tItanIum

cannulated
tIbIal naIl
Expert Nailing System

SurgIcal technIque
Table of Contents

Introduction Titanium Cannulated Tibial Nail Expert Nailing System 2

AO Principles 4

Indications5

Clinical Cases 6

Surgical Technique Preoperative Planning 8

Opening the Tibia 9

Reaming (optional) 14

Inserting the Nail 15

Locking Options 19

Locking Holes 20

Distal Locking 21

Proximal Locking 27

End Cap Insertion 41

Implant Removal 43

Product Information Implant Specifications 48

Implants49

Instruments56

Set Lists 61

Image intensifier control

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma
Titanium Cannulated Tibial Nail
Expert Nailing System

Advanced solutions
Advanced proximal locking options

x Three innovative locking options, in x Two state-of-the-art mediolateral

combination with dual core locking (ML) locking options enable primary
screws, to increase the stability of compression or secondary controlled
the proximal fragment for proximal dynamization
third fractures

Improved stability
End caps
x Gold end caps securely lock the most
proximal oblique locking screw to
create a fixed-angle construct
x Gray end caps feature a lead-in
design for easier end cap insertion 15 mm 10 mm 5 mm 0 mm
x End caps prevent ingrowth of tissue
and facilitates nail extraction
x Self-retaining T40 StarDrive recess for
easy pick up and insertion of end cap
x Cannulated
x 0 mm end caps sit flush with nail
x 5, 10, and 15 mm end caps extend
nail height if nail is overinserted
15 mm 10 mm 5 mm 0 mm

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2    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Titanium Cannulated Tibial Nail
Expert Nailing System

Advanced nail design Advanced distal locking options

x Anatomic bend for ease of nail x Distal oblique locking options to
insertion prevent soft tissue damage and
x Titanium alloy* for improved increase stability of the distal
mechanical and fatigue properties fragment
x Cannulated nails (from 8 mm–13 mm x Two ML and one anteroposterior
diameter) for reamed or unreamed (AP) locking options for stability
techniques, enabling nail insertion of the distal fragment
over guide wire
x All DePuy Synthes 2.5 mm or
3.0 mm ball tipped guide wires may
be removed through the nail and
insertion handle assembly (no
exchange tube required)

Multidirectional locking options for improved stability

All locking screws Dual-core locking screws
x Double-lead thread for more contact x Indicated for the three proximal
points enhance stability and ease locking options of all tibial nails
of insertion x Dual-core design for optimized
x Thread closer to screw head provides purchase in cancellous bone
better bone purchase in the near x Unicortical
cortex and improved stability x Lengths: 30 mm–90 mm
x Titanium alloy* for improved
mechanical and fatigue properties Standard locking screws
x Self-tapping blunt tip
x Larger cross-section for improved
x Self-retaining T25 StarDrive recess
mechanical resistance
allows improved torque transmission
x 4.0 mm diameter for 8 mm and 9 mm
and increased resistance to stripping
tibial nails, lengths: 18 mm–80 mm
relative to a hex recess and secure
x 5.0 mm diameter for 10 mm–13 mm
locking screw pick-up
tibial nails, lengths: 26 mm–100 mm
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Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    3
AO Principles

In 1958, the AO formulated four basic principles, which have

become the guidelines for internal fixation.1 They are:

Anatomic reduction
Fracture reduction and fixation to restore anatomical
relationships.

Stable fixation
Stability by fixation or splintage, as the personality
of the fracture and the injury requires.

Preservation of blood supply

Preservation of blood supply to soft tissue and bone
by careful handling.

Early, active mobilization

Early, active mobilization of the part and patient.

1. Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of Internal

Fixation, 3rd Edition. Berlin: Springer-Verlag. 1991.

4    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Indications

The Tibial Nail– EX is intended to stabilize fractures of the

proximal and distal tibia and the tibial shaft, open and closed
tibial shaft fractures, certain pre- and postisthmic fractures,
and tibial malunions and nonunions.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    5
Clinical Cases

Shaft fracture

Case 1
For simple shaft fractures, two proximal ML and two distal
ML locking screws are normally sufficient to stabilize the
fracture. Secondary dynamization is achieved by removing
the proximal static locking screw.

Fracture involving the distal component

Case 2
The use of four distal locking screws is sometimes necessary
to achieve stabilization of the distal fragment. In many cases,
three locking screws placed in the most distal locking options
are sufficient to stabilize the distal fragment.

Note: Results from clinical cases are not predictive of results in other cases.
Results in other cases may vary.

6    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Clinical Cases

Preoperative Intraoperative Follow-up (3 weeks after surgery)

Preoperative Postoperative Follow-up (3 weeks after surgery)

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    7
Preoperative Planning

Use the AO preoperative planner template for the Tibial

Nail–EX to estimate nail diameter and nail length. To estimate
nail diameter, place the template on the AP or lateral x-ray
of the uninjured tibia and measure the diameter of the
medullary canal at the narrowest part that will contain
the nail.

To estimate nail length, place the template on the AP x-ray

of the uninjured tibia and select the appropriate nail length
based on patient anatomy. When selecting nail size, consider
canal diameter, fracture pattern, patient anatomy, and post-
operative protocol.

Note: Templates are available in two sizes: actual size

and 115% magnification in which the image is enlarged
15% to correspond to typical radiographic magnification;
however, variations in magnification levels are common.

8    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Opening the Tibia

1
Position patient

Position the patient supine on the radiolucent table. Ensure

that the knee of the injured leg can be flexed at least 90°.
Position the image intensifier so that visualization of the
tibia, including the articular surface proximally and distally,
is possible in AP and lateral views.

Optionally, the procedure can be performed on a fracture

table with the leg placed in traction.

Note: The knee roll can be placed under the lower part
of the thigh if it obstructs the view of the tibial plateau
in the AP view.

2
Reduce fracture

Instrument

394.35* Large Distractor

Perform closed reduction manually by axial traction under

image intensification. The use of the large distractor may
be appropriate in certain circumstances.

Note: The reduction can be temporarily fixed with reduc-

tion clamps. In epiphyseal fractures the condyles or the
pilon are fixed first in order to enable the nail insertion.

*Also available

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    9
Opening the Tibia

3
Confirm nail length and diameter

Instrument

03.010.021 Radiographic Ruler, for Titanium

Cannulated Tibial Nails–EX

The required nail length must be determined after reduction

of the lower leg fracture.

Position the C-arm for an AP view of the distal tibia. With

long forceps, hold the radiographic ruler along the leg,
parallel to and at the same level as the tibia. Adjust the ruler
until the distal tip is at the level of the physeal scar or the
desired nail insertion depth. Mark the skin at that site.

Move the C-arm to the proximal tibia, replace the distal end
of the ruler at the skin mark, and take an AP image of the
proximal tibia. Read nail length directly from the ruler image,
selecting the measurement at or just below the level of the
anterior edge of the tibial plateau.

When using the large distractor, measure the distance from

the inferior border of the distal pin to the superior border of
the proximal pin to determine optimal nail length.

Position the C-arm for an AP or lateral view of the tibia at

the level of the isthmus. Hold the radiographic ruler over
the tibia so that the diameter gauge is centered over the
narrowest part of the medullary canal. Read the diameter
measurement on the circular indicator that fills the canal.

Note: Compression or dynamization must be taken into

account when determining the nail length. A shorter
nail should be chosen when active compression is
planned for the procedure. The dynamic locking option
allows for 7 mm of travel.

Important: The ruler is not at the same level as the

tibia. This affects the accuracy of the measurement,
providing only an estimate of the canal diameter.

11    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Opening the Tibia

4
Approach

Make an incision in line with the central axis of the

intramedullary canal. Depending on the anatomy of the
patient, this incision can be transpatellar, medial or even
lateral parapatellar.

The incision starts proximally at the distal third of the patella

along the patellar ligament down to the tibial tuberosity.

Mobilize the infrapatellar corpus adiposum laterally and

dorsally without opening the synovia. Free access of the nail
to the insertion point must be guaranteed.

Prepare the entry site of the nail on the ventral edge of the
tibial plateau.

5
10°
Determine entry point

The entry point defines the optimal position of the nail in the
intramedullary canal. This is more important for proximal and
distal-third fractures to prevent fragment displacement.

In AP view, the entry point is in line with the axis of the

intramedullary canal and with the lateral tubercle of the
intercondylar eminence.

In lateral view, the entry point is at the ventral edge of the

tibial plateau.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    11
Opening the Tibia

6
Insert guide wire

Instrument

357.399 3.2 mm Guide Wire, 400 mm

Slightly punch mark the insertion point at a 10° angle to

the shaft axis in the lateral view.

Hold a sterile nail on the side of the lower leg with its distal
end parallel to the tibia shaft. The curved proximal nail end
determines the angle of insertion for the guide wire.

Insert the guide wire for approximately 8 cm – 10 cm and

check the position under image intensification in the AP
and lateral views.

11    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Opening the Tibia

7
Open medullary canal

Instruments

03.010.035 12.0 mm Protection Sleeve

03.010.036 12.0 mm Cannulated Drill Bit, large quick

coupling, 190 mm

357.399 3.2 mm Guide Wire, 400 mm

Place the protection sleeve and the drill bit over the guide
wire and down to the bone. Drill to a depth of approximately
8 cm – 10 cm. The guide wire and the drill bit should not
touch the posterior cortex.

Remove the guide wire, drill bit, and protection sleeve.

Note: Dispose of the guide wire. Do not reuse.

Alternative instruments

03.010.040 12.0 mm Cannulated Awl

357.399 3.2 mm Guide Wire, 400 mm

Place the cannulated awl over the guide wire and open
the medullary canal. Use a twisting motion to advance the
awl to a depth of approximately 8 cm–10 cm.

The awl should not touch the posterior cortex.

Remove the guide wire and awl.

Note: Dispose of the guide wire. Do not reuse.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    11
Reaming (optional)

8
Reaming medullary canal (optional)

Instruments

03.010.024 Holding Device, for Guide Wires

and Reaming Rods

03.010.093 Reaming Rod Push Rod

351.706S* 2.5 mm Reaming Rod with ball tip,

950 mm, sterile

351.707S* 2.5 mm Reaming Rod with ball tip and

extension, 950 mm, sterile

Also available set

150.060 Flexible Reamer Set for IM Nails

If necessary, enlarge the tibial canal with the medullary

reamer, to the desired diameter.

Check fracture reduction under the image intensification.

Inserting the reaming rod

Insert the reaming rod with ball tip into the medullary canal,
using the holding device to the desired insertion depth.

Reaming
Starting with the 8.5 mm diameter reaming head, ream
to a diameter of 0.50 mm–1.0 mm greater than the nail
diameter. Ream in 0.5 mm increments and advance the reamer
with steady, moderate pressure. Do not force the reamer.
Partially retract the reamer often to clear debris from the
medullary canal.

Note: All nails in the cannulated Tibial Nail Expert

System can be inserted over the reaming rod with ball
tip. Reaming rod exchange is not required.

Option
Use the reaming rod push rod to help retain the reaming
rod during reamer extraction.

*Also available

11    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Inserting the Nail

1
Assemble insertion instruments

Instruments

03.010.044 Cannulated Connecting Screw,

for Standard Insertion Handle

03.010.045 Standard Insertion Handle

03.010.092 Ball Hex Screwdriver, 8 mm

Orient the insertion handle anteriorly, and match the tang

on the handle to the notch in the nail.

Place the connecting screw into the insertion handle and

thread it into the proximal nail end, using the 8 mm ball
hex screwdriver.

Verify the nail is oriented properly on the insertion handle;

secure the assembly with the 8 mm ball hex screwdriver.

Alternative instruments

03.010.017 Tibial Nail–EX Insertion Handle

03.010.145 Cannulated Connecting Screw, for Short

Insertion Handle, with internal thread
or
03.010.046 Percutaneous Insertion Handle

03.010.146 Cannulated Connecting Screw, for

Percutaneous Insertion Handle, with
internal thread

Optional instrument

03.010.093 Reaming Rod Push Rod

Optionally, slide the connecting screw onto the reaming

rod push rod. Slide the assembly through the insertion handle
and match the tang of the handle to the notch of the nail.
Tighten, using the hex on the reaming rod push rod.

Secure the assembly using the 8 mm ball hex screwdriver.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    11
Inserting the Nail

2
Insert nail

Note: Hyperflex the knee to aid nail insertion into the

medullary canal.

Insert the nail into the intramedullary canal. Use a twisting

motion to advance the nail.

Monitor the nail passage across the fracture; control in two

planes to avoid malalignment.

Insert the nail until it is at or below the tibial opening.

Check final nail position in AP and lateral views.

Note: For proximal locking, mount the aiming arm

only when the tibial nail has been completely inserted,
otherwise the aiming arm may loosen during nail
insertion.

Optional instruments

03.010.047 Driving Cap

03.010.056 Slide/Fixed Hammer, 700 grams

321.17 4.5 mm Pin Wrench

321.20 11 mm Ratchet Wrench

357.22 Hammer Guide, for Slide Hammer

357.398 Cannulated Shaft with 8 mm hex

If needed, use light, controlled hammer blows to seat the

nail. Slide the driving cap into the grooves on the insertion
handle and secure it, using the 11 mm wrench. Lock the
head of the hammer in place by tightening the nut onto the
threads located below the hammer head, using the 4.5 mm
pin wrench. Strike the driving cap directly.

Optionally, the hammer guide can be threaded into the

driving cap and the hammer can be used as a slide hammer.
Loosen the nut from the threads located below the hammer
head and secure onto the threads located above the handle.

11    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Inserting the Nail

Note: If nail insertion is difficult, choose a smaller

diameter tibial nail or ream the medullary canal to a
larger diameter.

Important: Confirm that the nail is securely connected to

the insertion handle, especially after hammering, using
either the 8 mm ball hex screwdriver or the cannulated
shaft with 8 mm hex.

Important: Do not strike the insertion handle directly.

3
Check proximal nail position

Instruments

03.010.052 Aiming Arm, for Titanium Cannulated

Tibial Nails–EX

357.399 3.2 mm Guide Wire, 400 mm

Attach the aiming arm and insert a 3.2 mm guide wire

through the hole as shown in the illustration.

The tip of the guide wire indicates the exact proximal

position of the tibial nail.

Remove the driving cap.

Remove the aiming arm, unless proximal locking is the

next step.
20 mm
15 mm
Check proximal nail position under image intensification 10 mm
in the lateral view. 5 mm
0 mm

Note: The distance between the markings on the insertion

handle is 5 mm and corresponds to the extensions of the
end caps. This feature can be used for overinsertion of
the nail or for correcting the nail location within the
medullary canal.

If primary compression or secondary dynamization are

planned, it is recommended to overinsert the nail by more
than 7 mm, which corresponds to the maximum distance
between the positions in static and dynamic modes.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    11
Inserting the Nail

4
Check distal nail position

Check final nail position under image intensification in

AP and lateral views.

Remove the reaming rod.

Important: Confirm that the nail is securely connected to

the insertion handle, especially after hammering, using
either the 8 mm ball hex screwdriver or the cannulated
shaft with 8 mm hex.

Note: Insertion depth is critical for distal third fractures

where a minimum of two locking screws below the
fracture line are required to stabilize the distal segment.

11    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Locking Options

Proximal segment fractures

For proximal fractures, it is recommended to lock the nail
with the knee in extension. This neutralizes the deforming
forces on proximal fragments caused by the quadriceps
mechanism, and relieves the pressure on the soft tissue
usually associated with tibial nail insertion instruments. This
position also facilitates assessment of rotational alignment
before locking.

Diaphyseal segment fractures

For diaphyseal fractures, it is recommended to lock distally
first, to allow intraoperative compression.

Distal segment fractures

For distal fractures, it is recommended to lock distally first,
to facilitate reduction.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    11
Locking Holes

14 mm
20 mm
Proximal oblique 30 mm
For use with 36 mm
Distal oblique
dual core
locking screws 57 mm
AP
AP view
Dynamic
7 mm
Stat 2

Stat 1

ML view

ML

AP
37 mm
ML
For anterolateral or 22 mm
13 mm
anteromedial locking Oblique
5 mm
(30° to the sagittal plane)

22    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Distal Locking

1
Distal locking

Instruments

03.010.017 Tibial Nail– EX Insertion Handle

03.010.145 Cannulated Connecting Screw

511.30 Radiolucent Drive

Use the appropriate locking screws and drill bit for the nail
diameter selected.

Nail diameter Locking screw Drill bit

8 mm and 9 mm 4.0 mm 3.2 mm

(blue) (blue) 03.010.100* or
03.010.103

10 mm to 13 mm 5.0 mm 4.2 mm
(green) (green) 03.010.101* or
03.010.104

It is recommended to lock distally first, enabling the use

of the backslap technique** to prevent loss of reduction.
Verify the nail has been inserted to the appropriate depth.

Locking of the tibial nail is usually performed from the

medial side, if possible with the leg extended. This position
helps counteract the forces exerted by the quadriceps muscle
that would tend to deform the proximal fragment and also
facilitates rotational control of the tibial axis before locking.

Note: When locking in extension use Tibial Nail–EX

insertion handle and the corresponding connecting screw.

Distal locking with the radiolucent drive is described on

pages 22 and 23.

Note: The use of the most distal locking option is

recommended for distal fractures. This locking option
is oriented 30° from the sagittal plane.

*For radiolucent drive/Also Available

**See page 26.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    22
Distal Locking

2
Align image

Check the reduction, correct alignment of the fragments,

and leg length before locking the nail.

Align the C-arm with the hole in the nail closest to the
fracture until a perfect circle is visible in the center of the
screen. (Distal ML hole shown in illustration).

3
Determine incision point

Place a scalpel blade on the skin over the center of the

hole to mark the incision point and make a stab incision.

22    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Distal Locking

4
Drill

Instruments

03.010.100* 3.2 mm Three-Fluted Drill Bit, quick

coupling, 145 mm, for Radiolucent Drive

03.010.101* 4.2 mm Three-Fluted Drill Bit, quick

coupling, 145 mm, for Radiolucent Drive

Using the radiolucent drive under image intensification, insert

the tip of the appropriate drill bit through the incision and
down to the bone.

Incline the drive so that the tip of the drill bit is centered over
the locking hole. The drill bit should almost completely fill
the circle of the locking hole. Hold the drill bit in this position
and drill through both cortices.

Technique tip: For greater drill bit control, discontinue

drill power after perforating the near cortex. Manually
guide the drill bit through the nail before resuming
power to drill the far cortex.

Alternative instruments

03.010.103 3.2 mm Three-Fluted Drill Bit, quick

coupling, 145 mm

03.010.104 4.2 mm Three-Fluted Drill Bit, quick

coupling, 145 mm

Standard freehand locking technique can be performed

without the radiolucent drive. Use the appropriate drill bit
shown above.

*Also available

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    22
Distal Locking

5
Determine locking screw length

Instruments

03.010.100* 3.2 mm Three-Fluted Drill Bit, quick

coupling, 145 mm, for Radiolucent Drive

03.010.101* 4.2 mm Three-Fluted Drill Bit, quick

coupling, 145 mm, for Radiolucent Drive

03.010.103 3.2 mm Three-Fluted Drill Bit, quick

coupling, 145 mm

03.010.104 4.2 mm Three-Fluted Drill Bit, quick

coupling, 145 mm

03.010.106 Direct Measuring Device, for Locking

Screws to 100 mm, for IM Nails

Stop drilling immediately after both cortices and disassemble

the drill bit from the radiolucent drive.

Ensure the correct position of the drill bit beyond the far cortex.

Place the direct measuring device onto the drill bit. Read the
graduation of the measuring device at the end of the drill bit.
This corresponds to the appropriate locking screw length.

Note: Drill bit location with respect to the far cortex is

critical for measuring the appropriate locking screw
length.

* Also available

22    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Distal Locking

Alternative instrument

03.010.072 Depth Gauge, for Locking Screws to

100 mm, for IM Nails

Measure the locking screw length using the depth gauge for
locking screws. Ensure the outer sleeve is in contact with the
bone and the hook grasps the far cortex.

Read the locking screw length directly from the depth gauge
at the back of the outer sleeve.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    22
Distal Locking

6 a
Insert locking screw

Instruments

03.010.107 StarDrive Screwdriver, T25, self-retaining

b
03.010.112 Holding Sleeve, with Locking Device

Insert the appropriate length locking screw using the T25

StarDrive screwdriver and the holding sleeve with locking
device, if needed.
c

Verify locking screw length under image intensification. If

needed, a second locking screw may be inserted using the
same technique.

Note: In the event of loss of reduction, the backslap

d
technique* can be used after insertion of the second
distal locking screw. Alternatively, the compression
device can be used; refer to page 31.

Use the holding sleeve as described below:

a Insert the holding sleeve onto the shaft of the screwdriver

and place the tip of the screwdriver in the recess of the
locking screw.
b Push the holding sleeve in the direction of the locking
screw, the sleeve now holds the locking screw.
c Lock the holding sleeve by tightening it counterclockwise.
d Release the holding sleeve after insertion of the locking
screw, by loosening it clockwise and pushing backwards.

*Backslap technique: with the hammer guide attached to the driving cap
and insertion handle (see page 16) light, reverse hammer blows may be used
to compress the fracture; monitor reduction radiographically.

22    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Proximal Locking—
Diaphyseal and Distal Segment Fractures

1
Choose locking screws and instruments

Use the correct locking screw, drill sleeve, trocar and drill bit
for the selected nail diameter, as shown in the table.

Three proximal ML locking options can be targeted using

the aiming arm:
1 The dynamic locking option (DYNAM) corresponds to
the upper position of the proximal locking slot. This type
DYNAM
of locking allows primary compression or secondary,
controlled dynamization of the bone fragments.
STAT 2
2 Static 2 (STAT 2) corresponds to the lower position of the
proximal locking slot. This type of locking does not allow
primary compression or secondary controlled dynamization.
STAT 1
3 S tatic 1 (STAT 1) corresponds to the most distal proximal
locking hole.

Nail Diameter Locking Screws Protection Sleeve Drill Sleeve Trocar Calibrated Drill Bit

8 mm and 9 mm 4.0 mm 12.0 mm /8.0 mm 8.0 mm/3.2 mm 3.2 mm 3.2 mm

(blue) (blue) 03.010.063 03.010.064 03.010.069 03.010.060

10 mm – 13 mm 5.0 mm 12.0 mm /8.0 mm 8.0 mm/4.2 mm 4.2 mm 4.2 mm

(green) (green) 03.010.063 03.010.065 03.010.070 03.010.061

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    22
Proximal Locking — Diaphyseal and Distal Segment Fractures

2
Mount aiming arm

Instrument

03.010.052 Aiming Arm, for the Titanium Cannulated

Tibial Nails–EX

Confirm that the nail is securely connected to the insertion

handle using the 8 mm ball hex. Mount the aiming arm to
the insertion handle.

Note: Do not exert forces on the aiming arm, protection

sleeve, drill sleeves and drill bits. These forces may
prevent accurate targeting through the proximal locking
holes and damage the drill bits.

3
Insert trocar combination

Instruments

03.010.063 12.0 mm/8.0 mm Protection Sleeve, 188 mm

03.010.064 8.0 mm/3.2 mm Drill Sleeve, 200 mm

(with blue and gold marking)

03.010.065 8.0 mm/4.2 mm Drill Sleeve, 200 mm

(with green marking)

03.010.069 3.2 mm Trocar, 210 mm (with blue and

gold marking)

03.010.070 4.2 mm Trocar, 210 mm (with green marking)

Insert the three-part trocar combination (protection sleeve,

corresponding drill sleeve and trocar) through the desired
ML hole in the aiming arm, make a stab incision and insert
the trocar to the bone. Remove the trocar.

22    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Proximal Locking — Diaphyseal and Distal Segment Fractures

4 
Drill and determine locking screw length

Instruments

03.010.060 3.2 mm Three-Fluted Drill Bit,

quick coupling, 330 mm, 100 mm
calibration (with blue and gold marking)

03.010.061 4.2 mm Three-Fluted Drill Bit,

quick coupling, 330 mm, 100 mm
calibration (with green marking)

Ensure that the drill sleeve is pressed firmly to the near cortex.
Using the corresponding drill bit (3.2 mm for 4.0 mm locking
screws, or 4.2 mm for 5.0 mm locking screws), drill through
both cortices until the tip of the drill bit penetrates the far
cortex.

Confirm drill bit position.

Ensure that the drill sleeve is pressed firmly to the near cortex
and read the measurement from the calibrated drill bit at the
back of the drill sleeve. This measurement corresponds to the
appropriate length locking screw. Remove the drill bit and
the drill sleeve.

Alternative instrument

03.010.072 Depth Gauge, for Locking Screws to

100 mm, for IM Nails

After drilling both cortices, remove the drill bit and the
drill sleeve.

Disassemble the depth gauge into two parts: the outer sleeve
and the measuring device with hook. Insert the measuring
device into the protection sleeve. Make sure that the hook
grasps the far cortex and that the protection sleeve is on
the bone.

Read the measurement from the back of the protection sleeve,

which indicates the appropriate length locking screw.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    22
Proximal Locking — Diaphyseal and Distal Segment Fractures

5
Insert locking screw

Instrument

03.010.107 StarDrive Screwdriver, T25, self-retaining

Insert the appropriate length locking screw through the

protection sleeve using the T25 StarDrive screwdriver.
Verify locking screw length under image intensification.

The tip of the locking screw should not project more than
1 mm – 2 mm beyond the far cortex.

Repeat Steps 3 to 5 for the second proximal ML locking

screw.

Option

Additional dual core locking screws can be added for

proximal fractures and highly unstable fractures.

Refer to page 34 for details on proximal locking with the

dual core locking screws.

33    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Proximal Locking— Compression Locking
Mode (optional)

1
Compression locking mode (optional)

For situations where the fracture gap needs compression

after nail insertion, this can be accomplished without
removing the insertion instruments.

The Tibial Nail– EX allows a maximum compression of

7 mm. If more compression of the fracture gap is needed,
the conventional backslap technique is recommended
(see page 26).

Note: Distal locking is required prior to compression

locking, refer to page 21.

Insert one proximal locking screw in the dynamic locking hole

(DYNAM). Refer to section Diaphyseal and Distal Segment
Fractures on pages 27 to 30, for details on inserting this
locking screw.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    33
Proximal Locking —Compression Locking Mode (optional)

2
Insert compression device

Instruments

03.010.015 Compression Device for Titanium

Cannulated Tibial Nails – EX, for use with
(03.010.044) and (03.010.045)

03.010.092 Ball Hex Screwdriver, 8 mm

Confirm that the nail is securely connected to the insertion

handle using the 8 mm ball hex screwdriver.

Insert the compression device through the connecting screw

and into the nail using the 8 mm ball hex screwdriver.

The compression device will contact the dynamic locking screw.

Advance the compression device until the fracture gap is

reduced. Monitor reduction under image intensification.
Each revolution of the compression device corresponds to
compression of 1 mm (maximum 7 mm).

Important: Do not overtighten the compression device,

as it may deform the locking screw.

Alternative instruments

03.010.136* Short Compression Device for Titanium

Cannulated Tibial Nails–EX, for use with
(03.010.145) and (03.010.017)
or
03.010.137* Long Compression Device for Titanium
Cannulated Tibial Nails–EX, for use with
(03.010.146) and (03.010.046)

*Also available

33    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Proximal Locking —Compression Locking Mode (optional)

3
Monitor fracture

Control the fracture gap before, during, and after the

compression procedure.

4
Insert static locking screw

Insert second proximal locking screw in the most distal hole

of the proximal locking options (Static 1). Refer to section
Diaphyseal and Distal Segment Fractures on pages 27 to 30.

Remove the compression device.

Additional oblique dual core locking screws can be inserted

if required. Refer to section Proximal Segment Fractures on
page 34.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    33
Proximal Locking—
Proximal Segment Fractures

1
Oblique proximal locking

Instruments

03.010.017 Tibial Nail–EX Insertion Handle

03.010.136* Short Compression Device

03.010.145 Cannulated Connecting Screw

Proximal locking can be performed with the leg in full

extension. This neutralizes the deforming forces on proximal
fragments caused by the quadriceps mechanism and relieves
the pressure on the soft tissue usually associated with tibial
nail insertion instruments. This position also facilitates
assessment of rotational alignment prior to locking.

Use the dual-core locking screws (gold) only in combination

with the two oblique proximal locking holes (PROXIMAL
OBLIQUE, DISTAL OBLIQUE) and AP proximal locking hole
for all nail diameters.

Use the 3.2 mm drill bit for the 5.0 mm dual-core

locking screws.

The aiming arm can target all three proximal oblique

locking options:
1 The oblique locking option (PROXIMAL OBLIQUE)
corresponds to the most proximal locking position.
Inserting a tibial nail end cap with this locking screw will
create a fixed-angle construct.
2 The oblique locking option (Distal Oblique) corresponds
to the second proximal locking position.
3 The oblique locking option in anteroposterior direction
(AP) corresponds to the third proximal locking position.

*Also available

33    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Important: Drilling for the oblique proximal locking
requires special attention. To avoid lesion of the
popliteal artery, the tibial nerve and the common
peroneal nerve, as well as damage to the proximal
tibiofibular joint, drilling must be stopped immediately
before penetrating the far cortex.

Note: When locking with the leg in full extension, it is

recommended to use the Tibial Nail–EX insertion handle
and cannulated connecting screw to prevent impingement
on the patella.

common
peroneal nerve
tibial nerve popliteal
artery

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    33
Proximal Locking — Proximal Segment Fractures

2
Mount aiming arm

Instruments

03.010.052 Aiming Arm, for Titanium Cannulated

Tibial Nail–EX

03.010.092 Ball Hex S crewdriver, 8 mm

Confirm that the nail is securely connected to the insertion

handle using the 8 mm ball hex screwdriver. Mount the aiming
arm to the insertion handle as shown in the illustration.

Note: Do not exert forces on the aiming arm, protection

sleeve, drill sleeves and drill bits. These forces may
prevent accurate targeting through the proximal locking
holes and damage the drill bits.

33    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Proximal Locking — Proximal Segment Fractures

3
Insert trocar combination

Instruments

03.010.063 12.0 mm/8.0 mm Protection Sleeve,

188 mm

03.010.064 8.0 mm/3.2 mm Drill Sleeve, 200 mm

(with blue and gold marking)

03.010.069 3.2 mm Trocar, 210 mm

(with blue and gold marking)

Insert the three-part trocar combination (protection sleeve,

corresponding drill sleeve and trocar) through the desired
hole for oblique locking options in the aiming arm, make
a stab incision and insert the trocar to the bone. Remove
the trocar.

4
Drill and determine dual core locking screw length

Instrument

03.010.060 3.2 mm Three-Fluted Drill Bit,

quick coupling, 330 mm, 100 mm
calibration (with blue and gold marking)

Ensure that the drill sleeve is pressed firmly to the near

cortex.

Insert the calibrated drill bit and start drilling the near cortex.

Stop drilling immediately after penetrating the near

cortex. DO NOT penetrate the far cortex.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    33
Proximal Locking — Proximal Segment Fractures

Monitor the position of the drill bit with image intensification.

This can be done by orienting the image intensifier
perpendicular to the drill bit.

Drill to the desired depth. A long dual core locking screw

will achieve better bone purchase than a shorter dual core
locking screw.

Important: Do not perforate the far cortex with the drill

bit. Do not damage the tibial plateau.

Confirm drill bit position after drilling.

Ensure that the drill sleeve is pressed firmly to the bone and
read the measurement from the calibrated drill bit at the
back of the drill sleeve.

This measurement indicates the appropriate length of the

dual core locking screw.

Remove the drill bit and the drill sleeve.

Important: To avoid perforation of the far cortex with

the dual core locking screw, a dual core locking screw
5 mm shorter than the measured length is recommended.

33    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Proximal Locking — Proximal Segment Fractures

5
Insert dual core locking screws

Instrument

03.010.107 StarDrive Screwdriver, T25, self-retaining

Insert the appropriate 5.0 mm dual core locking screw

through the protection sleeve,
using the T25 StarDrive
screwdriver. Do not overtighten.

Verify locking screw length under image intensification.

Repeat this procedure for the second dual core locking screw.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    33
Proximal Locking — Proximal Segment Fractures

Option
Repeat the same steps as described above for the third
proximal dual core locking screw in the AP direction.

The position of the dual core locking screw should be

controlled under image intensification to ensure a correct
position of the AP dual core locking screw.

44    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
End Cap Insertion

1
Insert end cap

Instruments

03.010.110 Cannulated StarDrive Screwdriver, T40

357.399 3.2 mm Guide Wire, 400 mm

All titanium end caps for the Tibial Nail–EX are available
in extension lengths of 0 mm, 5 mm, 10 mm, and 15 mm.
They prevent bone ingrowth into the nail and they extend
the nail height if it is overinserted.

The gold end caps lock the proximal oblique screw providing
a stable fixed-angle construct.

The gray end caps have a lead-in design for easier end
cap insertion. These are only used for standard transverse
proximal locking. The two proximal oblique locking holes
cannot be used in conjunction with the gray end caps.

The end caps are cannulated for use over a guide wire,
if necessary.

Remove the nail insertion instruments.

Optionally, to aid in end cap insertion, remove the connecting

screw only. The insertion handle can remain to help align the
end cap to the top of the nail. The end cap fits through the
barrel of the insertion handle.

Note: The leg should be positioned in flexion to facilitate

end cap insertion.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    44
End Cap Insertion

Engage the end cap with the cannulated T40 StarDrive

screwdriver by exerting axial pressure. To prevent cross-
threading, align the end cap with the nail axis and turn the
end cap counterclockwise until the thread of the end cap
aligns with that of the nail.

Turn the end cap clockwise to thread the end cap into the nail.

Remove the guide wire and T40 StarDrive screwdriver.

Note: The end cap will engage the most proximal

oblique locking screw to create a fixed-angle construct.

44    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Implant Removal

1
Remove end cap and locking screws

Instruments

03.010.107 StarDrive Screwdriver, T25, self-retaining

03.010.110 Cannulated StarDrive Screwdriver, T40,

self-retaining

03.010.112 Holding Sleeve, with Locking Device

Implant removal is an optional procedure.

Clear the StarDrive socket of the end cap and the locking
implants of any tissue ingrowth. Remove the end cap with
the T40 StarDrive screwdriver.

Remove all locking screws except one of the proximal

locking screws, using the T25 StarDrive screwdriver and
holding sleeve.

Note: Always remove the most proximal dual core

locking screw in order to insert the extraction screw
into the proximal end of the Tibial Nail–EX.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    44
Implant Removal

2
Attach extraction screw and hammer guide

Instruments

03.010.107 StarDrive Screwdriver, T25, self-retaining

357.133 Extraction Screw

357.22 Hammer Guide

Before removing the final locking screw, screw the extraction

screw into the tibial nail and tighten it to prevent rotation or
displacement of the nail posteriorly below the tibial plateau.

Attach the hammer guide to the extraction screw.

Remove the remaining locking screw with the T25

StarDrive screwdriver.

3
Remove nail

Instrument

03.010.056 Slide/Fixed Hammer, 700 grams

Extract the nail by applying gentle blows with the hammer.

44    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Implant Removal

Alternative Technique–Extraction Hook

For removal of broken nail

Instruments

03.010.044 Cannulated Connection Screw

355.399◊ Extraction Hook, for Titanium Cannulated

Nails

357.133 Extraction Screw

393.10 Universal Chuck with T-Handle

or
393.105 Small Universal Chuck with T-Handle

1
Clear tissue from the end of the nail and remove the end cap.

2
Remove the locking bolts and/or screws with the appropriate
screwdriver.

3
Insert the extraction hook into the universal chuck with
T-handle. The hook should be parallel with the T-handle. This
facilitates visualization of the hook position in the bone.

◊Availablenonsterile or sterile-packed. Add “S” to product number to indicate

sterile product.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    44
Implant Removal

4
Attach appropriate extraction bolt or connecting screw to
the nail. Remove the near nail fragment using the extraction
bolt or connecting screw.

Note: The extraction hook can be used as an alternative

to extraction instrumentation.

5
Ream the medullary canal 1 mm larger than the diameter to
clear a path for the distant nail fragment.

6
Insert the extraction hook and explanted, near nail fragment
into the medullary canal. The near nail fragment aligns the
extraction hook with the cannulation of the distant nail
fragment.

7
Pass the extraction hook through the cannula of the distant
nail fragment.

Note: Under image intensification, verify that the hook

has passed through and engaged the distant end of
the nail.

8
Extract both nail fragments.

Note: Keep the patient’s limb restrained to increase the

efficiency of the extraction force.

44    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Implant Removal

For removal of an intact nail

Instruments

355.399◊ Extraction Hook, for Titanium Cannulated

Nails

393.10 Universal Chuck with T-Handle

or
393.105 Small Universal Chuck with T-Handle

1
Clear tissue from the end of the nail and remove the end cap.

2
Remove the locking bolts and/or screws with the appropriate
screwdriver.

3
Insert the extraction hook into the universal chuck with
T-handle. The hook should be parallel with the T-handle.
This facilitates visualization of the hook position in the bone.

4
Insert the extraction hook through the nail cannula.

Note: Under image intensification, verify that the hook

has passed through and engaged the distant end of
the nail.

5
Extract the nail.

Note: Keep the patient’s limb restrained to increase the

efficiency of the extraction force.

◊Availablenonsterile or sterile-packed. Add “S” to product number to indicate

sterile product.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    44
Implant Specifications

10.5º

Titanium Cannulated Tibial Nails–EX

Universal design for the left or right tibia 14 mm
Proximal
Oblique 20 mm

Material Distal 36 mm
Oblique 30 mm
Titanium-6% aluminum-7% niobium alloy 57 mm
AP
Dynamic
Diameters Stat 2 7 mm
8 mm – 13 mm (1 mm increments)
x 8 mm – 10 mm nails have a proximal Stat 1
diameter of 11 mm
x 11 mm – 13 mm nails have a proximal
diameter consistent with the shaft Start of bend
is 75 mm
diameter

Colors
x 8 mm and 9 mm (blue) use 4.0 mm
titanium locking screws (blue)
x 10 mm – 13 mm (green) use 5.0 mm
titanium locking screws (green)
Radius varies
Lengths
255 mm – 435 mm (15-mm increments)

Cross Section
x 8 mm – 10 mm nails are round
x 11 mm – 13 mm nails are fluted

End of bend is
half length of nail

ML

AP 37 mm

ML
22 mm
13 mm
Oblique 5 mm

44    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Implants

Titanium Cannulated Tibial Nails–EX, sterile*

Length 8 mm dia. 9 mm dia. 10 mm dia.
(mm) dark blue dark blue light green
255 04.004.231S 04.004.331S 04.004.431S
270 04.004.234S 04.004.334S 04.004.434S
285 04.004.237S 04.004.337S 04.004.437S
300 04.004.240S 04.004.340S 04.004.440S
315 04.004.243S 04.004.343S 04.004.443S
330 04.004.246S 04.004.346S 04.004.446S
345 04.004.249S 04.004.349S 04.004.449S
360 04.004.252S 04.004.352S 04.004.452S
375 04.004.255S 04.004.355S 04.004.455S
390 04.004.258S 04.004.358S 04.004.458S
405 04.004.261S 04.004.361S 04.004.461S
420 04.004.264S 04.004.364S 04.004.464S
435 04.004.267S 04.004.367S 04.004.467S

Length 11 mm dia. 12 mm dia. 13 mm dia.
(mm) light green light green light green
255 04.004.531S 04.004.631S 04.004.731S
270 04.004.534S 04.004.634S 04.004.734S
285 04.004.537S 04.004.637S 04.004.737S
300 04.004.540S 04.004.640S 04.004.740S
315 04.004.543S 04.004.643S 04.004.743S
330 04.004.546S 04.004.646S 04.004.746S
345 04.004.549S 04.004.649S 04.004.749S
360 04.004.552S 04.004.652S 04.004.752S
375 04.004.555S 04.004.655S 04.004.755S
390 04.004.558S 04.004.658S 04.004.758S
405 04.004.561S 04.004.661S 04.004.761S
420 04.004.564S 04.004.664S 04.004.764S
435 04.004.567S 04.004.667S 04.004.767S

8 mm 10 mm 11 mm
9 mm 12 mm
13 mm

*Titanium-6% aluminum-7% niobium alloy

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    44
Implants

5.0 mm Titanium Dual Core Locking Screws, with T25

StarDrive recess, for IM nails (gold) ◊
x Titanium alloy*
x Lengths: 30 mm– ­90 mm (5-mm increments)
x Used for proximal locking in the metaphysis
(through the 3 most proximal holes)
x Dual core: smaller core (3.4 mm) for better purchase
in cancellous bone, larger core (4.3 mm) to withstand
load-bearing from the nail
x Fully threaded
x Self-tapping, blunt tip

5.0 mm Titanium Dual Core Locking Screws, with

T25 StarDrive recess, for IM Nails (gold)

Length (mm) Length (mm)

04.015.520 30 04.015.555 65
04.015.525 35 04.015.560 70
04.015.530 40 04.015.565 75
04.015.535 45 04.015.570 80
04.015.540 50 04.015.575 85
04.015.545 55 04.015.580 90
04.015.550 60

5.0 mm Titanium Dual Core Locking Screws, with

T25 StarDrive recess, for IM Nails (gold), sterile

Length (mm) Length (mm)

04.015.518S 28 04.015.552S 62
04.015.522S 32 04.015.557S 67
04.015.527S 37 04.015.562S 72
04.015.532S 42 04.015.567S 77
04.015.537S 47 04.015.572S 82
04.015.542S 52 04.015.577S 87
04.015.547S 57

◊Available
nonsterile or sterile-packed. Add “S” to catalog number to order sterile product.
*Titanium-6% aluminum-7% niobium alloy

55    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Implants

4.0 mm Titanium Locking Screws ◊, with T25 StarDrive

recess, for IM nails (blue)
x Titanium alloy*
x Lengths: 18 mm–80 mm (2 mm increments)
x 3.3 mm core diameter
x Fully threaded
x Self-tapping, blunt tip

Length (mm) Length (mm)

04.005.408 18 04.005.440 50
04.005.410 20 04.005.442 52
04.005.412 22 04.005.444 54
04.005.414 24 04.005.446 56
04.005.416 26 04.005.448 58
04.005.418 28 04.005.450 60
04.005.420 30 04.005.452 62
04.005.422 32 04.005.454 64
04.005.424 34 04.005.456 66
04.005.426 36 04.005.458 68
04.005.428 38 04.005.460 70
04.005.430 40 04.005.462 72
04.005.432 42 04.005.464 74
04.005.434 44 04.005.466 76
04.005.436 46 04.005.468 78
04.005.438 48 04.005.470 80

◊Available
nonsterile or sterile-packed. Add “S” to catalog number to order sterile product.
*Titanium-6% aluminum-7% niobium alloy

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    55
Implants

5.0 mm Titanium Locking Screws ◊, with T25 StarDrive

recess, for IM nails (light green)
x Titanium alloy*
x Lengths: 26 mm–80 mm (2-mm increments)
85 mm–100 mm (5-mm increments)
x 4.3 mm core diameter
x Fully threaded
x Self-tapping, blunt tip

Length (mm) Length (mm)

04.005.516 26 04.005.548 58
04.005.518 28 04.005.550 60
04.005.520 30 04.005.552 62
04.005.522 32 04.005.554 64
04.005.524 34 04.005.556 66
04.005.526 36 04.005.558 68
04.005.528 38 04.005.560 70
04.005.530 40 04.005.562 72
04.005.532 42 04.005.564 74
04.005.534 44 04.005.566 76
04.005.536 46 04.005.568 78
04.005.538 48 04.005.570 80
04.005.540 50 04.005.575 85
04.005.542 52 04.005.580 90
04.005.544 54 04.005.585 95
04.005.546 56 04.005.590 100

◊Available nonsterile or sterile-packed. Add “S” to catalog number to order sterile product.
*Titanium-6% aluminum-7% niobium alloy

55    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Implants

Titanium Angular Stable Locking Screws, with

T25 StarDrive recess, for intramedullary nails, sterile*
x Titanium alloy** D1
x Available lengths
• 4.0 mm ASLS screw: 26 mm–80 mm
• 5.0 mm ASLS screw: 30 mm–100 mm
x Fully threaded shaft with 3 diameters
• D1: Provides purchase in reamed near cortex D2

• D2: Expands sleeve, providing angular stability

• D3: Holds unexpanded sleeve for screw insertion,
provides purchase in far cortex
x T25 StarDrive recess
x Sterile packaged D3

01.025.008  .0 mm Angular Stable Locking System

4 01.025.009  .0 mm Angular Stable Locking System
5
Screw Set Screw Set
4.0 mm Titanium Angular Stable Locking Screws, with T25 5.0 mm Titanium Angular Stable Locking Screws, with T25
StarDrive recess, for intramedullary nails, sterile, 2 ea. StarDrive recess, for intramedullary nails, sterile, 2 ea.

Length (mm) Length (mm) Length (mm) Length (mm)

04.025.416S 26 04.025.444S 54 04.025.520S 30 04.025.550S  60
04.025.418S 28 04.025.446S 56 04.025.522S 32 04.025.552S  62
04.025.420S 30 04.025.448S 58 04.025.524S 34 04.025.554S  64
04.025.422S 32 04.025.450S 60 04.025.526S 36 04.025.556S  66
04.025.424S 34 04.025.452S 62 04.025.528S 38 04.025.558S  68
04.025.426S 36 04.025.454S 64 04.025.530S 40 04.025.560S  70
04.025.428S 38 04.025.456S 66 04.025.532S 42 04.025.562S  72
04.025.430S 40 04.025.458S 68 04.025.534S 44 04.025.564S  74
04.025.432S 42 04.025.460S 70 04.025.536S 46 04.025.566S  76
04.025.434S 44 04.025.462S 72 04.025.538S 48 04.025.568S  78
04.025.436S 46 04.025.464S 74 04.025.540S 50 04.025.570S  80
04.025.438S 48 04.025.466S 76 04.025.542S 52 04.025.575S  85
04.025.440S 50 04.025.468S 78 04.025.544S 54 04.025.580S  90
04.025.442S 52 04.025.470S 80 04.025.546S 56 04.025.585S  95
04.025.548S 58 04.025.590S 100

**Also available
**Titanium-6% aluminum-7% niobium alloy

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    55
Implants

ASLS Sleeves*

Resorbable Sleeves for Angular Stable Locking Screws,

sterile*
x 70:30 poly (L/ DL-lactide)
x Bioresorbable polymer material gradually resorbs
within 18 – 24 months 1
x Inner thread for secure fit to ASLS screw
x Expands in nail’s locking hole to provide angular stability
x 4.0 mm and 5.0 mm sleeves used with
corresponding ASLS screws
x Sterile packaged (2 per package)

Resorbable Sleeve for Angular Stable Locking Screws,

sterile, 2/pkg.
08.025.032S for 4.0 mm ASLS Screws
08.025.044S for 5.0 mm ASLS Screws

ASLS Compatibility with Existing Nails

The Angular Stable Locking System is compatible with all
DePuy Synthes titanium cannulated nailing systems.

Angular Stable Locking Systems

Nail 4.0 mm 5.0 mm
Nailing System Diameters (mm) (brown) (light blue)
Tibia Titanium Cannulated Tibial Nail-EX 8, 9 •
and Tibial Nail-EX with Proximal Bend 10–13 •
Titanium Tibial Nail (cannulated) 10–13 •

*Must be ordered separately.

1Based on in-vivo animal testing. In-vivo animal testing may not necessarily be

indicative of human clinical performance.

55    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Implants

Titanium End Caps ◊, with T40 StarDrive recess,

for Titanium Tibial Nails–EX
x Titanium alloy*
x Protect nail threads from tissue ingrowth
x Cannulated
x T40 StarDrive recess

0 mm
x Sits flush with end of nail

5 mm, 10 mm and 15 mm extensions

x Extend nail height if nail is overinserted

Titanium End Caps ◊, with T40 StarDrive recess,

for Titanium Tibial Nails–EX (gold)
x Securely lock the proximal oblique dual core locking screw

Extension (mm)
04.004.000 0
04.004.001 5 0 mm 5 mm 10 mm 15 mm

04.004.002 10
04.004.003 15

Titanium End Caps ◊, with T40 StarDrive recess,

for Titanium Tibial Nails–EX (gray)
x Lead-in design for easier end cap insertion
x Will block the two most proximal oblique locking holes

Extension (mm)
04.004.008 0
04.004.009 5 0 mm 5 mm 10 mm 15 mm
04.004.010 10
04.004.011 15

◊Available nonsterile or sterile-packed. Add “S” to product number to indicate sterile product.

*Titanium-6% aluminum-7% niobium alloy

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    55
Instruments

03.010.015 Compression Device, for Titanium

Cannulated Tibial Nails–EX

03.010.021 Radiographic Ruler, for Titanium

Cannulated Tibial Nails

03.010.023 Radiographic Canal Width Estimator,

for IM Nails

03.010.024 Holding Device, for Guide Wires and

Reaming Rods

03.010.035 12.0 mm Protection Sleeve

03.010.036◊ 12.0 mm Cannulated Drill Bit, large quick

coupling, 190 mm

◊Available nonsterile or sterile-packed. Add “S” to product number to indicate

sterile product.

55    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Instruments

03.010.040 12.0 mm Cannulated Awl

03.010.044 Cannulated Connecting Screw,

for Standard Insertion Handle

03.010.045 Standard Insertion Handle

03.010.047 Driving Cap with Handle Adapter

03.010.052 Aiming Arm, for Titanium Cannulated

Tibial Nails– EX

03.010.056 Slide/Fixed Hammer, 700 grams

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    55
Instruments

03.010.060◊ 3.2 mm Three-Fluted Drill Bit, quick

coupling, 330 mm, 100 mm calibration

03.010.061 4.2 mm Three-Fluted Drill Bit, quick

coupling, 330 mm, 100 mm calibration

03.010.063 12.0 mm/8.0 mm Protection Sleeve,

188 mm

03.010.064 8.0 mm/3.2 mm Drill Sleeve, 200 mm

03.010.065 8.0 mm/4.2 mm Drill Sleeve, 200 mm

03.010.069 3.2 mm Trocar, 210 mm

03.010.070 4.2 mm Trocar, 210 mm

03.010.072 Depth Gauge, for Locking Screws to 100

mm, for IM Nails

◊Available nonsterile or sterile-packed. Add “S” to product number to indicate

sterile product.

55    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Instruments

03.010.092 Ball Hex Screwdriver, 8 mm

03.010.093 Reaming Rod Push Rod, with ball handle

03.010.103◊ 3.2 mm Three-Fluted Drill Bit,

quick coupling, 145 mm

03.010.104◊ 4.2 mm Three-Fluted Drill Bit,

quick coupling, 145 mm

03.010.106 Direct Measuring Device, for locking

screws to 100 mm, for IM nails

03.010.107 StarDrive Screwdriver, T25, self-retaining

03.010.110 Cannulated StarDrive Screwdriver, T40,

self-retaining

◊Available nonsterile or sterile-packed. Add “S” to product number to indicate

sterile product.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    55
Instruments

03.010.112 Holding Sleeve, with Locking Device

321.17 4.5 mm Pin Wrench, 120 mm

321.20 Ratchet Wrench, 11 mm width across flats

357.133 Extraction Screw, for Titanium Femoral and

Tibial Nails

357.22 Hammer Guide, for Slide Hammer

357.398 Cannulated Shaft with 8 mm hex,

125 mm

357.399 3.2 mm Guide Wire, 400 mm

66    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Tibial Nail– EX Instrument Set (01.004.303)

Graphic Case
69.004.300 Tibial Nail–EX Instrument Set Graphic Case

Instruments
03.010.015 Compression Device, for Titanium
Cannulated Tibial Nails–EX
03.010.021 Radiographic Ruler, for Titanium
Cannulated Tibial Nails
03.010.023 Radiographic Canal Width Estimator,
for IM Nails
03.010.024 Holding Device, for Guide Wires and
Reaming Rods
03.010.035 12.0 mm Protection Sleeve
03.010.036◊ 12.0 mm Cannulated Drill Bit, large quick
coupling, 190 mm
03.010.040 12.0 mm Cannulated Awl
03.010.044 Cannulated Connecting Screw, for Standard
Insertion Handle, 2 ea.
03.010.045 Standard Insertion Handle
03.010.047 Driving Cap with Handle Adapter
03.010.052 Aiming Arm, for Titanium Cannulated Tibial
Nails–EX
03.010.056 Slide/Fixed Hammer, 700 grams
03.010.060◊ 3.2 mm Three-Fluted Drill Bit, quick coupling,
330 mm, 100 mm calibration, 2 ea.
03.010.061◊ 4.2 mm Three-Fluted Drill Bit, quick coupling,
330 mm, 100 mm calibration, 2 ea.
03.010.063 12.0 mm/8.0 mm Protection Sleeve, 188 mm
03.010.064 8.0 mm/3.2 mm Drill Sleeve, 200 mm
03.010.065 8.0 mm/4.2 mm Drill Sleeve, 200 mm
03.010.069 3.2 mm Trocar, 210 mm
03.010.070 4.2 mm Trocar, 210 mm
03.010.072 Depth Gauge, for Locking Screws to 100 mm,
for IM Nails
03.010.092 Ball Hex Screwdriver, 8 mm
03.010.093 Reaming Rod Push Rod, with ball handle

◊Available nonsterile or sterile-packed. Add “S” to product number to indicate

sterile product.

For detailed cleaning and sterilization instructions, please refer to:

www.synthes.com/cleaning-sterilization
In Canada, the cleaning and sterilization instructions will be provided with
the Loaner shipments.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    66
Tibial Nail – EX Instrument Set (01.004.303)

Instruments
03.010.103◊ 3.2 mm Three-Fluted Drill Bit, quick coupling,
145 mm, 2 ea.
03.010.104 4.2 mm Three-Fluted Drill Bit, quick coupling,
◊

145 mm, 2 ea.

03.010.106 Direct Measuring Device, for Locking Screws
to 100 mm, for IM nails
03.010.107 StarDrive Screwdriver, T25, self-retaining
03.010.110 Cannulated StarDrive Screwdriver, T40,
self-retaining
03.010.112 Holding Sleeve, with Locking Device
321.17 4.5 mm Pin Wrench, 120 mm, 2 ea.
321.20 Ratchet Wrench, 11 mm width across flats
357.133 Extraction Screw, for Titanium Femoral
and Tibial Nails
357.22 Hammer Guide, for Slide Hammer
357.398 Cannulated Shaft with 8 mm hex, 125 mm
357.399 3.2 mm Guide Wire, 400 mm, 3 ea.

◊Available nonsterile or sterile-packed. Add “S” to product number to indicate sterile product.

66    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Tibial Nail– EX Implant Set (01.004.304)

Graphic Case
690.504 Locking Screw Rack, for Tibial Nail–EX Implants

Instrument
319.97 Screw Forceps

Implants
Titanium End Caps, with T40 StarDrive recess,
for Tibial Nails – EX◊ (gold)
Extension (mm)
04.004.000 0
04.004.001 5
04.004.002 10
04.004.003 15

Titanium End Caps, with T40 StarDrive recess, extended tip,

for Tibial Nails – EX◊(gray), 2 ea.
Extension (mm)
04.004.008 0
04.004.009 5
04.004.010 10
04.004.011 15

5.0 mm Titanium Dual Core Locking Screws,

with T25 StarDrive recess, for IM Nails◊, 2 ea.
Length (mm) Length (mm)
04.015.520 30 04.015.555 65
04.015.525 35 04.015.560 70
04.015.530 40 04.015.565 75
04.015.535 45 04.015.570 80
04.015.540 50 04.015.575 85
04.015.545 55 04.015.580 90
04.015.550 60

◊Available nonsterile or sterile-packed. Add “S” to product number to indicate sterile product.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    66
Tibial Nail – EX Implant Set (01.004.304)

Implants
4.0 mm Titanium Locking Screws, with T25 StarDrive recess,
for IM Nails◊, 2 ea.
Length (mm) Length (mm)
04.005.416 26 04.005.444 54
04.005.418 28 04.005.446 56
04.005.420 30 04.005.448 58
04.005.422 32 04.005.450 60
04.005.424 34 04.005.452 62
04.005.426 36 04.005.454 64
04.005.428 38 04.005.456 66
04.005.430 40 04.005.458 68
04.005.432 42 04.005.460 70
04.005.434 44 04.005.462 72
04.005.436 46 04.005.464 74
04.005.438 48 04.005.466 76
04.005.440 50 04.005.468 78
04.005.442 52 04.005.470 80

5.0 mm Titanium Locking Screws, with T25 StarDrive recess,

for IM Nails◊, 2 ea.
Length (mm) Length (mm)
04.005.516 26 04.005.544 54
04.005.518 28 04.005.546 56
04.005.520 30 04.005.548 58
04.005.522 32 04.005.550 60
04.005.524 34 04.005.552 62
04.005.526 36 04.005.554 64
04.005.528 38 04.005.556 66
04.005.530 40 04.005.558 68
04.005.532 42 04.005.560 70
04.005.534 44 04.005.562 72
04.005.536 46 04.005.564 74
04.005.538 48 04.005.566 76
04.005.540 50 04.005.568 78
04.005.542 52 04.005.570 80

◊Available nonsterile or sterile-packed. Add “S” to product number to indicate sterile product.

66    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Tibial Nail–EX Instrument and Titanium
Implant Set (01.004.300)

01.004.300 consists of:

01.004.303 Tibial Nail–EX Instrument Set
01.004.304 Tibial Nail–EX Implant Set

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    66
ASLS Screw Sets

01.025.008  .0 mm Angular Stable Locking System

4 Alternative Set Configurations
Screw Set
01.025.001 Angular Stable Locking System Screw Set
4.0 mm Titanium Angular Stable Locking Screws, with T25 Consists of:
StarDrive recess, for intramedullary nails, sterile, 2 ea. 4.0 mm ASLS Screw Set (01.025.008) and
Length Length 5.0 mm ASLS Screw Set (01.025.009)
(mm) (mm)
04.025.416S 26 04.025.444S 54 ASLS Sleeves*
04.025.418S 28 04.025.446S 56 Resorbable Sleeve for Angular Stable
04.025.420S 30 04.025.448S 58 Locking Screws, sterile, 2/pkg.
04.025.422S 32 04.025.450S 60 08.025.032S for 4.0 mm ASLS Screws
04.025.424S 34 04.025.452S 62 08.025.044S for 5.0 mm ASLS Screws
04.025.426S 36 04.025.454S 64
04.025.428S 38 04.025.456S 66
04.025.430S 40 04.025.458S 68
04.025.432S 42 04.025.460S 70
04.025.434S 44 04.025.462S 72
04.025.436S 46 04.025.464S 74
04.025.438S 48 04.025.466S 76
04.025.440S 50 04.025.468S 78
04.025.442S 52 04.025.470S 80

01.025.009  .0 mm Angular Stable Locking System

5
Screw Set

5.0 mm Titanium Angular Stable Locking Screws, with T25

StarDrive recess, for intramedullary nails, sterile, 2 ea.
Length Length
(mm) (mm)
04.025.520S 30 04.025.550S  60
04.025.522S 32 04.025.552S  62
04.025.524S 34 04.025.554S  64
04.025.526S 36 04.025.556S  66
04.025.528S 38 04.025.558S  68
04.025.530S 40 04.025.560S  70
04.025.532S 42 04.025.562S  72
04.025.534S 44 04.025.564S  74
04.025.536S 46 04.025.566S  76
04.025.538S 48 04.025.568S  78
04.025.540S 50 04.025.570S  80
04.025.542S 52 04.025.575S  85
04.025.544S 54 04.025.580S  90
04.025.546S 56 04.025.585S  95
04.025.548S 58 04.025.590S 100
* Must be ordered separately.

66    DePuy Synthes Trauma  Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique
Also Available

Instruments Power Equipment

03.010.017 Tibial Nail–EX Insertion Handle 511.30 Radiolucent Drive
03.010.046 Percutaneous Insertion Handle 511.73 Jacobs Chuck with Key (large)
03.010.100◊ 3.2 mm Three-Fluted Drill Bit, quick coupling, 511.75 Quick Coupling for drill bits
145 mm, for Radiolucent Drive 511.761 Large Quick Coupling
03.010.101 4.2 mm Three-Fluted Drill Bit, quick coupling,
◊
511.785 Reduction Drive Unit
145 mm, for Radiolucent Drive 511.791 Quick Coupling for Kirschner wires
03.010.119 4.6 mm Cleaning Brush 530.100 Power Drive
03.010.120 4.6 mm Cleaning Stylet 530.200 Battery, for Power Drive
03.010.121 Large Hexagonal Screwdriver, 3.5 mm width 530.280 Battery Casing, for Power Drive
across flats
03.010.136 Short Compression Device for Titanium Sets
Cannulated Tibial Nails–EX 01.004.305 Suprapatellar Instrument Set
03.010.137 Long Compression Device for Titanium 01.004.306 Flexible Reamer Set, Long, for IM Nails
Cannulated Tibial Nails–EX
150.060 Flexible Reamer Set for IM Nails
03.010.145 Cannulated Connecting Screw, for short
insertion handle
Implants
03.010.146 Cannulated Connecting Screw, for
5.0 mm Titanium Dual Core Locking Screws (sterile only),
percutaneous insertion handle
with T25 StarDrive recess, for IM Nails (gold)
314.119 StarDrive Screwdriver Shaft, T25,
self-retaining, quick coupling, 165 mm Length (mm)
351.706S 2.5 mm Reaming Rod with ball tip, 04.015.518S 28
950 mm, sterile 04.015.522S 32
351.707S 2.5 mm Reaming Rod with ball tip 04.015.527S 37
and extension, 950 mm, sterile 04.015.532S 42
357.408 Cleaning Stylet (3.2 mm) 04.015.537S 47
357.409 Cleaning Brush (3.2 mm) 04.015.542S 52
04.015.547S 57
360.251 7.5 mm Intramedullary Reduction Tool,
04.015.552S 62
460 mm
04.015.557S 67
393.105 Small Universal Chuck with T-Handle
04.015.562S 72
394.35 Large Distractor, complete 04.015.567S 77
399.43 Hammer, 700 grams 04.015.572S 82
04.015.577S 87

◊Available nonsterile or sterile-packed. Add “S” to product number to indicate

sterile product.

Titanium Cannulated Tibial Nail Expert Nailing System  Surgical Technique  DePuy Synthes Trauma    66
CAUTION: Federal Law restricts these devices to sale by or on the order of a physician.

The legal manufacturers for the US and Canada are listed below:

Synthes (USA) Synthes (Canada) Ltd.

1302 Wrights Lane East 2566 Meadowpine Boulevard
West Chester, PA 19380 Mississauga, Ontario L5N 6P9
Telephone: (610) 719-5000 Telephone: (905) 567-0440
To order: (800) 523-0322 To order: (800) 668-1119
Fax: (905) 567-3185
www.depuysynthes.com

© DePuy Synthes Trauma, a division of DOI 2013. All rights reserved.

J6471-F 1/14