M/DN Femoral

Interlocking
& Recon Nail
Intramedullary
Fixation Surgical
Technique

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Surgical Techniques
for Fixation of
Femoral Fractures
with an M/DN Nail

Table of Contents
Introduction

Indications

Surgical Technique

Preoperative Planning

Patient Positioning and Radiographic Control

Reduction

Incision and Exposure

Creating the Entry Portal

Guide Wire Replacement and Reaming

Nail Insertion

Interlocking Application
Recon Application

Proximal Locking
For Interlocking Application
For Recon Application

9
11

12
12
14

End Cap Placement

17

Distal Locking

17

Technique for Using Freehand Targeting Device

17

Closure and Postoperative Care

20

Nail Cap

20

Extraction

20

Instrument Case Options

21

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Introduction
Closed intramedullary nailing has long
been a common method of treating
noncomminuted fractures of the femur
and tibia. The interlocking nail has
extended the indications of closed
intramedullary nailing to include
comminuted fractures, fractures with
bone loss, and proximal and distal
fractures of the femur.

Fig A

The multi-point fixation provided by the

cross-section of the M/DN Nail makes
it appropriate for use unlocked (Fig. A)
as well as locked in either the dynamic
(Fig. B) or static mode (Fig. C). It also
makes it appropriate for reamed or
unreamed applications.
The successful use of any
intramedullary nail is technically
demanding. Close attention to
positioning, reduction, rod placement,
and insertion of the proximal and distal
locking screws is mandatory.

Fig B

Fig C

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Indications

Fig. 1

The M/DN femoral nail is indicated for

use in a variety of femoral fractures
(Fig. 1), such as:

A. Comminuted fractures
B. Segmental fractures
C. Fractures with bone loss
D. Proximal and distal fractures
E. Nonunions
F. Subtrochanteric fractures
G. Intertrochanteric fractures

A Comminuted
Fracture

D Proximal and
Distal Fractures

E Nonunions

B Segmental
Fracture

F1 Subtrochanteric Fracture

C Fracture with
Bone Loss

G1 Intertrochanteric
Fracture

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Surgical Technique
The M/DN Femoral Nail is designed for
varied use. A single nail can be used for
both right and left standard interlocking
or recon procedures. The femoral nail is
available in the most commonly used
sizes. These nails range in diameters
from 8.0mm to 16.0mm and lengths
from 24cm to 50cm.

Preoperative Planning
Proper preoperative planning is
essential to successful interlocking or
recon nailing of the femur. To determine
the appropriate nail size, an ossimeter,
roentgenogram templates, and an
x-ray film of the unaffected extremity
are necessary for determining canal
size at the isthmus and for measuring
the length of the femur to aid in
determining nail length.
The Nail Length Gauge or Harris/
Galante Bulb-Tip Guide Wires (Sounds),
available in diameters from 10mm17mm, can be used as alternate
techniques to determine nail diameter
and length.
X-rays taken at a 36-inch distance
from the x-ray source result in 10-15
percent magnification of bone. The
ossimeter has both an actual size
scale and one that takes into account
this magnification. It should be used
routinely to determine nail diameter
and length.
The proper length of nail should extend
from the tip of the greater trochanter
to the epiphyseal scar. The diameter
of the femoral nail should match the
isthmus in the lateral x-ray projection.
The surgeon should review the x-ray
to assure that there are no unusual
anatomic variations.

Patient Positioning and

Radiographic Control

Supine

The patient may be placed in either

the supine or the lateral decubitus
position (Fig. 2).
In multiple trauma patients, the supine
position may be used for easier access
to the airways as well as to facilitate
the treatment of other injuries. The
supine position also facilitates fracture
reduction and rotational alignment
of the femur. The disadvantage to the
supine position is that it impairs access
to the tip of the greater trochanter for
insertion of the nail.
It is essential to obtain excellent A/P
and lateral images of the femoral head
and neck prior to beginning the surgery
regardless of which patient position
is used.
The use of image intensification or
other x-ray imaging is required. The
image intensifier should be steriledraped and may be positioned from
either the contralateral or ipsilateral
side of the operating table. Confirm
visualization of the hip as well as
the shaft of the femur using image
intensification before prepping and
draping. Bend the patients torso away
from the affected extremity to improve
access to the greater trochanter. If
access to the greater trochanter is still
inadequate, adduct the affected leg.
However, to achieve proper alignment
of the fracture, this adducted position
must be corrected prior to insertion
of the nail.

Reduction
It is important to reduce the
fracture before beginning the
surgical procedure.

Lateral

Fig. 2 Supine and lateral decubitus positions.

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Incision and Exposure

Begin the skin incision 1cm proximal
to the greater trochanter and carry
it proximally about 5cm in line with
the gluteus maximus muscle (Fig. 3).
A larger incision may be desired for
obese patients. Split the fascia of
the gluteus maximus in line with its
fibers. Identify the subfascial plane of
the gluteus medius, and palpate the
posterior tip of the greater trochanter.
Retract the muscles to facilitate
visualization of the piriformis fossa
This may be difficult in the obese
patient, especially if flexion causes the
tip of the trochanter to lie against the
ilium. Positioning techniques used to
expose the tip of the trochanter include
adduction of the leg and positioning
of the patients torso away from the
affected extremity.

the Awl at the piriformis fossa (Fig. 4)

and check its position with A/P and
lateral views.
For the recon procedure, place the
Awl in the anterior portion of the
piriformis fossa approximately 5mm

the portal. On the A/P image, the awl

should lie at the base of the femoral
neck adjacent to the greater trochanter.
On the lateral view, it should be
oriented just posterior to the center
of the femoral neck. When the correct
position is achieved, rotate the Awl to
create the entry portal for the Ball-Tip
Guide Wire.
If using the Long Cannulated Awl,
the 3.0mm Ball-Tip Guide Wire can
be inserted through the Awl.
An alternative method is to insert
a 3.2mm Steinmann Pin into the
piriformis fossa while checking the
position with A/P and lateral image
intensification. The Steinmann Pin must
lie at the base of the femoral neck just
medial to the greater trochanter on the
A/P view, and oriented just posterior to
the center of the femoral neck on the
lateral view. Seat the Steinmann Pin
well into the proximal femur and use
the optional 9mm Trochanteric Reamer
to create the entry portal (Fig. 6).

Creating the Entry Portal

Locating the correct entry portal in the
piriformis fossa is extremely important.
For the interlocking procedure, place

Fig. 4

anterior to the position you would

choose when doing a standard femoral
nailing (Fig. 5). This will facilitate
screw placement in the center of
the femoral neck.
Check the position of the awl with both
A/P and lateral images before creating
Entry Portal for Recon

Entry Portal for

Interlocking

Fig. 3

Fig. 5

Fig. 6

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Guide Wire Replacement

and Reaming
Conventional Guide Wire/
Exchange Tube Technique
Attach the 3.0mm Ball-Tip Guide Wire
to the Wire-Grip T-Handle (Fig. 7) and
tighten. The Ball-Tip Guide Wire may also
be described as a Bulb-Tip or Bullet-Tip
Guide Wire. To aid in manipulation,
bend the tip of the Guide Wire at about
a 10 angle 5cm from the end. Insert the
Guide Wire through the entry hole and
manipulate it down the proximal femur.
At the fracture site, manipulate the Guide
Wire under C-arm control (Fig. 8). Once in
the distal canal, pass the wire to its final
position in the epiphyseal scar (Fig. 9).

If reduction of the abducted and flexed

hip is difficult, place pressure on the
anterior aspect of the proximal fragment
either with the hand or directly with an
instrument.
The Reduction Finger can be used to
assist in femoral fracture reduction.
To use the Reduction Finger, advance
the Ball-Tip Guide Wire and ream the
proximal segment. Pass the Reduction
Finger over the Ball-Tip Guide Wire.
Manipulate the fracture externally
While using the Reduction Finger
internally to aid in fracture reduction.
Once the Ball-Tip Guide Wire has passed
through the fracture site, the Ball-Tip

CAUTION: If the guide wire is bent

shorter than 5cm from the end of the
wire and/or more than 10 degrees it
may be difficult to remove from the nail.
If the wire becomes lodged inside the
nail, utilize the WIRE GRIP T-HANDLE and
mallet to remove the guide wire from the
nail.

Fig. 7

Fig. 8

Fig. 9

Guide Wire is advanced to epiphyseal

scar. If the Ball-Tip Guide Wire can not
advance through the fracture site, the
ball tip of the Guide Wire should be bent
slightly and then reinserted to aid in
internal reduction.
Determine the proper nail length by
placing a second guide wire of equal
length at the greater trochanter. The
length of the wire that is not overlapping
is the correct nail length (Fig. 10). The
50cm Ruler or ossimeter may be used for
an accurate measurement.
Another way to measure the length
is to use the C-arm to position the 0
mark on the metal ruler at the tip of the
trochanter. Then read the correct length
at the epiphyseal scar directly off the
metal ruler.

Fig. 10

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Alternatively, the IM Nail Length Gauge

can be used to measure the appropriate
Nail length through measurement of
one 100cm Guide Wire. To use, place
a 100cm Ball-Tip Guide Wire down the
medullary canal. Slide the IM Nail Length
Gauge over the
Guide Wire, ensuring that the distal
portion of the gauge is resting on the
piriformis fossa in order to determine
correct nail length. Nail length is
determined by noting the location of
the remaining Guide Wire and reading
the Nail Length Gauge at that particular
location. If the length indicated is
between two available nail sizes, it is
recommended that the shorter nail
be chosen.
NOTE: Nail Length Gauge can only be
used with 100cm Guide Wire.
Remove the Wire-Grip T-Handle, and
place a Pressure Sentinel intramedullary
reamer over the guide wire. The Pressure
Sentinel Intramedullary Reaming System
is a system of one-piece reamers ranging
in size from 5mm diameter to 27mm
diameter in half millimeter increments.
Each reamer is composed of a fluted
reamer head, a shaft and a quick-connect
drive end. The quick-connect end can

be connected to a manual or powered

driver. The width of the isthmus of
the medullary canal is determined by
preoperative x-ray examination. The
instrument with the smallest possible
diameter is used for initial reaming into
the medullary canal. Reamers with a
diameter of
5mm to 7.5mm use a 2.4mm BallTip Guide Wire while reamers with
a diameter of 8mm to 27mm use a
3.0mm Ball-Tip Guide Wire. As reaming
continues, the reamer size should
be increased by 0.5mm or 1.0mm
increments until an opening of the
desired size is obtained (Fig. 11).
NOTE: To avoid reamer lodging during
use, reaming should be immediately
stopped and the reamers retracted
when there is too much resistance.
If the reamer becomes lodged, stop
reaming immediately. Reverse the
direction of rotation of the handpiece
and back the reamer out of the canal.
The reamer can also be extracted
by snapping the T-Handle Extractor
onto the reamer end and then gently
tapping the Extractor with a small
mallet or hammer.
CAUTION: Excessive blows to the
T-Handle Extractor may damage the
reamer or the Extractor.

New Guide Wire Technique

Option
If using a Ball-Tip Guide Wire that does
NOT have a gold coated end OR if using
a nail less than 10mm:
When the reaming is complete and
the final measurements are made,
insert the plastic Exchange Tube
over the Ball-Tip Guide Wire. Remove
the Ball-Tip Guide Wire, and insert a
Smooth Guide Wire (Fig. 12).
If using a Ball-Tip Guide Wire that DOES
have a gold coated end and if using a
nail equal to or greater than 10mm:
The Ball-Tip Guide Wire can remain in
place. It is NOT NECESSARY to exchange
the Ball-Tip Guide Wire for a Smooth
Guide Wire.

Smooth
Guide Wire

Ball-Tip
Guide
Wire

Plastic
Exchange
Tube

NOTE: The proximal diameter of the

8mm and 9mm M/DN Femoral Nail
is 12mm. Therefore, over ream the
proximal femur to 13mm for these nail
diameters. The proximal diameter of
the 10mm, 11mm, and 12mm M/DN
Femoral Nail is 13mm. Therefore, over
ream the proximal femur to just below
the level of the lesser trochanter to
14mm for these nail diameters.
NOTE: If the Guide Wire becomes
lodged within the reamer, use the
Wire-Grip T-Handle to push the Guide
Wire back into the IM Canal.

Fig. 11

Fig. 12

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Nail Insertion
Select the appropriate sized M/DN
Femoral Nail (Table 1).
Attach the selected nail to the
appropriate left or right Femoral
Proximal Targeting Guide. Insert the
Femoral Locking Bolt through the
barrel of the Proximal Targeting Guide
(Fig. 13). Using the thumb or finger
to apply a steady downward pressure
on the Locking Bolt, hand-tighten
the Locking Bolt into the proximal
end of the nail (Fig. 14). Use the Pin
Wrench to ensure that the locking
mechanism is tightened securely. A
keyway in the proximal end of the nail
will help ensure proper alignment of
the Guide and nail (Fig. 15). The Lock
Washer mechanism will prevent the
Locking Bolt from loosening during the
insertion of the nail. Tighten until the
Lock Washer is flattened between the
Guide and the Locking Bolt (Fig. 16).

Table 1. M/DN Femoral Recon Nails Expanded Set

Nail Diameter (mm)

Nail Length
(cm)

10

11

12

13

24

26

28

30

32

34

36

38

40

42

44

46
48
50

14

15

16

Keyway

Femoral Locking Bolt

M/DN
Intramedullary Nail

Fig. 15

PinWrench

Proximal Targeting Guide

Lock Washer

Fig. 13

Fig. 14

Fig. 16

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Interlocking Application
Verify proper alignment of the construct
by inserting the 5mm Femoral Drill
Bushing into the 8mm Femoral Screw
Bushing (Fig. 17).
Insert the two nested bushings through
the interlocking hole. Insert the 5mm
Drill into the bushing and through the
interlocking hole. When the device
is properly aligned, the drill will pass
through the proximal hole of the nail
and will not contact the nail (Fig. 18).

Place the selected nail over the BallTip Guide Wire and into the femur. Do
not strike the guide directly to seat the
nail. Screw the Threaded Driver or the
Slaphammer into the back end of
the Locking Bolt or onto the offset
threaded drive. Begin seating the nail
using gentle impaction.

The Slotted Mallet can be used with the

Threaded Driver to make slight upward
adjustments in depth (Fig. 19).
While impacting the nail, use the
Femoral Proximal Guide to maintain the
proper rotation during impaction. Use
caution when crossing the fracture site.
Visualize the fracture in two planes
with image intensification to assure
proper passage of the nail into the
distal fragment. Reduce the force of
impaction as the proximal end of the
nail approaches the greater trochanter.

Slotted
Mallet

Nested
Bushing

5.0mm
8.0mm

Fig. 17

Fig. 18

Fig. 19

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M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Recon Application
When performing the recon
procedure, slide a 14in. Steinmann
Pin percutaneously along the anterior
aspect of the trochanter, parallel to
the femoral neck. Verify pin placement
with the C-arm (Fig. 20). This will help
to identify the anteversion of the neck.
During the insertion, the Femoral
Proximal Guide must remain parallel to
this pin to ensure proper anteversion
for the locking screws.
If excessive resistance is encountered
during nail driving, remove the nail and
check the size of both the reamer and
the nail. Once proper sizing has been
confirmed, the surgeon may choose to
over ream the canal or select a smaller
size nail.
Continue to seat the nail until it is flush
with the trochanter. When the nail is
fully seated, REMOVE THE GUIDE WIRE
so that it does not get trapped in the
bone. Remember, it might be concealed
inside the driver or Slaphammer.
Reassess the integrity of the Locking
Bolt Nail connection and re-tighten
with the Pin Wrench if necessary
(Fig. 21).

Fig. 20

Fig. 21

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M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Verify proper alignment by inserting

the 3.2mm Femoral Pin/Drill Bushing
into the 5mm Femoral Drill Bushing;
then insert these two nested bushings
into the 8mm Femoral Screw Bushing
(Fig. 22). Place the three nested guide
bushings through one of the recon
holes in the Femoral Proximal Guide.
Insert the 3.2mm, 14in. Steinmann
Pin through the inner bushing. When
the device is properly aligned, the
Steinmann Pin will pass through the
proximal hole of the nail and will not
contact the nail (Fig. 23).

Threaded Locking Bolt

Offset Threaded Drive

3.2mm
5.0mm
8.0mm

Fig. 22

Fig. 23

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M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Proximal Locking
For Interlocking Application
Screw the 5mm Femoral Drill Bushing
(Color Code: Green), into the 8mm
Femoral Screw Bushing (Fig. 24),
and insert them into the Femoral
Proximal Guide (Fig. 25). Insert the
5mm Femoral Drill (Color Code: Green),
into the assembled bushings and
drill until the medial femoral cortex is
penetrated (Fig. 26).

Drill
Nested
Bushing

Bushing Construct

Fig. 24

Fig. 25

Fig. 26

Table 2. Implant / Instrumentation Specifications for Femoral Nails

Nail Diameter (mm)

10

11

12

13

14

15

16

Head Diameter (mm)

12

12

13

13

13

13

14

15

16

Guide Wire, Smooth (mm)

3.0

3.0

3.0

3.0

3.0

3.0

3.0

3.0

3.0

Proximal Screw Size (mm)

5.5

5.5

5.5

5.5

5.5

5.5

5.5

5.5

5.5

green

green

green

green

green

green

green

green

green

Drill Bushing Size (mm)

5.0

5.0

5.0

5.0

5.0

5.0

5.0

5.0

5.0

Proximal Drill Size (mm)

5.0

5.0

5.0

5.0

5.0

5.0

5.0

5.0

5.0

Distal Screw Size (mm)

3.7

4.2/4.5

4.2/4.5

4.2/4.5

5.5

5.5

5.5

5.5

5.5

yellow

blue

blue

blue

green

green

green

green

green

Trocar Diameter (mm)

3.2

3.7

3.7

3.7

5.0

5.0

5.0

5.0

5.0

Distall Drill Size (mm)

3.2

3.7

3.7

3.7

5.0

5.0

5.0

5.0

5.0

13

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Remove the 5mm Femoral Drill

Bushing, leaving the 8mm Femoral
Screw Bushing in place.
Use the Proximal Screw Depth Gauge to
determine screw length (Fig. 27 & 28).
Use the T-Handle Screwdriver to insert
the appropriate length 5.5mm screw
(Color Code: Green) (Fig. 29), to the
correct reference line on the T-Handle
Screwdriver (Fig. 30). Use the C-arm
to check the position of the screw and
tighten it appropriately.

Proximal Screw
Depth Gauge

Remove the screwdriver and the 8mm

Femoral Screw Bushing. Take A/P and
lateral C-arm views to check for correct
positioning. If using a second Proximal
screw, repeat the previous technique.
Disengage the Locking Bolt from the
nail using the Pin Wrench.
NOTE: 5.5mm Screws (Color Code:
Green), are used proximally for all
Femoral Nails.
3.7mm screws (Color Code: Yellow), are
used distally for 8mm Femoral Nails.

Fig. 27

Fig. 29

4.2mm or 4.5mm screws (Color Code:

Blue), are used distally for all 9mm
11mm Femoral Nails.
Reference Lines

5.5mm Screws (Color Code: Green),

are used distally for all 12mm 16mm
Femoral Nails.

Fig. 28

Fig. 30

14

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

For Recon Application

Correct rotation of the nail is
imperative for retrograde insertion
of the two screws through the nail
and into the femur. Be sure that the
nail is inserted to the correct depth
to allow placement of both screws
with the correct anteversion.
Screw the 3.2mm Proximal Pin/Drill
Bushing, into the 5mm Femoral Drill
Bushing (Color Code: Green). Screw
this construct into the 8mm Femoral
Screw Bushing (Fig. 31), and insert
the assembled three bushings into
the inferior recon hole of the Femoral
Proximal Guide to the level of the skin,
(Fig. 32). Make an incision in the skin
and fascia at this point and continue
to insert the bushings until contact is
made with the lateral femoral cortex.
Drill a 14in. Steinmann Pin into the
femoral head to the required level to
achieve fracture fragment stability,
without penetrating the femoral head
cortex (Fig. 33). Verify the proper
position and anteversion of the pin
with A/P and lateral C-arm views.
Avoid excessive twisting or torquing
of the Femoral Guide to ensure proper
targeting. If the position is not correct,
remove the pin and adjust the nail
rotation and/or nail depth. Verify the
new pin placement with the C-arm.

Nested
Bushings

Fig. 32

Fig. 31

3.2mm
Steinmann Pin

Fig. 33

15

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Assemble the second set of three

bushings in the same fashion and
place them into the superior hole of
the Femoral Proximal Guide. Drill the
second 14in. Steinmann Pin in to
the bone and verify its position with the
C-arm (Fig. 34 & 35). If the position is
unacceptable, remove both Steinmann
Pins and reposition the nail. If the
correct position is obtained, remove
the Threaded Driver or Slaphammer.
Also remove the inferior Steinmann
Pin and the 3.2mm Proximal Pin/
Drill Bushing.
Insert the 5mm Femoral Drill (Color
Code: Green), into the 5mm Femoral
Drill Bushing (Color Code: Green). Drill
the inferior proximal screw hole while
monitoring image intensification to
prevent penetration of the femoral
head (Fig. 36). Read the appropriate
screw length directly from the
calibrated Femoral Drill (Fig. 37).
Remove the 5mm Drill and Femoral
Drill Bushing. Insert the Recon Screw
Counterbore through the outer
8mm Femoral Screw Bushing and
counterbore. The blunt end of the
Counterbore serves as a stop.

5.0mm
Femoral Drill

Fig. 34

Fig. 36

Read Length

Fig. 35

Fig. 37

16

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Screw length may alternatively be

measured using the Proximal Screw
Depth Gauge. Select a screw equal
to the measured length to avoid
penetration of the joint (Fig. 38).
Another gauge that can be used
to measure screw length is the
Cannulated Depth Gauge. Slide the
Cannulated Depth Gauge over the
Steinmann Pin, i.e., the inferior of the
two Steinmann Pins if two pins are
used, until the gauge contacts the
lateral aspect of the femur. Assess that
the gauge is seated against the bone
using the C-arm. Read and record the
length of the Steinmann Pin from the
calibrated depth gauge.

NOTE: This measurement designates

the correct length of the screw to
be implanted.
Remove the counterbore using the
T-Handle Screwdriver, insert the
appropriate length 5.5mm Partially
Threaded Recon Screw (Fig. 39) through
the outer bushing to the level of the
correct reference line on the T-Handle
Screwdriver (Fig. 40). Use the C-arm to
ensure proper seating of the locking
screw well within the femoral head.
Tighten it appropriately.

The first screw should lie in the inferior

neck to allow room for the second
screw to be placed. This may be
difficult in small patients or in patients
with varus hips. Be certain to seat
the inferior screw tightly against
the medial cortex to prevent varus
deformity and to allow for placement
of the proximal screw.
Remove the T-Handle Screwdriver
and the Femoral Bushing. Take A/P
and lateral C-arm views to check for
correct positioning. Repeat the same

Screw
Screw Guage

Fig. 38

Fig. 39

Fig. 40

17

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

procedures for insertion of the superior

locking screw (Fig. 41). Again, observe
A/P and lateral C-arm views to ensure
proper seating within the femoral head
and neck. Using the Pin Wrench, loosen
and remove the Locking Bolt and
Femoral Proximal Guide.
NOTE: 5.5mm Recon Screws (Color
Code: Candy Stripe Green) are used
proximally for all recon procedures.
3.7mm screws (Color Code: Yellow), are
used distally for 8mm Femoral Nails.
4.2mm or 4.5mm screws (Color Code:
Blue), are used distally for all 9mm
11mm Femoral Nails.
5.5mm Screws (Color Code: Green),
are used distally for all 12mm 16mm
Femoral Nails.

End Cap Placement

Insert an M/DN End Cap of the
appropriate length (0mm, 5mm, 10mm,
15mm) in the proximal nail. These caps
help protect the internal threads of the
nail, facilitate future extraction, and
allow the surgeon to adjust the length
of the nail.

Distal Locking
Technique for Using Freehand
Targeting Device
The distal locking screws may be
inserted with a freehand technique
using the Freehand Targeting Device.
Insert an appropriate size Trocar
[2.7mm (Color Code: Yellow) for 3.7mm
screw, 3.2mm (Color Code: Blue) for
4.2mm or 4.5mm screw, 4.5mm (Color
Code: Green) for 5.5mm screw]
(Fig. 42) into the Freehand Targeting
Device. Finger tighten the set screw.

Choose the appropriate locking hole

based on the need for dynamization.
The superior locking hole on the M/DN
Nail is used for static locking, while the
distal locking hole is used for dynamic
locking. If static locking is preferred,
but there is a potential need for later
dynamization, insert screws in both
locking holes. The locking screw in
the static hole can then be removed
to achieve later dynamization.
For success with this technique,
proper placement of the lateral
x-ray beam is critical. Position the
C-arm so the locking hole of the
nail appears perfectly round on the
monitor (Fig. 43).

Incorrect

Correct

Fig. 43

Fig. 42

Fig. 41

18

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

When this is achieved, bring the tip of

the Trocar to the skin and use the C-arm
to center it over the hole. Make a lateral
stab wound opposite the appropriate
locking hole, and dissect down to
bone. Bring the tip of the Trocar to the
bone and center it over the locking hole
using the C-arm (Fig. 44a).
Align the Trocar with the axis of the
x-ray beam (Fig. 44b and c). Drive the
Trocar into the bone and across the
hole in the nail in line with the lateral
x-ray beam, but do not penetrate the
medial cortex.
Remove the Targeting Device by
loosening the set screw. Verify Trocar
placement in both the A/P and lateral
planes (Fig. 45).
After it has been correctly placed,
remove the Trocar. The path of the
Trocar in the bone acts as a pilot hole
for the appropriate size drill (Fig. 46).
Attach the appropriate drill (same size
as the Trocar) to the Freehand Targeting
Device. Insert the drill into the pilot
hole made by the Trocar. Before drilling
through the medial cortex, check the
A/P and lateral C-arm image to assure
that the drill is in the hole in the nail.
Then drill through the medial cortex.

a.

Trocar

b.

Fig. 45

c.

Drill

Fig. 44

Fig. 46

19

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Remove the drill and insert the Distal

Screw Depth Gauge (Fig. 47). The
length of the screw is determined by
reading it directly off the Distal Screw
Depth Gauge. Select an appropriate
length screw to ensure adequate
engagement of the medial cortex. Insert
the appropriate size M/DN Screw using
the Distal Screwdriver (Fig. 48).
If desired, insert the second screw in
the second locking hole of the nail in
an identical manner (Fig. 49). Check the
position of both screws with the C-arm
in the A/P and lateral planes (Fig. 50).
Bushings are available that can be
used with the Freehand Targeting
Device. A separate radiolucent Bushing
Insert is available to aid in targeting.

Fig. 47

Fig. 48

Fig. 50

Fig. 49

Table 3. Distal Screw Sizes for M/DN Femoral Recon Nails

Screw Diameter
Nail Diameter
(mm)

Distal 3.7mm
Cortical

Distal 4.2/4.5mm
Cortical

10

11

Distal 5.5mm
Cortical

12

13

14

15

16

20

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Closure and Postoperative Care

Close the proximal wound over
suction drains, and apply a soft
compression dressing.

Nail Cap
If desired, a nail cap can be placed
into the proximal threaded portion of
the M/DN Nail (Fig. 51). Nail Caps are
available in 0mm, 5mm, 10mm, and
15mm heights.

Extraction
Should extraction of the nail become
necessary, attach the Threaded
Extractor to the end of the nail and
use the Slaphammer to extract the
nail (Fig. 52).
NOTE: The cannulated Locking
Bolt should not be used for nail
removal. Extraction of the nail
should be accomplished by using
the Threaded Extractor.

Fig. 52
Fig. 51

21

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Instrument Case Options

Retrograde Femoral Instruments (base of case holds the

following)

M/DN Instruments
Option A (Metal Femoral/MIS Femoral/Retrograde)

Prod. No.

Description

00-2241-001-00

Retro. Targ. Guide Assembly (4 pcs.)

00-2241-001-01

Adj. Targ. Arm Assembly (5 pcs.)

00-2241-006-00

Cortical Nut Screwdriver

00-2241-008-37

3.7mm Drill Bushing

Description

00-2241-008-50

5.0mm Drill Bushing

00-2255-001-03

Locking Bolt Assembly

00-2258-067-00

ITST Threaded Guide Pin 355mm

00-2255-002-10

Fem. Prox. Targeting Guide

00-2255-001-00

Locking Bolt

00-2255-002-11

Fem. Prox. Targeting Guide

00-2255-004-80

8.0mm Screw Bushing

Pin Wrench

Set Number 00-2255-000-17 (includes case/tray/lid + instruments)

Case Set Number 00-2237-090-00 (includes trays and lid)
Metal Femoral Guides/Instruments (top tray holds the
following)
Prod. No.

00-2255-004-32

3.2mm Pin Bushing

00-2255-028-00

00-2255-004-50

5.0mm Drill Bushing

00-2255-031-37

3.7mm Drill

5.0mm Drill, Large

Nail Cap Inserter

(captured screwdriver)

00-2255-004-80

8.0mm Screw Bushing

00-2255-035-50

00-2255-011-00

Recon Screw Counterbore

00-2255-059-00

00-2258-067-00

ITST Threaded Guide Pin 355mm

00-2255-028-00

Pin Wrench

00-2255-035-50

5.0mm Femoral Drill, Large

MIS Guides (middle tray holds the following; must be used

with above tray)
Prod. No.

Description

00-2255-003-03

Perc. Recon Arm Set Screw

00-2255-028-00

Pin Wrench

00-2255-050-01

Fem. Perc. Targeting Guide

00-2255-050-02

Fem. Perc. Targeting Guide

00-2255-051-00

Perc. Recon Arm

00-2255-053-00

Perc. Cannula

00-2255-054-00

Perc. Centering Bushing

00-2255-058-00

Per. Locking Bolt

22

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

M/DN Instruments
Option B (Metal Femoral/Tibial/Humeral/Retrograde)

Retrograde Femoral Instruments (base of case holds the

following)

Set Number 00-2255-000-18 (includes case/tray/lid + instruments)

Case Set Number 00-2237-068-00 (includes trays and lid)

Prod. No.

Description

00-2241-001-00

Retro. Targ. Guide Assembly (4 pcs.)

Metal Femoral Guides/Instruments (top tray holds the

following)

00-2241-001-01

Adj. Targ. Arm Assembly (5 pcs.)

00-2241-006-00

Cortical Nut Screwdriver

Prod. No.

Description

00-2241-008-37

3.7mm Drill Bushing

00-2255-001-03

Locking Bolt Assembly

00-2241-008-50

5.0mm Drill Bushing

00-2255-002-10

Fem. Prox. Targeting Guide

00-2258-067-00

ITST Threaded Guide Pin 355mm

00-2255-002-11

Fem. Prox. Targeting Guide

00-2255-001-00

Locking Bolt

00-2255-004-32

3.2mm Pin Bushing

00-2255-004-80

8.0mm Screw Bushing

00-2255-004-50

5.0mm Drill Bushing

00-2255-028-00

Pin Wrench

00-2255-004-80

8.0mm Screw Bushing

00-2255-031-37

3.7mm Drill

00-2255-011-00

Recon Screw Counterbore

00-2255-035-50

5.0mm Drill, Large

00-2258-067-00

ITST Threaded Guide Pin 355mm

00-2255-059-00

Pin Wrench

Nail Cap Inserter

(captured screwdriver)

00-2255-028-00
00-2255-035-50

5.0mm Femoral Drill, Large

Plastic Tibial/Humeral Instruments (middle tray holds the

following)
Prod. No.

Description

00-2255-001-00

Locking Bolt

00-2255-003-00

Tibial Proximal Targeting Guide

00-2255-003-01

Tibial Oblique Hole Adapter

00-2255-003-03

Set Screw

00-2255-004-00

Humeral Proximal Targeting Guide

00-2255-004-01

Humeral Oblique Hole Adapter

00-2255-036-37

Tib./Hum. 3.7mm Drill Bushing

00-2255-036-80

Tib./Hum. 8.0mm Screw Bushing

00-2255-028-00

Pin Wrench

00-2255-032-37

Tib./Hum. 3.7mm Drill

23

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

General Instrument Set

General Instruments (base of case holds the following)

Set Number 00-2255-000-16 (includes case/tray/lid + instruments)

Case Set Number 00-2237-095-00 (includes trays and lid)

Prod. No.

Description

00-2255-009-00

Slaphammer

General Instruments (top tray holds the following)

00-2255-028-00

Pin Wrench

Prod. No.

Description

00-2237-065-00

Threaded Extractor (17cm)

00-2237-053-00

Wire Grip T-Handle

00-2237-065-01

Threaded Extractor (32cm)

3.2mm Trocar

00-2237-061-00

Long T-Handle Cannulated Awl

00-2255-012-33

00-2237-066-00

Short T-Handle Cannulated Awl

00-2255-012-37

3.7mm Trocar

5.0mm Trocar

00-2255-016-00

7mm Angled Femoral Awl*

00-2255-012-50

00-2255-034-00

Reduction Finger

00-2255-033-32

3.2mm Drill

00-2255-052-00

9mm/14mm Perc. Tapered Reamer

00-2255-033-37

3.7mm Drill

5.0mm Drill

00-2255-060-00

8mm Trochanteric Reamer

00-2255-033-50

00-2258-067-00

ITST Threaded Guide Pin 355mm

00-2255-018-00

Distal Screw Depth Gauge

Distal Screwdriver 3.5mm Hex

00-2255-038-00

T-Handle

00-2255-013-01

00-4816-060-00

Ball-Spiked Pusher

00-2255-015-03

Wand Handle

00-4817-011-00

Shoulder Hook

00-2255-015-01

Wand Insert

00-2255-015-02

Wand Set Screw

General Instruments (middle tray holds the following)

Prod. No.

Description

00-2228-097-00

Diameter Gauge

The 7mm Straight Awl (00-2237-001-07) OR the

7mm Angled Femoral Awl (00-2255-016-00) will
fit in the case. However, when you order the set
number (00-2255-000-16), you will get the Angled Awl.

00-2237-055-00

Ruler

See Sales representative for optional instruments.

00-2255-057-00

Flexible Reamer Extension

00-2305-024-00

Screwdriver, Small Hexhead

00-2237-060-00

Slotted Mallet

00-2237-062-00

Threaded Driver

00-2237-063-00

Screw Depth Gauge, Long

00-2255-013-00

Screwdriver 3.5mm Hex, Long

00-2255-017-00

Flared Exchange Tube

00-2237-064-00

Nail Length Gauge

00-2258-057-00

Cannulated Depth Gauge

24

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Pressure Sentinel Intramedullary Reaming System

Order Information
Prod.No.

00-2228-000-00
Pressure Sentinel Reamer Full Set
Includes the following instruments & case:

Description

00-2228-005-00

5.0mm Flexible Reamer

00-2218-000-00
Long Pressure Sentinel Reamers

Tray/Case/Lid
Includes the following instruments & case:

00-2228-005-05

5.5mm Flexible Reamer

00-2228-006-00

6.0mm Flexible Reamer

00-2218-008-00

8.0mm Long Flexible PS Reamer

00-2228-006-05

6.5mm Flexible Reamer

00-2218-008-05

8.5mm Long Flexible PS Reamer

00-2228-007-00

7.0mm Flexible Reamer

00-2218-009-00

9.0mm Long Flexible PS Reamer

00-2228-007-05

7.5mm Flexible Reamer

00-2218-009-05

9.5mm Long Flexible PS Reamer

00-2228-008-00

8.0mm Flexible Reamer

00-2218-010-00

10.0mm Long Flexible PS Reamer

00-2228-008-05

8.5mm Flexible Reamer

00-2218-010-05

10.5mm Long Flexible PS Reamer

00-2228-009-00

9.0mm Flexible Reamer

00-2218-011-00

11.0mm Long Flexible PS Reamer

00-2228-009-05

9.5mm Flexible Reamer

00-2218-011-05

11.5mm Long Flexible PS Reamer

00-2228-010-00

10.0mm Flexible Reamer

00-2218-012-00

12.0mm Long Flexible PS Reamer

00-2228-010-05

10.5mm Flexible Reamer

00-2218-012-05

12.5mm Long Flexible PS Reamer

00-2228-011-00

11.0mm Flexible Reamer

00-2218-013-00

13.0mm Long Flexible PS Reamer

00-2228-011-05

11.5mm Flexible Reamer

00-2218-013-05

13.5mm Long Flexible PS Reamer

00-2228-012-00

12.0mm Flexible Reamer

00-2218-014-00

14.0mm Long Flexible PS Reamer

00-2228-012-05

12.5mm Flexible Reamer

00-2218-014-05

14.5mm Long Flexible PS Reamer

00-2228-013-00

13.0mm Flexible Reamer

00-2218-015-00

15.0mm Long Flexible PS Reamer

00-2228-013-05

13.5mm Flexible Reamer

00-2218-015-05

15.5mm Long Flexible PS Reamer

00-2228-014-00

14.0mm Flexible Reamer

00-2218-016-00

16.0mm Long Flexible PS Reamer

00-2228-014-05

14.5mm Flexible Reamer

00-2218-016-05

16.5mm Long Flexible PS Reamer

00-2228-015-00

15.0mm Flexible Reamer

00-2218-017-00

17.0mm Long Flexible PS Reamer

00-2228-015-05

15.5mm Flexible Reamer

00-2218-017-05

17.5mm Long Flexible PS Reamer

00-2228-016-00

16.0mm Flexible Reamer

00-2218-018-00

18.0mm Long Flexible PS Reamer

00-2228-016-05

16.5mm Flexible Reamer

00-2228-030-00

T-Handle Extractor

00-2228-017-00

17.0mm Flexible Reamer

00-2228-097-00

Diameter Gauge

00-2228-017-05

17.5mm Flexible Reamer

00-5044-012-00

Adapter 3 Jaw Chuck

00-2228-018-00

18.0mm Flexible Reamer

00-2228-098-10

Soak Tray

00-2228-018-05

18.5mm Flexible Reamer

00-2218-025-00

Long Cleaning Brush

00-2228-019-00

19.0mm Flexible Reamer

00-2218-030-00

Torque Limiter

00-2228-019-05

19.5mm Flexible Reamer

00-2237-075-00

Long Reamer/Instrument
Case Assembly

00-2228-020-00

20.0mm Flexible Reamer

00-2228-020-05

20.5mm Flexible Reamer

00-2237-076-00

Long Reamer/Instrument Case Base

00-2228-021-00

21.0mm Flexible Reamer

00-2237-077-00

Long Reamer/Instrument Case Lid

00-2228-021-05

21.5mm Flexible Reamer

00-2237-078-00

Long Reamer/Instrument Top Tray

(8mm-13.5mm)

00-2228-022-00

22.0mm Flexible Reamer

00-2237-079-00

Long Reamer/Instrument Middle Tray

00-2228-030-00

T-Handle Extractor

00-2228-097-00

Diameter Gauge

00-2228-098-00

Soak Tray

00-5044-012-00

1/4in. Jacobs Chuck to Zimmer

Adapter, Qty=2

00-2228-090-00

Sterilization Case

25

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

Optional Reamer Sizes

Prod.No.

Description

00-2228-022-05

22.5mm Flexible Reamer

00-2228-023-00

23.0mm Flexible Reamer

00-2228-023-05

23.5mm Flexible Reamer

00-2228-024-01

24.0mm Flexible Reamer

00-2228-024-05

24.5mm Flexible Reamer

00-2228-025-01

25.0mm Flexible Reamer

00-2228-025-05

25.5mm Flexible Reamer

00-2228-026-01

26.0mm Flexible Reamer

00-2228-026-05

26.5mm Flexible Reamer

00-2228-027-01

27.0mm Flexible Reamer

Pressure Sentinel Sets

Prod. No.

Description

00-2228-000-01
Pressure Sentinel Reamer Trauma Set
Includes the following instruments & case:
5.0mm, 6.0mm, 7.0mm & 8.00mm-17.5mm
Flexible Reamers in .5mm increments (1ea.)
00-2228 -030-00

T-Handle Extractor

00-5044-012-00

1/4in. Jacobs Chuck to Zimmer

Adapter, Qty=2

00-2228-090-00

Sterilization Case

00-2228-000-02
Pressure Sentinel Reamer Hip Set
Includes the following instruments & case:
8.0mm-18.0mm Flexible reamers in 1mm increments (1ea.)
00-2228-030-00

T-Handle Extractor

00-5044-012-00

1/4in. Jacobs Chuck to Zimmer

Adapter, Qty=1

00-2228-090-00

Sterilization Case

00-2228-000-03
Pressure Sentinel Reamer Expanded

Hip Set
Includes the following instruments & case:
8.0mm-18.0mm Flexible reamers in .5mm increments (1ea.)
00-2228-030-00

T-Handle Extractor

00-5044-012-00

1/4in. Jacobs Chuck to Zimmer

Adapter, Qty=1

00-2228-090-00

Sterilization case

00-2228-90-00
Sterilization Case
Includes the following components:
00-2228-091-00

Base

00-2228-092-00

18.0mm to 22.0mm Reamer Tray

00-2228-093-00

12.0mm to 17.5mm Reamer Tray

00-2228-094-00

5.0mm to 11.5mm Reamer Tray

00-2228-096-00

Case Lid

00-9975-011-00
Pressure Sentinel Reamer ZMR Hip Set
Includes the following components:
8.0mm-27.0mm Flexible reamers in .5mm increments (1ea.)
00-9965-081-10

ZMR Flexible Reamer

Diameter Gauge

00-9975-099-00

Case Lid

00-2228-040-00

ZMR Flexible Reamer Metal Case

* Set includes case and contents without the

00-9975-099-00 Case Lid. The Case Lid must
be ordered separately.
Optional Instruments
Prod. No.

Description

00-2255-008-00

Guide Wire 2.4mm, Ball-Tip,

70cm box (required for 5.0mm-7.5mm
Pressure Sentinel Reamers)

47-2255-008-01

Guide Wire 3.0mm, Ball-Tip, 100cm

Sterile/box (required for 8.0mm and larger
Pressure Sentinel Reamers)

00-2255-008-01

Guide Wire 3.0mm, Ball-Tip, 100cm

Non-sterile/box (required for 8.0mm and
larger Pressure Sentinel Reamers)

26

M/DN Femoral Interlocking & Recon Nail Intramedullary Fixation

This documentation is intended exclusively for physicians and is not intended for laypersons.
Information on the products and procedures contained in this document is of a general nature
and does not represent and does not constitute medical advice or recommendations. Because
this information does not purport to constitute any diagnostic or therapeutic statement with
regard to any individual medical case, each patient must be examined and advised individually,
and this document does not replace the need for such examination and/or advice in whole or
in part. Please refer to the package inserts for important product information, including, but not
limited to, contraindications, warnings, precautions, and adverse effects.

Contact your Zimmer representative or visit us at www.zimmer.com

The CE mark is valid only if it is also printed on the product label.

97-2252-005-01 Rev. 3 1108-T30 9/2/2011 2005, 2010 , 2011 Zimmer, Inc. LL