Reference Description519 002ND • Medium drill diam. 4.3mm for calcaneus screws 519 004ND • Drill diam. 4.3mm for tibial screws519 005ND • Drill diam. 5mm 519 008ND • Long drill diam. 4.3mm for calcaneus screws519 007ND Cannulated drill diam. 7mm519 009ND Cannulated drill diam. 9mm519 011ND Reamer diam. 11mm519 012ND Reamer diam. 12mm519 013ND Reamer diam. 13mm519 014ND Reamer diam. 10.5mm519 015ND Reamer diam. 11.5mm519 016ND Reamer diam. 12.5mm519 017ND Reamer diam. 13.5mm519 020ND Optional quick coupling519 021ND T-handle with AO attachment519 028ND Internal protection sleeve diam. 3.2mm519 029ND Central protection sleeve diam. 9mm519 030ND External protection sleeve diam. 13.5mm519 032ND Guide wire diam. 3.2mm, L. 400mm519 034ND Guide wire diam. 3.2mm, L. 600mm519 040ND Trocar awl519 110ND Support device519 120ND Nail fixation axis519 121ND Toothed wheel519 130ND Compression device519 131ND Threaded axis519 133ND Teflon ring519 135ND Compression wheel519 160ND Depth gauge519 175ND • Compression rod519 178ND • Medium drill guide diam. 4.3mm519 180ND • Long Drill guide diam. 4.3mm519 181ND • Drill guide diam. 5mm519 183ND • Medium soft tissue protector diam. 7mm519 185ND • Long soft tissue protector diam. 7mm519 190ND Hexagonal screwdriver tip diam. 3.5mm519 195ND Hexagonal screwdriver diam. 3.5mm519 910ND Sterilization container519 911ND Insert519 920ND Lid

SURGICAL TECHNIQUE

PANTA®

a r t h r o d e s i s n a i l

Lower

extremity

SoLutionS

PANTA®

T a b l e o f C o n t e n t sIntroductIon ........................................................................................................................................................................ 02

Design Rationale .................................................................................................................................................................. 02

inDications ............................................................................................................................................................................ 02

implant DescRiption .............................................................................................................................................................. 03

instRument DescRiption ........................................................................................................................................................ 04

SurgIcal technIque .............................................................................................................................................................. 05

patient positioning ............................................................................................................................................................... 05

pRepaRation of the Joint suRfaces ....................................................................................................................................... 05

incision ................................................................................................................................................................................. 05

step 1: fiRst DRilling ........................................................................................................................................................... 06

step 2: canal enlaRgement .................................................................................................................................................. 07

step 3: Reaming anD nail choice .......................................................................................................................................... 07

step 4a: nail inseRtion with suppoRt Device ........................................................................................................................ 08

step 4b: nail inseRtion anD guiDe wiRe Removal ................................................................................................................. 09

step 5: nail positioning ....................................................................................................................................................... 10

step 6: calcaneus pRe-DRilling............................................................................................................................................ 11

step 7: calcaneus DRilling (1/2) .......................................................................................................................................... 11

step 8: calcaneus DRilling (2/2).......................................................................................................................................... 11

step 9: measuRement methoD .............................................................................................................................................. 12

step 10: calcaneus fixation ................................................................................................................................................ 12

step 11: compRession Device ................................................................................................................................................ 13

step 12: RoD incision............................................................................................................................................................ 13

step 13: pRoximal DRilling ................................................................................................................................................... 14

step 14: Distal DRilling ....................................................................................................................................................... 14

step 15: Distal RoD inseRtion .............................................................................................................................................. 14

step 16: pRoximal RoD inseRtion .......................................................................................................................................... 15

step 17: compRession ........................................................................................................................................................... 15

step 18: tibial scRew incision .............................................................................................................................................. 16

step 19: tibial DRilling ........................................................................................................................................................ 16

step 20: tibial scRew measuRement ..................................................................................................................................... 17

step 21: tibial scRew inseRtion ............................................................................................................................................ 17

step 22 talaR scRew (optional) .................................................................................................................................... 18

step 23: suppoRt Device Removal ........................................................................................................................................ 19

step 24: enD cap inseRtion .................................................................................................................................................. 19

BIBlIography ......................................................................................................................................................................... 20

InStrumentatIon Set ............................................................................................................................................................. 21

referenceS ............................................................................................................................................................. Back cover

The talo-tibio-calcaneal arthrodesis is characterized by its challenging technique.The use of a retrograde nail is part of the therapeutic option that allows:

Precise and radiolucent instrumentation

A unique system to apply compression balanced with multi-planar screw fixation — in the tibia, the talus and the calcaneus — and enhanced calcaneal fixation to optimize stability and alignment of the arthrodesis

The Panta® nail system has been designed to best achieve these goals through:

Re-alignment of the foot on the weight-bearing axis

Correction of coronal and sagittal plane deformities

Rotational stability

Axial compression

DESIGN RATIONALE

2

Indications

The Panta Nail is intended for use in tibio-talo-calcaneal arthrodesis and treatment of trauma to the hindfoot and distal tibia. Depending on particular patient factors, indications may include:

Post-traumatic and degenerative arthritis involving both ankle and subtalar joints

Rheumatoid arthritis

Revision of failed ankle arthrodesis with subtalar involvement or with insufficient talar body

Revision of failed total ankle arthroplasty with subtalar intrusion

Talar deficiency conditions (requiring a tibiocalcaneal arthrodesis)

Avascular necrosis of the talus

Neuroarthropathy or neuropathic ankle deformity

Severe deformity as a result of talipes equinovarus, cerebral vascular accident, paralysis or other neuromuscular disease

Severe pilon fractures with trauma to the subtalar joint

• See package insert for full prescribing information.

End cap to protect internal thread from tissue ingrowth.

IMPLANTS

Implant Description

Screw Description

The Panta Nail is available in eight sizes: 10 ,11, 12 and 13mm diameters by 150 and 180mm lengths. All nails are color coded for easy size identification.

Bony fixation is achieved using two tibial screws, two calcaneal screws and one (optional) talar screw.

The screws are available in lengths from 20mm to 110mm in 5mm increments. An optional end cap may be inserted into the distal nail threads to prevent tissue ingrowth and facilitate future nail removal.

The nail, screws and end cap are manufactured from titanium alloy:

Ti-6Al-4V ELI, ISO 5832-3, ASTM F136.

Round holes for transverse tibial screws.

Oblong holes to enable compression.

LENGTH

Diameter 150mm 180mm

10mm Orange Salmon

11mm Dark Blue LightBlue

12mm Dark Red Light Red

13mm Dark Green Light Green

3

7 mm

5 mm

Multiaxial Fixation

5 mm

3.5 mm

Round holes for transverse tibial screws

Oblong holes to enable compression

Multi-axial fixation: - Oblique antero-posterior calcaneal screws - Medio-lateral tibial screws

Specific end cap for each kind of screw: - Locking end cap for partially threaded screws - End cap for fully threaded screws

Two kinds of screws : - Fully Threaded with cortical threads on the entire length: - The thread provides increased bony fixation - The head provides a positive stop at the cortex

- Partially Threaded with cortical threads with a shoulder in the middle: - The smooth part provides increased strength - The headless design reduces the potential for soft tissue irritation

A radiolucent targeting frame to allow optimal placement of the calcaneal screws

A dual armed targeting device to allow medial or lateral tibial and talar screw placement and equal application of compression

A simple design conforming to natural hindfoot anatomy (calcaneus and ankle joint)

A threaded compression mechanism to provide increased mechanical advantage and enhanced bony apposition

Application of compression through the bone rather than through the soft tissue allowing more effective, direct and controllable alignment of the arthodesis sites

INSTRUMENTATION

Instrument Rationale

Compression System

Applying Compression

The Panta Nail instrumentation is designed to achieve controlled compression across the ankle and subtalar joints.

The compression/targeting device incorporates the following features:

The compression/targeting device consists of a radiolucent frame and metallic support that are assembled together.

Compression rods are used to stabilize the device to the bone and offer compression.

When the compression wheel is turned clockwise, the metallic support slides distally, applying compression.

Up to 12 mm of internal, controlled compression may be applied.

Compression wheel is zeroed out. Compression wheel is turned clockwise. Compression is applied

18

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01

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18

01

50

18

01

80

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0

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50

18

01

80

18

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50

18

01

50

COMPRESSIONDEVICE SUPPORT

DEVICE

1 • COMPRESS 2 • SCREW

COMPRESSION RODS SCREW PLACEMENT

180 mm nail

150 mm nail

180 mm nail

150 mm nail

0

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4

PANTA®

A r t h r o d e s i s N a i l

Surgical Technique

Patient Positioning

Preparation of the Joint Surfaces

Incision

The patient is placed supine with the foot close to the end of the table to facilitate the procedure.

A range of surgical approaches and incisions can be utilized including anterior, anterolateral or lateral approaches to the tibiotalar joint and subtalar joint.

Single or separate incisions can be utilized depending upon the particular characteristics of the case.

The essential issue is to achieve satisfactory preparation of the bone surfaces for arthrodesis and satisfactory alignment of the limb through the arthrodesis sites.

A plantar incision is made to prepare for insertion of the nail and support device assembly. This may be a longitudinal or transverse incision.

Care must be taken to protect the plantar neurovascular structures, both in the dissection and during the procedure, as these structures are at risk.

THIS TECHNIQUE HAS BEEN DEVELOPED WITH THE HELP OF JAMES W. BRODSKY, MD.

As the manufacturer of this device, Integra does not practice medicine and does not recommend this or any other surgical technique for use on a specific patient. The surgeon who performs any implant procedure is responsible for determining and using the appropriate techniques for implanting the device in each patient.

Lateral plantar nerve

Possibleincision axes

Calcanealramification

Medial plantar nerve

5

A r t h r o d e s i s N a i l

Step 1 • First Drilling

519 028ND (A)Protection sleevediam. 3.2 mm

519 029ND (B)Protection sleevediam. 9 mm

519 034NDGuide wire diam. 3.2 mmLength 600 mm

519 030ND (C)Protection sleevediam. 13.5 mm

519 032NDGuide wire diam. 3.2 mmLength 400 mm

PREPARE

Appropriate Alignment Is Critical

Assemble the plantar protection sleeves:

- internal 3.2mm (A) 519 028ND

- central 9mm (B) 519 029ND

- external 13.5mm (C) 519 030ND

The guide wire insertion point should be slightly lateral to accommodate the lateral offset of the calcaneus relative to the medullary canal of the tibia.

Advance through the calcaneus and the talus using fluoroscopy to control the position in both the anteroposterior and mediolateral planes

Confirm the alignment of the calcaneus and talus and the anatomic axis of the tibia.

Laser marks on the guide wire may assist in the approximate length of the final implant. The final length determination is made based on the final reamer depth described in the next step.

Advance the guide wire into the tibia.

Introduce the 3.2 mm diameter guide wire through the protection sleeves.

Use the 400 mm (519 032ND) or the 600mm (519 034ND) guide wire depending on surgeon preference.

- 519 034ND for 600 mm length.

- 519 032ND for 400 mm length.

1-1

1-2

1-3

1-4

1-5

1-6

A B

C

1-1

Contact betweensleeves and cortical

1-2

1-1

1-3

Axes now alignAxes of talus and tibia do not align

Posterior Views1-4

Laser marks

1-5 1-6

6

Step 2 • Canal Enlargement

519 020NDQuick coupling

519 009NDCannulated drilldiam. 9 mm

519 007NDCannulated drilldiam. 7 mm

519 011ND to 017NDReamersdiam. 10.5 to 13.5 mm

PREPARE

2-1 2-2

3-2 3-3

DepthMarkings

56 mm

Talar dome

Plantar cortex of the calcaneus

Diam.

11 mm

Diam.

10 mm

L. 180 mm L. 150 mm

3-3

Step 3 • Reaming and Nail Choice

2-1

2-2

3-1

3-2

3-3

Remove the central protection sleeve (B).

The 9mm central protection sleeve has a built in stop for the 7mm and 9mm drills. The nail insertion point is enlarged by inserting with the 7mm drill (519 007ND) until it contacts the back (plantar) side of the sleeve. Insert the 9mm drill (519 009ND) to further enlarge the opening.

Attach the reamers to power using the cannulated quick coupling (519 020ND).

(Note: Reamers should be used with a CANNULATED POWER DRILL).

A

B

C

Reamer diameter Nail diameter - Nail length

10.5mm 10mm - 150mm (proximal) 10mm - 18mm (proximal)

11mm

11.5mm 10mm - 150mm (Distal) 11mm - 180mm (Distal)

11mm - 150mm 11mm - 180mm

12mm

12.5mm 12mm - 150mm 12mm - 180mm

13mm

13.5mm 13mm - 150mm 13mm - 180mm

7

Check insertion with biplanar fluoroscopy and control the insertion depth using the position of the appropriate laser mark (150mm or 180mm) relative to the back surface of the outer sleeve.

For 11, 12, and 13mm nails, start reaming by inserting the 10.5mm diameter reamer (519 014ND) to the desired depth, 150 or 180mm. Proceed sequentially to the appropriate reamer size for the selected nail. Refer to the table below for appropriate final reamer size. It is recommended to ream .5mm over the final nail size, e.g. the 11.5mm reamer is the final reamer used to prepare for the 11mm nail.

The distal diameter of the first 55mm of the 10mm nail is 11mm. Thus the following reaming steps must be followed precisely to adequately prepare the bone for nail insertion.

For the 10mm nail, the 10.5mm reamer is inserted to the desired depth as indicated above. The 11 and 11.5mm reamers are then inserted 70mm past the plantar calcaneal cortex to prepare for the distal portion of the nail. The reamers should not be inserted past the proximal aspect of the talus.

Change to the central protection sleeve (B) by removing the internal sleeve (A).

A

B+C

Fig. 3.3 (specific 10 mm

diam. nail)

The final reamer diameter should be .5 mm larger than the final implant.Warning

519 121Toothed wheel

519 110Support device

519 120Nail fixation axis

PREPARE

Check the reamer under fluoroscopy in the anteroposterior and mediolateral planes to verify satisfactory position within the medullary canal.

4-1a

4-2a 4-3a

Insert the nail fixation axis.

Engage the nail on the thread.

Position the nail on the three

support teeth.

Finalize assembly.

Tip

4-4a

Special care should be exercised when handling the nail fixation axis. It is not attached to the support device and may fall out of the sterile field if dropped.

Warning

Step 4 • Nail InsertionBased on surgeon’s preference, step 4 can be performed one of two ways.

Step 4A • Nail Insertion / Support Device

4-1a

4-2a

Nail insertion with support device and guide wire removed

Assemble the toothed wheel (519 121ND) to the nail fixation axis (519 120ND).

Introduce the assembly through the support device (519 110ND).

Position the implant on the nail fixation axis by aligning it with the three teeth on the support device.

This ensures the proper orientation of the screw holes.

Lock the implant to the support device by tightening the toothed wheel.

Remove the guide wire.

While holding the alignment of the arthrodesis, manually insert the nail assembly under fluoroscopic control.

Ba

ck

T

ab

le

O

pe

ra

ti

on

8

Do not discard the end cap. (If the end cap is accidentally discarded or dropped, sterile packaged replacement end caps are available.)

Warning

4-4a

4-3a

Step 4B • Manual Nail Insertion

519 110Support device

519 120Nail fixation axis

519 121Toothed wheel

PREPARE

4-1b

4-2b

4-3b

4-4b

4-1b 4-2b

4-3b 4-4b

Special care should be exercised when handling the nail fixation axis. It is not attached to the support device and may fall out of the sterile field if dropped.

Warning

Open the final implant and remove the end cap.

DO NOT DISCARD THE END CAP.

Insert the implant two-thirds of the way over the guide wire.

Remove the guide wire.

Assemble the toothed wheel (519 121ND) to the nail fixation axis (519 120ND).

Introduce the assembly through the support device (519 110ND).

Position the fixation axis by aligning it with the three teeth on the support device.

This ensures the proper orientation of the screw holes.

Attach support device to the implant by tightening the toothed wheel.

Complete insertion of the assembly.

Ba

ck

T

ab

le

9

Step 5 • Nail Positioning

5-1

5-2

5-3

5-4

The groove between the axis and the distal end of the nail should be at or slightly above the plantar cortex.

The vertical axis of the support device should appear to be pointed approximately to the head of the first metatarsus.

Tip

Tip

The arthrodesis sites must be satisfactorily aligned under direct vision as well as radiographically.

The arthrodesis sites are manually compressed.

The final position of the nail/support device assembly is determined based on multiple factors, including the anatomy of the arthrodesis, and osseous structures, and the position of the proximal interlocking screw holes relative to position of the fibula. (For example, if the tibial screws are placed from lateral to medial, the rod is rotated slightly to move the screw holes anterior to the fibula).

After final positioning ensure that the distal end of the nail is flush with the plantar cortex of the calcaneus.

A visual verification of the height is made under fluoroscopy by ensuring that the groove is inside of the calcaneus.

10

PREPARE

Step 6 • Calcaneus Pre-Drilling

519 040NDTrocar awl

519 002NDShort drill for calcaneus screwsdiam. 4.3 mm

519 183NDSoft tissue protector diam. 7 mm

519 178NDMedium drill guide diam. 4.3 mm

519 008NDLong drill for calcaneus screwsdiam. 4.3 mm

PREPARE

6-1 6-2

7-1

8-1

Step 7 • Calcaneus Drilling

Step 8

Assemble the 4.3 mm drill guide with the 7 mm soft tissue protector • (519 178ND and 519 183ND). Both instruments contain blue dots for easy identification. The blue dots also correspond to the appropriate insertion holes on the support device.

Place the sleeves on the skin to precisely determine the incision point. Make the incision.

Using the short 4.3 mm short drill • (519 002ND) drill the proximal hole.

Control the drill depth using fluoroscopy.

The surgeon may read the screw length from the calibrated drill bit (read from back (posterior side) of the guide).

The drill guides must contact the cortex to provide the accurate screw depth. Read step 9 for measurement method. Leave drill in place.

Drill the distal hole with the 4.3 mm long drill • (519 008ND).

Control the depth with fluoroscopy.

The surgeon may read depth directly on drill bit.

Insert the trocar awl through the protection sleeves and into the posterior cortex of the calcaneus to prepare the bone for drilling.

6-1

7-1

8-1

6-2

If the drill guide is not in contact with the cortex, the depth gauge (519 160 ND) must be used to determine the length of the calcaneal screws. See step 9 for more detail on the screw measurement technique.

Warning

11

Step 9 • Measurement Method

519 190NDHexagonal screwdriver tipdiam. 3.5 mm

519 160NDDepth gauge

519 195NDHexagonal screwdriverdiam. 3.5 mm

PREPARE

BONE

SUPPORTDEVICE

SUPPORTDEVICE

BONE

READ HERE

READ HERE

READ HERE

READ ON DEPTH GAUGE (optional)

BBOONENE

BBOONNEE

SSUUPPOPPORTRTDDEVICEEVICE

SSUUPPOPPORTRTDDEVICEVICEE

CASE 1 • Sleeves are in contact with the cortex

CASE 2 • Sleeves are not in contact with the cortex

READ ON DEPTH GAUGE

READ ON DRILL BIT

SUPPORTDEVICE

BONE

"C" IS FLUSH WITH THE SLEEVE

Approaching posterior calcaneal cortex

The graduated drill bit indicates the length of screw to be used. To get an accurate measurement from the drill, the inner sleeve must be in contact with the cortex. When the inner sleeves do not contact the cortex, the depth gauge should be used to verify the depth measurement.

Tip

The “C” laser mark on the screwdriver or screwdriver (power) tip indicates the relative position of the screw head with respect to the posterior cortex of the calcaneus. When the “C” laser mark is flush with the rear face of the tissue protector the screw head is nearly seated.

Tip

Two depth measurement methods may be used to determine the correct screw length. If the graduated drill bit is used the inner sleeve must be in contact with the bone.

Step 10 • Calcaneus Fixation

10-1

10-2

10-3

Remove the distal drill after reading the length of the screw on the bit.

Remove the drill guide, leaving the soft tissue protector in place.

Assemble the hexagonal screwdriver tip with AO attachment (519 190ND) to the power drill.

Fully or partially threaded screws are inserted by hand or under power and then completed by hand.

NOTE: The partially threaded screws are designed to work with the locking end cap as shown in Step 24

Screw insertion should be done using fluoroscopic control in perpendicular planes throughout the procedure.

Repeat these steps for the proximal screw.

Control the insertion depth using fluoroscopy.

12

Step 11 • Compression Device

519 133ND (x2)Teflon ring

519 130NDCompression device

519 181ND (x4) •Drill guidediam. 5 mm

PREPARE

11-2

11-3

12-1

Rod Position180 mm nail

Rod Position150 mm nail

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Step 12 • Rod Incision

Remove the toothed wheel and assemble the compression device (519 130ND).

If one of the rings is missing, replace it with one of the extra rings in the instrument set.

Insert the compression device into the support device and assemble the compression wheel (519 135ND).

(The Newdeal laser markings and the mm scale should face anteriorly. This will ensure that the scale can be read easily when the patient is in the supine position).

Zero out the compression wheel by turning it counterclockwise (so that the millimeter scale on the medial and lateral sides is no longer visible).

Recheck nail position under fluoroscopy.

Position two drill guides • (519 181ND) on each side of the green dotted holes.

Holes • will be selected based on the final length of the implant.

Make the incisions.

11-1

11-2

11-3

12-1

Turn 0 PostionCounterclockwise

Compression Rod Positiong

Insert

AssemblyVerify that both teflon rings are properly positioned on the compression device.

• Assemble the compression device with:

– threaded axis (519 131ND).

– compression wheel (519 135ND)

13

Step 13 • Proximal Drilling

519 175ND (x2) •Compression rod

519 005ND •Drill diam. 5 mm

519 021NDT handle AO attachment

PREPARE

13-1

14-1

15-1

AO T-Handle Assembly

Step 14 • Distal Drilling

Step 15 • Distal Rod Insertion

14-1

15-1

13-1

13-2

Drill the distal hole with the second 5 mm drill • (519 005ND) up to the coaxial drill guide.

Remove the distal drill and introduce the compression rod using the T-handle.

The 5mm drill guides should be in contact with both sides of the tibial cortex. This facilitates the insertion of the compression rods across the tibia.

At this stage, the position of the foot with the tibia should be controlled and aligned at its final position.

Drill the proximal hole up to the second drill guide using the 5 mm diameter drill (indicated with a green dot) • (519 005ND).

Leave it in place.

Assemble the compression rod (519 175ND) to the AO T-Handle (519 021ND).

Push + Release

14

Step 16 • Proximal Rod Insertion

16-216-1

17-1Step 17 • Compression

Remove the proximal drill bit and insert the second compression rod using the T-handle.

Ensure that each rod is secured within both the medial and the lateral sleeves that pass through each arm of the compression device.

Remove the T handle attachment.

Gently apply compression by turning the compression wheel clockwise. Up to 12mm of compression may be applied.

The compression can be visualized at any point using fluoroscopy.

Stop when desired compression is reached.

16-1

16-2

17-1

Warning

No Compression. Maximum Compression.

Avoid over-compressing the arthrodesis sites!

This may have adverse effects and impede removal of the compression rods.

0

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Step 18 • Tibial Screw Incision

Step 19 • Tibial Drilling

519 180ND (x2) • long drill guidediam. 4.3 mm

519 185ND (x2) •Long soft tissue protectordiam. 7 mm

519 004ND (x2) • Drill for tibial screwsdiam. 4.3 mm

PREPARE

Screw Position150 mm nail

Screw Position180 mm nail1

80

1

50

18

0

15

0

18-1

19-1 19-2

19-1

19-2

Use the proximal drill • (519 004ND) for pre-drilling the proximal interlocking screws. Leave the drill bit in the guide.

Using the second • (519 004ND) 4.3 mm drill bit, drill the distal hole.

Screw Positioning

18-1 Assemble the long soft tissue protectors (orange dotted • ) with the long 4.3 mm drill guides • (519 180ND) .

Position the protector/sleeve assembly in the compression device according to the length of the nail to determine incision height.

The screws can be placed from medial to-lateral or lateral-to-medial in the tibia. The advantage of medial-to-lateral is that the insertion process passes through less soft tissue. The advantage of lateral-to-medial screw placement is greater soft tissue protection over the screw head.

Make incision.

Insert the assembly into the orange holes • until the drill guide contacts the tibial cortex. The guide must contact the cortex to provide an accurate measurement of screw length when using the calibrated scale on the drill.

Fluoroscopy is used to control the proper contact of the drill guide and the bone.

16

For easy identification, instruments concerning tibial and talus screws contain orange dots. They also correspond to the appropriate insertion holes on the support device.

Step 20 • Tibial Screw Measurement

Step 21 • Tibial Screw Insertion

Read the screw length either from the calibrated drill bit (read from top of sleeve) or with the depth gauge. See instructions for measurement. (Step 9)

Remove the distal drill bit and its protection sleeve.

Assemble the hexagonal screwdriver tip (519 190ND) to the power drill.

The screws may be inserted by hand or by power.

Check each step of the screw insertion as noted above using fluoroscopy in perpendicular AP and lateral planes.

Remove proximal drill bit.

Proceed as described for the distal screw.

Finalize locking manually with the screwdriver.

519 195NDHexagonal screwdriverdiam. 3.5 mm

519 160NDDepth gauge

519 190NDHexagonal screwdriver tipdiam. 3.5 mm

PREPARE

20-1

21-1

21-2

21-3

21-4

BONE

SUPPORTDEVICE

SUPPORTDEVICE

BONE

READ HERE

READ HERE

READ HERE

READ ON DEPTH GAUGE (optional)

BBOONENE

BBOONNEE

SSUUPPOPPORTRTDDEVICEEVICE

SSUUPPOPPORTRTDDEVICEVICEE

CASE 1 • Sleeves are in contact with the cortex

CASE 2 • Sleeves are not in contact with the cortex

READ ON DEPTH GAUGE

READ ON DRILL BIT

21-1

21-2 21-3

TipThe “T” laser mark on the shaft flush with the soft tissue protector indicates that the head of the screw is flush with the bone.

17

Step 22 • Talar Screws (Optional)

22-1

22-3

22-2

22-1

22-2

22-3

An optional talar screw may be implanted after final fixation.

Assemble the long 4.3mm drill guide • (519 180ND) and the soft tissue protector (519 185ND), previously used for tibial screw preparation, and use the orange color coded drill • (519 004ND) to prepare the screw hole.

Control depth directly using the calibrated scale on the drill or with the depth gauge (519 160ND).

Read the screw length from the calibrated drill bit (read from top of sleeve). See step 20 for measurement method.

Assemble the hexagonal screwdriver tip (519 190ND) to the power drill.

The screw may be inserted by hand or partially by power and then completed by hand.

Check each step of the screw insertion as noted above using fluoroscopy in perpendicular AP and lateral planes.

18

Step 23 • Support Device Removal

Step 24 •

Release the compression device by turning the compression wheel one half revolution counter clock wise to ease the tension on the compression rods.

Removing the sleeves will further release the tension and facilitate removal of the compression rods.

Using the T-handle, remove all the compression rods (519 175ND), drill guides and soft tissue protectors .

Reattach the toothed wheel to the nail fixation axis and unscrew it to release the compression device from the implant.

Remove the support device.

The end cap is screwed into the planter hole of the nail. If desired, the locking end cap (510 004ND) can be used to lock the distal calcaneal screw to the nail when the partially threaded screws are used.

Setup the end cap (510 004ND) with the screwdriver (519 195ND). The distal screw is locked by the end cap

519 121NDToothed wheel

PREPARE

23-1

23-2

23-3

24-1

23-3

24-1

23-1 23-2

WarningExercise care to prevent the end cap from falling into the soft tissues.

19

(SPECIFIC Lag Screws)

SP

EC

IFIC

LA

G S

CR

EW

S

20

Tibiotalocalcaneal Arthrodesis with Retrograde Intramedullary Nailing

Mendicino R, Catanzariti A, Saltrick K, Domberk M, Tullis B, Statler T, Johnson B

The Journal of Foot and Ankle Surgery • Volume 42, N° 2 • 2004

Calcaneotalotibial Arthrodesis with a Retrograde Posterior-To-Anterior Locked Nail as a Salvage Procedure for Severe Ankle Pathology

Mader K, Pennig D, Gausepohl T, Patsalis T

The Journal of Bone and Joint Surgery • Volume 85-A: 123-128 • 2003

Tibiotalocalcaneal Arthrodesis with Medullary Rod Fixation

Quill G

Techniques in Foot and Ankle Surgery • Volume 2, Issue 2:135-143 • 2003

Evaluation of Compression in Intramedullary Hind Foot Arthrodesis

Berson L, McGarvey W, Clanton T

Foot and Ankle International • Volume 23, n° 11:992-995 • 2002

Tibiotalocalcaneal Arthrodesis: A Biomechanical Analysis of the Rotational Stability of the Biomet Ankle Arthrodesis Nail

Mann M, Parks B, Pak S, Miller S

Foot and Ankle International • Volume 22, n° 9:731-733 • 2001

Tibiotalocalcaneal Arthrodesis

Chou L, Mann R, Yaszay B, Graves S, McPeake W, Dreeben S, Horton G, Katcherian D, Clanton T, Miller R, Van Manen J

Foot and Ankle International • Volume 21, n° 10:804-808 • 2000

Stress Fractures and Tibial Cortical Hypertrophy After Tibiotalocalcaneal Arthrodesis with an Intramedullary Nail

Thordarson D, Chang D

Foot and Ankle International • Volume 20, n° 8:497-500 • 1999

Ankle Arthrodesis in Rheumatoid Arthritis Using an Intramedullary Nail with Fins

Fujimori J, Yoshino S, Koiwa M, Nakamura H, Shiga H, Nagashima S

Foot and Ankle International • Volume 20, n° 8:485-489 • 1999

A Biomechanical Comparison of Intramedullary Nail and Crossed Lag Screw Fixation for Tibiotalocalcaneal Arthrodesis

Berend M, Glisson R, Nunley J

Foot and Ankle International • Volume 18, n° 11:639-643 • 1997

Charcot Ankle Fusion with a Retrograde Locked Intramedullary Nail

Pinzur M, Kelikian A

Foot and Ankle International • Volume 18, n° 11:699-704 • 1997

This List Is Provided For Illustrative Purposes Only And Is Not ExhaustiveBIBLIOGRAPHY

PANTA®

I n s t r u m e n t a t i o n S e t

2

3

4 5

1

18

19

21

20

22

26

26

23

2525

24

8

817

1610

11

7

6

17

1314

15 13

12

9

21

Insert

Basic – Upper level

Basic – Lower level

I n s t r u m e n t a t i o n S e t

1. • 519 028ND Internal protection sleeve diam. 3.2mm

• 519 029ND Central protection sleeve diam. 9mm

• 519 030ND External protection sleeve diam. 13.5mm

2. • 519 032ND Guide wire diam. 3.2mm, L. 400mm

3. • 519 007ND Cannulated drill diam. 7mm

• 519 009ND Cannulated drill diam. 9mm

4. • 519 01XND Reamers diam. 10.5 mm to diam. 3.5mm (x7)

5. • 519 020ND Quick Coupling (optional)

6. • 519 110ND Support device

7. • 519 131ND Threaded axis

8. • 519 183ND Medium soft tissue protector diam. 7mm (x2)

9. • 519 002ND Medium drills diam. 4.3mm for calcaneus

10. • 519 040ND Trocar awl

11. • 519 175ND Compression rods (x2)

12. • 519 195ND Hexagonal screwdriver diam. 3.5mm

13. • 519 185ND Long soft tissue protector diam. 7mm (x2)

14. • 519 004ND Drill diam. 4.3mm for tibial screws

15. • 519 160ND Depth gauge

16. • 519 008ND Long drill diam. 4.3mm (x2)

17. • 519 181ND Drill guide diam. 5mm (x4)

18. • 519 021ND T-handle with AO attachment

19. • 519 120ND Nail fixation axis

• 519 121ND Toothed wheel

20. • 519 133ND Teflon rings (x2)

21. • 519 135ND Compression wheel

22. • 519 130ND Compression device

23. • 519 005ND Drill diam. 5mm (x2)

24. • 519 190ND Hexagonal screwdriver tip diam. 3.5mm

25. • 519 178ND Medium drill guide diam. 4.3mm (x2)

26. • 519 180ND Long drill guide diam. 4.3mm (x2) 22

Insert

Basic – Upper level

Basic – Lower level

Newdeal and Panta are registered trademarks of Integra LifeSciences Corporation or its subsidiaries. The Integra wave logo is a trademark of Integra LifeSciences Corporation. ©2008 Integra LifeSciences Corporation. All r ights reserved. Printed in the USA 5K ER1685-05/09

End Cap (Sterile)

Reference Description519 002ND • Medium drill diam. 4.3mm for calcaneus screws 519 004ND • Drill diam. 4.3mm for tibial screws519 005ND • Drill diam. 5mm 519 008ND • Long drill diam. 4.3mm for calcaneus screws519 007ND Cannulated drill diam. 7mm519 009ND Cannulated drill diam. 9mm519 011ND Reamer diam. 11mm519 012ND Reamer diam. 12mm519 013ND Reamer diam. 13mm519 014ND Reamer diam. 10.5mm519 015ND Reamer diam. 11.5mm519 016ND Reamer diam. 12.5mm519 017ND Reamer diam. 13.5mm519 020ND Optional quick coupling519 021ND T-handle with AO attachment519 028ND Internal protection sleeve diam. 3.2mm519 029ND Central protection sleeve diam. 9mm519 030ND External protection sleeve diam. 13.5mm519 032ND Guide wire diam. 3.2mm, L. 400mm519 034ND Guide wire diam. 3.2mm, L. 600mm519 040ND Trocar awl519 110ND Support device519 120ND Nail fixation axis519 121ND Toothed wheel519 130ND Compression device519 131ND Threaded axis519 133ND Teflon ring519 135ND Compression wheel519 160ND Depth gauge519 175ND • Compression rod519 178ND • Medium drill guide diam. 4.3mm519 180ND • Long Drill guide diam. 4.3mm519 181ND • Drill guide diam. 5mm519 183ND • Medium soft tissue protector diam. 7mm519 185ND • Long soft tissue protector diam. 7mm519 190ND Hexagonal screwdriver tip diam. 3.5mm519 195ND Hexagonal screwdriver diam. 3.5mm519 910ND Sterilization container519 911ND Insert519 920ND Lid

Reference Description510 001ND Standard End cap510 004ND Locking End cap

Partially Threaded Screw Diam 5mm (Sterile)

Reference Description500 050ND Diam. 10mm, L. 150mm500 080ND Diam. 10mm, L. 180mm500 150ND Diam. 11mm, L. 150mm500 180ND Diam. 11mm, L. 180mm500 250ND Diam. 12mm, L. 150mm500 280ND Diam. 12mm, L. 180mm500 350ND Diam. 13mm, L. 150mm500 380ND Diam. 13mm, L. 180mm

Fully Threaded Screw Diam 5mm (Sterile)Reference Description 501 020ND L. 20mm501 025ND L. 25mm501 030ND L. 30mm501 035ND L. 35mm501 040ND L. 40mm501 045ND L. 45mm501 050ND L. 50mm501 055ND L. 55mm501 060ND L. 60mm501 065ND L. 65mm501 070ND L. 70mm501 075ND L. 75mm501 080ND L. 80mm501 085ND L. 85mm501 090ND L. 90mm501 095ND L. 95mm501 100ND L. 100mm501 105ND L. 105mm501 110ND L. 110mm

Reference Description511 020ND L. 20mm511 025ND L. 25mm511 030ND L. 30mm511 035ND L. 35mm511 040ND L. 40mm511 045ND L. 45mm511 050ND L. 50mm511 055ND L. 55mm511 060ND L. 60mm 511 065ND L. 65mm 511 070ND L. 70mm 511 075ND L. 75mm 511 080ND L. 80mm 511 085ND L. 85mm 511 090ND L. 90mm 511 095ND L. 95mm 511 100ND L. 100mm511 105ND L. 105mm511 110ND L. 110mm

PANTA Nail (Sterile) Asscociated Instruments

PANTA®

a r t h r o d e s i s n a i l

Integra LifeSciences Corporation 311 Enterprise Drive • Plainsboro, NJ 08536

877-444-1122 (USA) • 609-936-5400 (Outside USA) • 866-800-7742 (Fax) www.Integra-LS.com