800
Fax: +44 (0)113 387 7890
DePuy France
24 rue Francis de Pressensé
BP 2175
F-69603 Villeurbanne Cedex
France
Telephone: +33 472 69 96 69
Fax: +33 478 93 12 30
0086
Revised: 05/11