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VET3D PO Box 6476 CV6 9LZ 01676 534927 [email protected] www.vet3d.co.uk SOP – osteotomy and reduction guide system Deformity correction Please read these notes carefully and contact us immediately if you require any additional information or have any concerns about the printed models or guides supplied. Pre-operative • Unless specified otherwise, two bone models and two guides will be supplied. o Pre-operative bone – translucent yellow plastic – for pre-op / intra-op practice of osteotomy guide fit – this can be autoclaved. o Post-operative bone – white plastic – usually with footprint of reduction guide in-situ – for pre-contouring of plate – autoclaving not recommended. o Osteotomy and reduction guides – biocompatible and autoclavable translucent orange plastic. Recommend autoclave protocols are below, however all standard protocols are acceptable. § 138°C for 3 minutes § 134°C for 6 minutes § 121°C for 15 minutes • Four Ellis pins will be required, and ideally four drill bits of similar or slightly smaller diameter. o The diameter varies according to patient size and will be confirmed following guide design and in this SOP when supplied with the models. • The 3D bone models, and especially the osteotomy and reduction guides, are UV light sensitive and should be stored away from direct sunlight (e.g. in a draw or box). Extended exposure to UV light may reduce the strength of the guides. Intra-operative • A standard surgical exposure of the affected bone is made. o Whenever possible the guide system will be designed to be applied to the most easily accessible aspect of the bone to be corrected, e.g. lateral humerus, medial tibia etc. Positioning of the guide system will be discussed with the surgeon during the planning stage. • Elevate soft tissues to the extent required for the osteotomy guide footprint. o Supra-periosteal exposure is appropriate i.e. as for plate application. o Note that adherent soft tissues of any significant thickness will adversely affect guide fit and should be removed – in juxta-articular locations these might include retinacular and capsular attachments, and in remodelled regions adherent fibrous material. • Identify the position of osteotomy guide fit. o This is usually obvious as the guide becomes stable once it’s footprint matches the cortical contours beneath. o Comparison to the printed bone helps identify the correct position. • Apply the Ellis pins through their channels (Figure 1). o Pre-drilling of the cis-cortex only with a drill bit of the same or slightly smaller diameter than the Ellis pin is recommended. Carefully align the drill bit with any one of the channels such that off-axis pressure on the guide channel (which could move the guide) is avoided. The transparent, cylindrical nature of the channels facilitates alignment. o Ideally after each cis-cortex is drilled the drill bit is left in-situ and a new bit used for the next hole. In this way the position of the guide cannot change, however with careful technique this can be achieved with fewer drill bits. o Each drill bit is removed sequentially and replaced with a bicortical Ellis pin. o If the drill chuck, or later the saw attachment, will contact the end of the previously placed Ellis pin, that pin can be cut leaving about 1cm emerging from the guide channel.

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Page 1: SOP – osteotomy and reduction guide system · SOP – osteotomy and reduction guide system ... Pre -operative ... o Pre-operative bone – translucent yellow plastic – for pre-op

Vet3D_Letterhead.indd 1 21/02/2017 10:50

VET3DPO Box 6476CV6 9LZ

01676 534927 [email protected] www.vet3d.co.uk

Vet3D_Letterhead.indd 1 21/02/2017 10:50

SOP–osteotomyandreductionguidesystem

Deformitycorrection

Pleasereadthesenotescarefullyandcontactusimmediatelyifyourequireanyadditionalinformationorhaveanyconcernsabouttheprintedmodelsorguidessupplied.

Pre-operative

• Unlessspecifiedotherwise,twobonemodelsandtwoguideswillbesupplied.o Pre-operativebone–translucentyellowplastic–forpre-op/intra-oppracticeofosteotomyguidefit–this

canbeautoclaved.o Post-operativebone–whiteplastic–usuallywithfootprintofreductionguidein-situ–forpre-contouringof

plate–autoclavingnotrecommended.o Osteotomyandreductionguides–biocompatibleandautoclavabletranslucentorangeplastic.Recommend

autoclaveprotocolsarebelow,howeverallstandardprotocolsareacceptable.§ 138°Cfor3minutes§ 134°Cfor6minutes§ 121°Cfor15minutes

• FourEllispinswillberequired, and ideally four drill bits of similar or slightly smaller diameter.o ThediametervariesaccordingtopatientsizeandwillbeconfirmedfollowingguidedesignandinthisSOP

whensuppliedwiththemodels.• The3Dbonemodels,andespeciallytheosteotomyandreductionguides,areUVlightsensitiveandshould

bestoredawayfromdirectsunlight(e.g.inadraworbox).ExtendedexposuretoUVlightmayreducethe strengthoftheguides.

Intra-operative

• Astandardsurgicalexposureoftheaffectedboneismade.o Wheneverpossibletheguidesystemwillbedesignedtobeappliedtothemosteasilyaccessibleaspectof the

bonetobecorrected,e.g.lateralhumerus,medialtibiaetc.Positioningoftheguidesystemwillbe discussed withthesurgeonduringtheplanningstage.

• Elevatesofttissuestotheextentrequiredfortheosteotomyguidefootprint.o Supra-periostealexposureisappropriatei.e.asforplateapplication.o Note that adherent soft tissues of any significant thickness will adversely affect guide fit and

should be removed – in juxta-articular locations these might include retinacular and capsularattachments, and in remodelledregionsadherentfibrousmaterial.

• Identifythepositionofosteotomyguidefit.o Thisisusuallyobviousastheguidebecomesstableonceit’sfootprintmatchesthecorticalcontoursbeneath.o Comparisontotheprintedbonehelpsidentifythecorrectposition.

• ApplytheEllispinsthroughtheirchannels(Figure1).o Pre-drillingofthecis-cortexonlywithadrillbitofthesameorslightlysmallerdiameterthantheEllispin

is recommended. Carefully align the drill bit with any one of the channels such that off-axis pressureon the guide channel (which couldmove the guide) is avoided. The transparent, cylindrical natureof thechannels facilitatesalignment.

o Ideallyaftereachcis-cortexisdrilledthedrillbitisleftin-situandanewbitusedforthenexthole.Inthisway thepositionoftheguidecannotchange,howeverwithcarefultechniquethiscanbeachievedwithfewerdrill bits.

o EachdrillbitisremovedsequentiallyandreplacedwithabicorticalEllispin.o If the drill chuck, or later the saw attachment, will contact the end of the previously placed Ellis pin,

that pin can be cut leaving about 1cm emergingfromtheguidechannel.

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• Cuttheconnectingbarsbetweentheosteotomyguideplanes(Figure2).o Cuttheconnectingbarsflushwiththeosteotomyguideplanesurfacesusinganoscillatingsawbladeheld

parallelto,andincontactwith,eachplane.o Althoughtheguidematerialisbiocompatible,amoistswabcanbeplacedbetweenthebarsandtheboneto

catchdebris,andtheareathenlavaged.• Maketheosteotomy/osteotomies(Figure3).

o Ensuretheoscillatingsawbladeremainsparallelto,andincontactwith,eachplane.o OccasionallytheguidemayrideuptheEllispinsduetocontactwiththeblade–aboneclampormanual

pressurewillpreventthis.o It isoftenhelpfultochangetheangleofattackofthebladeoncetheosteotomyhasbeenstarted.This is

sometimesnecessarytoavoidcontactbetweenthesawandthetopoftheguideplane.• Removebothendsoftheosteotomyguide(Figure4).

o TheseshouldslideofftheEllispins.• Placethereductionguide(Figure5).

o ThiswillalignallfourEllispinsinparallel,and,whencontactingthecortexproximallyanddistally,resultsinoptimalre-orientationoftheproximalanddistalbonesegmentsaspre-planned.

o Notethatforclosingwedgeosteotomiestheguidemaybindduetofrictionbetweentheosteotomysurfacesif thesearepoorlyaligned. It isveryhelpful tomanuallyreducethebonesegmentswithall fourEllispinsparallelandtheosteotomysurfacesappropriatelyreducedbeforeslidingthereductionguidedowntheEllispins.

o FulllengthEllispinsarenotnecessary–itiseasiertoslidetheguideifthesehavebeenshortened.Sterilelubricatingjellyappliedtothepinscanalsomakeiteasiertoplacetheguide.

o Contactbetweentheguidebaseandthecortexproximallyanddistallyisnecessaryforplannedalignment–ifrequirednon-pointedreductionforcepscanbeusedtopushtheguideontothebone.

o Pleasenotethereductionguideisdesignedtobeasstrongaspossiblewithinthesizelimitationsimposedbypatientsize,but isnot indestructible.Avoidtheuseofexcessiveforceorapplicationofpoint loading(e.g.pointedreductionforceps)–largeforcesshouldnotbenecessaryiftheaboveguidelinesarefollowed.

• Applytheprecontouredplate(Figure6).o Thiswillbeappliedadjacenttothereductionguide.o CheckthattheEllispinsdonotimpedeplannedscrewpilotholes.Shouldthisoccurpilotholesforcortical

screwscanusuallybeslightlyangled;forlockingscrewsremovaloftheEllispinoncesufficientotherscrewshavebeenplacedisnecessary.

o DonotattempttocompresstheosteotomywiththereductionguideattachedwithallfourEllispinsasthiswillproducestressatthepin/boneinterface.Ifyouwishtocompresstheosteotomytheplateshouldbeappliedsecurelywithatleasttwoscrewseitherproximallyordistally.Ascrewisplacedattheotherendoftheplateinaloadedpositioned,incontactwiththeplatebutnottightened.OnepairofEllispinsisremoved(from either end), and the screw tightened. Obviously undesired relative movement of the osteotomysegmentsispossiblebutunusualunlessplatecontouringisinaccurate.Lightlyappliedbone-holdingforcepsbetween the reduction guide and bone can help maintain alignment but still permit slight compressivemovementofthebones.

• RemovethereductionguideandEllispins.o Asecondplatecanbeappliedinthevacatedspaceifnecessary.

Post-operative

• Weactivelyencouragefeedback–pleaseletusknowyourthoughts.

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Vet3D_Letterhead.indd 1 21/02/2017 10:50

Figure1–Theosteotomyguidehasbeenappliedtothe

deformedboneandstabilisedwithfourEllispins

Figure2-Oscillatingsawplaneorientation(paralleltoandincontact

withtheosteotomyguideplane)duringconnectingbarcuttingandthe

osteotomy

Page 4: SOP – osteotomy and reduction guide system · SOP – osteotomy and reduction guide system ... Pre -operative ... o Pre-operative bone – translucent yellow plastic – for pre-op

Vet3D_Letterhead.indd 1 21/02/2017 10:50

Figure3a–theosteotomieshavebeencompletedparallel

totheguideplanes

Page 5: SOP – osteotomy and reduction guide system · SOP – osteotomy and reduction guide system ... Pre -operative ... o Pre-operative bone – translucent yellow plastic – for pre-op

Vet3D_Letterhead.indd 1 21/02/2017 10:50

Figure3b–theosteotomieshavebeencompletedparallel

totheguideplanes

Figure4–thetwoendsoftheosteotomyguidehave

beenremoved

Page 6: SOP – osteotomy and reduction guide system · SOP – osteotomy and reduction guide system ... Pre -operative ... o Pre-operative bone – translucent yellow plastic – for pre-op

Vet3D_Letterhead.indd 1 21/02/2017 10:50

Figure5–thereductionguidehasbeenslidalongtheEllispinsaligningthe

proximalanddistalbonesegmentsasplanned.Reductionismaintainedfor

plateplacement

Figure6–theprecontouredplateisappliedadjacenttothereductiongeode.Theguideandpinsarethen

removed.


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