T2 Alpha ™

Tibia Nailing System

Operative technique
T2 Alpha
T2 Alpha Tibia Nailing System,
IMN Screws System and IMN Instruments System
Contents
Indications and contraindications . . . . . . . . . . . . 3 Reaming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

MRI safety information . . . . . . . . . . . . . . . . . . . . 4 Nail selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Additional information . . . . . . . . . . . . . . . . . . . . . 5 Nail insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Infrapatellar approach Guided proximal locking mode . . . . . . . . . . . . . . 27

• Patient positioning . . . . . . . . . . . . . . . . . . . . . 8
• Entry point . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Static locking mode . . . . . . . . . . . . . . . . . . . . . . . 30
• Opening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Internal apposition/compression mode. . . . . . . . 33
Suprapatellar approach External apposition/compression mode . . . . . . . 34
• Patient positioning . . . . . . . . . . . . . . . . . . . . . 12
• Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Guided distal locking. . . . . . . . . . . . . . . . . . . . . . 35
• Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
• Sleeve insertion technique . . . . . . . . . . . . . . . 16 Freehand distal locking. . . . . . . . . . . . . . . . . . . . 44
• Entry point . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Advanced locking screws. . . . . . . . . . . . . . . . . . . 46
• Opening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
• Reamed technique . . . . . . . . . . . . . . . . . . . . . 20 End cap insertion. . . . . . . . . . . . . . . . . . . . . . . . . 49
Guide wire insertion . . . . . . . . . . . . . . . . . . . . . . 21 Nail removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

This publication sets forth detailed recommended Please remember that the compatibility of different
procedures for using Stryker devices and instruments. product systems has not been tested unless specified
It offers guidance that you should heed, but, as with in the product labeling.
any such technical guide, each surgeon must consider See package insert (Instructions for Use) (L22000035,
the particular needs of each patient and make L22000044, L22000045, L22000007) for a complete
appropriate adjustments when and as required. list of potential adverse effects, contraindications,
A workshop training is recommended prior to warnings and precautions.
performing your first surgery. All nonsterile devices The surgeon must discuss all relevant risks including
must be cleaned and sterilized before use. the finite lifetime of the device with the patient
when necessary.
Follow the instructions provided in our cleaning
and sterilization guide (OT-RG-1). Multi-component
instruments must be disassembled for cleaning. CAUTION
Please refer to the corresponding assembly/
Use instruments/implants only as described
disassembly instructions.
in this operative technique to avoid damage
to instruments/implants, bone or soft tissue.

The terms 'all Stryker IM Nailing Systems' / 'all titanium-made Stryker

IM Nailing Systems' (described in IFU L22000035 and L22000045) are
defined as T2 Alpha Femur Antegrade GT/PF Nailing System and T2
Alpha Tibia Nailing System.
2
Indications and
contraindications
This document applies to the devices of the Contraindications
T2 Alpha Tibia Nailing System, IMN Screws
The physician’s education, training and professional
System and IMN Instruments System. judgement must be relied upon to choose the most
T2 Alpha Tibia Nailing System appropriate device and treatment. Conditions
presenting an increased risk of failure include:
Intended use
• Any active or suspected latent infection or
The T2 Alpha Tibia Nailing System is intended
marked local inflammation in or about the
for temporary stabilization of bone segments
affected area
or fragments until bone consolidation has been
achieved. • Compromised vascularity that would inhibit
adequate blood supply to the fracture or the
Indications for Use operative site
(United States and Canada)
• Bone stock compromised by disease, infection
The indications for use of this internal fixation or prior implantation that can not provide
device include: adequate support and / or fixation of the devices
• Open and closed tibia fractures • Material sensitivity, documented or suspected
• Pseudarthrosis and correction osteotomy
• Obesity. An overweight or obese patient can
• Pathologic fractures, impending pathologic produce loads on the implant that can lead to
fractures, and tumor resections failure of the fixation of the device or to failure
of the device itself
• Nonunion and malunion
• Fractures involving osteopenic and osteoporotic • Patients having inadequate tissue
bone coverage over the operative site
• Implant utilization that would interfere with
The End Cap Lower Extremity and the Nail
anatomical structures or physiological
Holding Screw Tibia / Femur PF may also be used
performance
in conjunction with the T2 Alpha Femur Antegrade
GT/PF Nailing System. • Any mental or neuromuscular disorder which
would create an unacceptable risk of fixation
Indications for Use failure or complications in post-operative care
(Europe and other countries)
• Other medical or surgical conditions which
The indications for use of this internal fixation
would preclude the potential benefit of surgery
device include:
• Open and closed tibial fractures IMN Screws System

• Nonunion and malunion

Intended use
The IMN Screws System is intended to stabilize the
The End Cap Lower Extremity and the Nail intramedullary nail-bone construct for temporary
Holding Screw Tibia / Femur PF may also be used stabilization.
in conjunction with the T2 Alpha Femur Antegrade
GT/PF Nailing System. IMN Instruments System
Intended use
The IMN Instruments System is intended to enable
the implantation and extraction of intramedullary
nail and screw.
3
MRI Safety Information

T2 Alpha Tibia Nailing System (9-15mm nails)

Non-clinical testing has demonstrated that the T2 Alpha Tibia Nailing System and IMN Screws System
are MR Conditional. A patient with this device can be safely scanned in an MR system meeting the
following conditions:
• Static magnetic field of 1.5 T or 3.0 T
• Maximum spatial field gradient of 3,000 gauss/cm (30 T/m)
• Maximum MR system reported, whole body averaged specific absorption rate (SAR) of 2 W/kg
(Normal Operating Mode)
Under the scan conditions defined above, the T2 Alpha Tibia Nailing Sy IMN Screws System are
expected to produce a maximum temperature rise of less tha fter 15 minutes of continuous scanning.
In non-clinical testing, the image artifact caused by the device extends approximately 27mm from the
T2 Alpha Tibia Nailing System and IMN Screws System whe- imaged with a spin echo or gradient echo
pulse sequence and a 3.0 T MRI system.

T2 Alpha Tibia Nailing System (8mm nails)

Non-clinical testing has demonstrated that the T2 Alpha Tibia Nailing System and IMN Screws System
are MR Conditional. A patient with this device can be safely scanned in an MR system meeting the
following conditions:
• Static magnetic field of 1.5 T or 3.0 T
• Maximum spatial field gradient of 3,000 gauss/cm (30 T/m)
• Maximum MR system reported, whole body averaged specific absorption rate (SAR) of 2 W/kg (Normal
Operating Mode)
• Scan time restriction: maximum 6 minutes of continuous scanning
Under the scan conditions defined above, the T2 Alpha Tibia Nailing System and IMN Screws System
are expected to produce a maximum temperature rise of less than 6.0 C after 6 minutes of continuous
scanning.
In non-clinical testing, the image artifact caused by the device extends approximately 27mm from the
T2 Alpha Tibia Nailing System and IMN Screws System when imaged with a spin echo or gradient echo
pulse sequence and a 3.0 T MRI system.

CAUTION
The MRI safety information provided
is based on testing which did not include supplementary devices. If there are
supplementary devices (i.e. plates, screws, wires, etc.) present in proximity to the T2
Alpha Tibia Nailing System and IMN Screws System, this could result in additional MRI
effects and the information provided above may not apply.

4
 0mm
A   /  P slope 10º

Additional Information 12
19
27
Compression
Slot
Range**
34
46
T2 Alpha Tibia Nail
Herzog Bend, 10 °
• Nail diameters 50mm
Ø8mm – Ø15mm* 
• Nail length
240mm – 420mm in 15mm increments

• Compression Screw Tibia**

• End Cap Lower Extremity and End Caps Tibia

Lower +5mm +10mm +15mm +20mm +25mm

Extremity (Ø11.5mm) (Ø11.5mm) (Ø11.5mm) (Ø11.5mm) (Ø11.5mm)
(Ø8mm)

IMN Screws
• Locking Screw
Ø5mm, 25mm –120mm
04mm, 20mm - 60mm for 8mm nails (distal screws only)
20mm - 60mm in 2.5mm increments
60mm - 120mm in 5mm increments

• Advanced Locking Screw

Ø5mm, 30mm – 100mm
04mm, 27 .5mm - 60mm for 8mm nails (distal screws only)
Distal Bend, 4°
27 .5mm - 60mm in 2.5mm increments 64mm
60mm - 100mm in 5mm increments

Drills
4.2mm - green 21
5.5mm - green (counterbore drill) 13

5
3.5mm - orange 0mm
4.5mm - orange (counterbore drill)
* Check with local representative regarding availability of implant sizes.
** Compression range Note: Screw length is measured from top of head to tip
Note: The suprapatellar instrumentation can only be used with nails with a
Total length of slot 12mm diameter of up to 13mm
Less screw diameter 5mm Note: 8mm nails require 4mm IMN Locking Screws or 4mm IMN Advanced
5 Locking Screws for distal locking. 5
Max movement of screw 7mm
Additional Information
Packaging

The implants in the T2 Alpha

Tibia Nailing and IMN Screws
Systems include packaging that
minimizes user contact with the
implant prior to implantation.
After the pouch is opened, all
implants include a sheath that is
introduced into the sterile field.
Example 1: Nail is removed
from pouch, sheath is opened
and attached to the targeting
arm (fig. 1, 2, 3).
Fig. 1

Fig. 2

Fig. 3

6
Additional Information
Packaging

Example 2: After removal from

pouch, screw (fig. 4, 5) or other
implant (fig. 6, 7) is attached to
the corresponding screwdriver.

Fig. 4

Fig. 5

Fig. 6

Fig. 7
7
Operative technique
Infrapatellar approach

Patient positioning
and reduction
There are two options for patient
positioning.
1. The patient is placed in the
supine position on a radiolucent
table and the knee of the injured
leg is flexed.
2. The patient is placed in the
supine position on a radiolucent
fracture table and the leg is
hyperflexed on the table with
the aid of a leg holder (fig. 8).
Fig. 8
The knee is flexed to >90°.
A triangle may be used under the
knee to accommodate flexion
intra-operatively. It is important
that the knee rest is placed under
the posterior aspect of the lower
thigh in order to reduce the risk
of vascular compression and of
pushing the proximal fragment
of the tibia anteriorly.
Anatomical reduction can be
achieved by internal or external
rotation of the fracture and by
traction, adduction or abduction,
and must be confirmed under
image intensification. Draping
Fig. 9
must leave the knee and the
distal end of the leg exposed.

Incision
Based on radiological image, at the junction of the medial
a paratendenous incision is made third, and lateral two-thirds
from the patella extending down of the patellar ligament. This
approximately 1.5 – 4cm determines the entry point (fig. 9).
in preparation for nail insertion.
The patellar tendon may be
retracted laterally or split

8
Operative technique
Infrapatellar approach

Entry point
The medullary canal is opened
through a superolateral plateau
entry portal. The center point
of the portal is located slightly
medial to the lateral tibia spine
as visualized on the A / P
radiograph and immediately
adjacent and anterior to the
anterior articular margin as
visualized on the true lateral
radiograph. It is located lateral
to the midline of the tibia by an
average of 6 percent of the tibia
plateau width.
Radiographic confirmation of this
area is essential to prevent damage
to the intra-articular structure
during portal placement and nail
Fig. 10
insertion (fig. 10, 11).

Fig. 11

9
Operative technique
Infrapatellar approach

Opening Opening
Trocar
The opening should be directed
with a central orientation in
relation to the medullary canal.
Insert the 3x285mm K-wire at
the identified entry point and
into the medullary canal.
Assemble the Opening Reamer
Handle and Opening Reamer
Sleeve, 11.5, and together with Opening
the Opening Trocar, 11.5 (fig. 12), Reamer Sleeve
Opening
guide the assembly over the Reamer
K-wire until the Opening Trocar Handle
is fully seated on the bone. It is
recommended to orient the sleeve
so that the convex tips are Fig. 12
positioned anteriorly/posteriorly
and the concave ends are
positioned medially/laterally.
If the initial K-wire is not
optimally positioned, the off-
center holes of the Opening
Trocar can be used to correct the
entry point by inserting a second
K-wire. To utilize, rotate the
trocar into the desired position
and place a second K-wire
through one of the off-center
holes. The distance from the
center hole is 4mm (fig. 13). Once
the second K-wire is positioned
as desired, remove the initial
K-wire and the Opening Trocar.

As an alternative to the
standard 3x285mm K-wire,
the 3x285mm Fixation K-wire Fig. 13
can be utilized as an entry 4mm
point guide wire. 4mm

10
Operative technique
Infrapatellar approach

If more than 4mm of

correction is required, 8mm of
correction can be achieved by
removing the sleeve and trocar
assembly from the initial K-wire
and reinserting the assembly
over the K-wire through one of
the off-center holes of the trocar.
Then insert a second K-wire
through the remaining off-center
hole. Once the second K-wire is
positioned as desired, remove the
initial K-wire and trocar.
After verifying that the Opening
Reamer Sleeve is fully seated on
the bone, advance the Opening
Reamer on power and ream over
the K-wire through the Opening
Reamer Sleeve to open the
medullary canal (fig. 14a). If hand
reaming is preferred, attach the
Opening Reamer to the Quick- Fig. 14a Fig. 14b
Lock Delta Handle and rotate the
reamer assembly. Remove the
K-wire.
As an alternative, the cortex can CAUTION
be opened with the Curved Awl Verify correct entry point Do not touch sharp edges of
(fig. 14b). If the Curved Awl is prior to opening the cortex. drill bits, reamer heads and
used, the Opening Reamer or cutting tools with surgical
Bixcut Reamer must be utilized CAUTION gloves. Take care when
to widen the entry portal. The Opening Reamer is handling sharp edges of
If using the Bixcut Reamer, a front and side cutting packaging and instruments.
ensure that the diameter of the instrument and should be
selected reamer is at least as used with care to ensure that
large as the diameter of the the sharp edges of the
proximal end of the nail. The reamer do not inadvertently
proximal diameter of the 9-11mm damage bone or soft tissue.
nails is 11.5mm; nail sizes 12- Use of the Opening Reamer
15mm have a constant diameter. Sleeve is recommended.
Ream far enough to accommodate
the proximal section of the nail.
Use X-ray to confirm depth.

11
Operative technique
Suprapatellar approach

Patient positioning
options and reduction
The patient is placed in the supine
position on a radiolucent table and
the leg is flexed approximately 15°.
To create this necessary flexion in
the knee, a cushion can be placed
underneath the tibia to create the Fig. 15a

appropriate angle (fig. 15a).

This positioning elevates the

fractured tibia out of the same
plane as the opposite tibia,
allowing for easier lateral X-ray
imaging. In addition, it provides
support under the fractured tibia
throughout the procedure.

Alternatively, a triangle or other

“bumps” may be placed under the
posterior aspect of the lower thigh
to accommodate flexion intra-
operatively (fig 15b).

Fig. 15b
Increasing the knee flexion
may limit the available space
within the joint and the
opportunity to maneuver
the sleeves during insertion.

Anatomical reduction can be

achieved by internal or external
rotation of the fracture and by
traction, adduction or abduction,
and must be confirmed under
image intensification. Draping
must leave the knee and the
distal end of the leg exposed.

12
Operative technique
Suprapatellar approach

Incision
A longitudinal incision is made
directly proximal to the patella,
measuring approximately 2-3cm
(fig. 16).
Then, a longitudinal split of the
quadriceps tendon is performed
along its midline.

CAUTION
Surgeons must evaluate
the available joint space.
Switching to a parapatellar
approach is recommended if
space within the joint is too Fig. 16
limited to permit smooth
sleeve insertion.

13
Operative technique
Suprapatellar approach
Trigger Modular Handle

Assembly: Modular Handle

and Drill Sleeve
Assemble the Modular Handle
(fig. 17a) by inserting the Fig. 17a
magnetically activated trigger.

Connect the appropriate Drill

Sleeve to the modular handle
by inserting the Drill Sleeve into
the ring of the modular handle
(fig. 17b). The trigger of the handle
can be pulled back to assemble or
disassemble the Drill Sleeve.

It is recommended to visibly
inspect the Drill Sleeve
Fig. 17b
before use, as it may become
damaged over time.
Drill Sleeve

The Drill Sleeve can be

engaged on the modular
handle every 90 degrees
to suit surgeon preference.

CAUTION
Due to the sleeve sizes the
suprapatellar approach can
only be performed with T2
Alpha Tibial Nails up to a
diameter of 13mm.
Fig. 17c

Final position of
assembled
Modular Handle
and Drill Sleeve.

The Modular Handle, Drill Sleeves, Trocars, Plug and Elastic Nail Insertion Sleeves are existing components
of the T2 System.
14
Operative technique
Suprapatellar approach

Sleeve insertion technique

The Elastic Nail Insertion Sleeve
is single-use only. All sleeves
and trocars are offered in two
different sizes: Ø8-11 and Ø8-13.
The Ø8-11 sleeves and trocars can
be used with the T2 Alpha Tibial
Nails up to a diameter of 11mm
and the Ø8-13 sleeves and trocars
can be used with the T2 Alpha
Tibial Nails up to a diameter of
13mm. Only sleeves and trocars of
corresponding sizes can be used
together.

Assemble the appropriate Drill

Sleeve, Reamer Sleeve, Elastic Nail
Insertion Sleeve, Trocar and Plug
(fig. 18)

Fig. 18

15
Operative technique
Suprapatellar approach

Sleeve insertion technique

Make sure that the Elastic Nail
Insertion Sleeves are correctly
aligned with the Drill Sleeve.
When the sleeves are correctly
aligned, there will be no gap
(fig. 19) between the interface of Fig. 19
the two sleeves.
Then, advance the corresponding
trocar and plug into the Drill
Sleeve until it is locked.

During the sleeve insertion

procedure, ensure the off-
center hole of the trocar
is lateral or medial to the
center hole in order to
facilitate smooth insertion.
Be sure to maintain this
position until the trocar
tip sits on the tibia plateau,
at which point the trocar
can then be rotated again
as desired.
The plug is not fixed in the
trocar. Therefore, the
surgeon should press the
plug with his or her palm
during insertion of the
assembly.

16
Operative technique
Suprapatellar approach

Sleeve insertion technique

Guided by the femoral condyles,
insert the entity comprised of
the Elastic Nail Insertion Sleeve,
Drill Sleeve, Trocar and Plug into
the patellofemoral joint until the
tip of the Trocar sits on the tibia
plateau (fig. 20a). Ensure that the
handle is positioned so that the
K-wire slots in the Elastic Nail
Insertion Sleeve are positioned
in the frontal plane during sleeve
insertion. Do not insert the sleeves
Fig. 20a
in any orientation other than what
is pictured in Figures 20a and
20b. Do not insert the sleeves as
exhibited in Figure 20c.

CAUTION
Proceed with caution
to not cause harm to the
patella, intercondylar notch,
and surrounding tissues.

The Plug can be removed

from the Trocar at this time.

Fig. 20b

Fig. 20c

17
Operative technique
Suprapatellar approach

Entry point
The medullary canal is opened In an additional M / L radiograph
through a superolateral plateau (fig. 16), the correct positioning
entry portal. of the entry point in the sagittal
plane should be confirmed.
The center point of the portal
is located slightly medial to the The opening should be directed
lateral tibia spine as visualized on with a central orientation in
the A / P radiograph (fig. 21a) and relation to the medullary canal
immediately adjacent and anterior in both (A / P and M / L) views.
to the anterior articular margin
as visualized on the true lateral
radiograph (fig. 21b). Fig. 21a
Do not use a bent K-wire
The entry point is located lateral for entry point definition.
to the midline of the tibia by an
average of 6 percent of the tibia
plateau width. Radiographic
confirmation of this area is
essential to prevent damage
to the intra-articular structure
during portal placement and
nail insertion.
The off-center hole of the Trocar
can be used either for guide wire Fig. 21b
placement or to correct an initially
misplaced entry point through the
center hole. The distance between
the center and the off-center hole
is 4.5mm.
To utilize the off-center hole,
rotate the Trocar into the desired
position and place either an
initial or second 3x285mm K-wire
through the off-center hole of the
Trocar (fig. 22). If an initial K-wire
was used in the center hole,
remove at this time. Fig. 22

4.5mm

18
Operative technique
Suprapatellar approach

Unlock the Trocar and push

the Drill Sleeve and Elastic Nail
Insertion Sleeve forward until the
sleeve tip lies on the tibia plateau
(fig. 23).
Fixation K-wires
Two 3x285mm fixation K-wires
can be used for fixation of the
sleeves to the tibia plateau.
Insert the K-wires through the
holes in the Drill Sleeve (fig. 24).

Fig. 23

The 3x285mm fixation K-wire

should extend into the tibia
as shown (fig. 24) to allow for Standard
proper fixation. 3x285mm K-wire

3x285mm
Fixation K-wire

Fig. 24

19
Operative technique
Suprapatellar approach

Opening
Remove the Trocar prior to
opening of the tibia. The Opening
Drill Ø12 is used to access the
medullary canal (fig. 25a).

Reamed technique
The Drill Sleeve and the 3x285mm
Fixation K-wires are not removed
prior to reaming. The Elastic Nail
Insertion Sleeve also remains
in place.
Fig. 25a Fig. 25b
The remaining operative steps
for both the infrapatellar and
suprapatellar approach are the
same unless otherwise
indicated. All of the following
pictures are shown using the
infrapatellar approach unless
otherwise indicated.

CAUTION
Use of the suprapatellar
instrumentation decreases
the working length and may
require longer reamer and
guide wire lengths than those
used with the infrapatellar Fig. 26
approach. Please plan
accordingly.

CAUTION
Opening drilling should be
performed through the drill
sleeve with the Elastic Nail
Insertion Sleeve or the Nail
Insertion Sleeve SPI remaining
in place. Advance the opening
drill until it stops.

20
Operative technique Adjustment wheel
Guide wire insertion
Fixation lever
Insert the Ball Tip Guide Wire
3x800mm through the Guide
Wire Handle (fig. 27a). Adjust the
Release lever
handle as desired and lock the
assembly by closing the fixation
lever.
The Guide Wire Handle can
accommodate guide wires and
K-wires with diameters from
1.8mm – 4mm. If necessary,
loosen or tighten the adjustment
wheel to increase or decrease the
diameter of the insertion hole.
Advance the Ball Tip Guide Wire
through the fracture site and
to the desired insertion depth. Fig. 27a
The guide wire should lie in the
center of the metaphysis and
the diaphysis in both the AP and
Lateral views to avoid offset
positioning of nail.
The Reduction Rod and Quick-
Lock Delta Handle Assembly may
be used as a fracture reduction tool
to facilitate guide wire insertion
through the fracture site (fig. 27b).

The ball tip at the end of

the guide wire will stop
Fig. 27b
the reamer head.

Do not use bent guide wires.

CAUTION
Confirm correct position of
Ball Tip Guide Wire prior to
reaming.

21
Operative technique
Reaming

Commence reaming (fig. 28)

in 0.5mm increments until
the desired diameter has been
achieved.
To help maintain the position
of the guide wire during reamer Fig. 29
shaft extraction, press the funnel
tip end of the Guide Wire Pusher
(fig. 29) at the end of the wire
while extracting the reamer from
the medullary canal.
The diameter of the selected
T2 Alpha Tibial Nail should be
1 - 1.5mm smaller than that of
the last reamer used.
Fig. 28
Alternatively, the diameter of the
nail may be determined by using
the X-ray Ruler under fluoroscopy
before or after guide wire
insertion. To determine diameter,
use the ruler at the smallest Fig. 30
diameter of the medullary canal
Image indicates an estimated
(fig. 30). canal/diameter width of 9mm.
If operating via the suprapatellar To ensure proper positioning
approach, remove the fixation of the Guide Wire tip during
K-wires and Drill Sleeve once reaming, the Guide Wire
reaming has been completed. Pusher may be replaced
The Elastic Nail Insertion with any other Stryker
3mm Guide Wire. CAUTION
Sleeve remains in place for nail
insertion. The proximal diameter of the
8mm-11mm diameter nails is
11.5mm. Additional
The smallest diameter
metaphyseal reaming may be
nail available is 8mm.
The diameter of the selected required to facilitate nail
The diaphyseal bone must
T2 Alpha Tibial Nail must be insertion. Nail sizes 12–15mm
be large enough to allow for
at least 1mm - 1.5mm smaller have a constant diameter.
reaming of the medullary
than the last reamer used.
canal up to at least 9mm.

CAUTION Care must be taken to ensure

In the suprapatellar approach,
Excessive heat generation that the entry portal is not
the maximum reaming
during reaming/drilling may extended anteriorly during
diameter for the Ø8-11 Drill
cause soft tissue or bone reaming. This could lead to an
Sleeve is 12.5mm, for the Ø8-13
damage. offset position for the nail and
Drill Sleeve 14.5mm.
a risk of shaft fracture.
22
Operative technique
Nail selection

Determine appropriate nail End of Guide Wire Ruler

is the measurement reference
length by measuring the
remaining length of the Ball Tip
Guide Wire. Remove the Opening
Reamer Sleeve and place the
Guide Wire Ruler through the
Opening Reamer Sleeve (fig.
31a) and on the Ball Tip Guide
Wire and read the correct nail Fig.  31
length at the end of the Ball Tip
Guide Wire on the Guide Wire
Ruler. Ensure that the tip of the
Guide Wire Ruler is fully seated
on the bone (fig. 31b) prior to
determining measurement. If the
Ball Tip Guide Wire is between
two length markings, use of the
shorter nail is recommended.

The end of the guide wire

ruler should align with the
proximal end of the nail once
inserted.

CAUTION CAUTION
If the fracture is suitable Use fluoroscopy to ensure
for apposition / compression that the Ball Tip Guide
the implant selected should Wire and Guide Wire Ruler
be at least 7-12mm shorter are correctly positioned
than measured to help avoid and verify nail length
migration of the nail beyond measurement prior to nail
the insertion site. insertion.

CAUTION
The Guide Wire Ruler is
calibrated for 800mm and
1000mm Guide Wires.

23
Operative technique
Nail insertion

The selected nail is assembled

onto the Nail Adapter Tibia with
the Nail Holding Screw Tibia /
Femur PF (fig. 32a).
If operating via the suprapatellar
approach, the Nail Adapter Tibia
SPI and the Nail Holding Screw
Tibia SPI must be used to as-
semble the nail (fig. 32b).
Pre-tighten the screw to the
nail by hand and then use the
Ball Tip Screwdriver to tighten
the assembly (fig. 33a, 33b).

CAUTION Nail Adapter Tibia and Nail Holding Screw

Tibia / Femur PF is shown and is used with
Nail Adapter Tibia SPI and Nail Holding
Screw Tibia SPI is shown and is used with
the infrapatellar approach. the suprapatellar approach.
Prior to nail insertion, ensure Fig. 32a Fig. 32b
that the following measures
are taken:
1. Verify that the nail is
tightly secured to the
Nail Adapter Tibia or Nail
Adapter Tibia SPI
2. Ensure that both the head
of the Nail Holding Screw
PF / Tibia or Nail Holding
Screw Tibia SPI and the
driving end of the nail
completely align with the
appropriate nail adapter
3. Verify correct alignment by
inserting a drill through the
sleeve and targeting arm
assembly. The drill must Fig. 33a Fig. 33b Fig. 33c
pass through the holes of
the nail (fig. 33c)
4. If guided distal locking is
to be performed, follow the
pre-operative assembly
instructions as described
in this operative
technique.

24
Operative technique
Nail insertion

Insert the nail by hand over the

Ball Tip Guide Wire and into the
entry site of the proximal tibia
(fig. 34a, fig. 34b).
Gently manipulate the nail to
help avoid penetration of the
posterior cortex. If the nail is
deflected towards the posterior
cortex, remove the nail and
hyperflex the knee. Under image
control, use a straight reamer
to ream an anterior tract in the Fig. 34a Fig. 34b
proximal fragment. Advance the
nail past the fracture site to the
appropriate level. Remove the
guide wire once the nail is past
the fracture site.
If dense bone is encountered,
first confirm that sufficient
reaming has been achieved. Infrapatellar approach Suprapatellar approach: Nail is inserted
through the Elastic Nail Insertion Sleeve
If hammering is desired, thread
the Delta Strike Plate into the
Nail Adapter Tibia or Nail
Adapter Tibia SPI and deliver
light blows with the Slotted
Hammer to further insert the
nail (fig. 35). Alternatively, the
T2 Strike Plate can be used for
nail insertion. Do not hit the
Nail Adapter Tibia or Nail
Adapter Tibia SPI. Do not hit
the Nail Adapter Tibia or Nail
Adapter Tibia SPI.
The nail depth should be well Fig. 35
below the chondral surface to
minimize irritation to the
patellar tendon.
Do not apply excessive force
CAUTION during reaming and nail
If Fixation K-wires have Do not impact or backslap insertion. If severe resistance
been utilized, they must the nail with the Targeting is encountered, removal of the
be removed followed by Arm, Tibia attached to the nail and additional reaming
removal of the drill sleeve Nail Adapter Tibia or Nail or selection of a nail with a
prior to nail insertion. Ada ter Tibia SPI. smaller diameter is
recommended. 25
Operative technique
Nail insertion
12
If the nail has been inserted
too far, reposition as needed.
Repositioning of the nail should
be carried out either by hand or
by using the Delta Strike Plate.
Backslapping may be performed
using the Slotted Hammer to
extract the assembly. Fig. 36
Alternatively, the T2 Universal 2 7
Rod may be used.
A chamfer is located on the
proximal end of the nail to help
identify the junction of the nail
and insertion post under
fluoroscopy. Three circumferential
grooves are located on the
insertion post of the target device
assembly at 2mm, 7mm and
12mm from the proximal end of
the nail (fig. 36). Depth
of insertion may be visualized
with the aid of fluoroscopy. When
the T2 Alpha Tibia Nail is
inserted in the dynamic mode,
or when it is inserted with active
apposition / compression,
the recommended depth
of insertion is at least 7mm
to avoid protrusion of the
T2 Alpha Tibial Nail. Fig. 37
To attach the Targeting Arm
Tibia to the Nail Adapter Tibia
or Nail Adapter Tibia SPI, ensure
that the knob on the Targeting
Arm Tibia is in the open position
and slide the arm down the shaft CAUTION
of the Nail Adapter Tibia or Nail
Do not hit the Nail Adapter Final implant position must
Adapter Tibia SPI until it hits the Tibia or Nail Adapter Tibia be confirmed by X-ray.
stop. Turn the knob to SPI with the Slotted Hammer;
lock (fig. 37). only hit the Strike Plate. CAUTION

CAUTION Ensure by fluoroscopy

that curvature, length and
Remove Ball Tip Guide diameter of selected nail
Wire prior to drilling. fit the patient's anatomy.
26
Operative technique
Guided proximal locking

Before locking the nail

proximally, verify that the 2
1
Nail Holding Screw Tibia /
Femur PF is securely tightened
and that the Targeting Arm
Tibia is properly attached to the
nail adapter. The Targeting Arm
Tibia is designed to provide four
options for proximal locking. 5 5

4 3
Proximal locking hole options - top view
Numeric markings are for
illustration only. The
targeting device is not
marked with numbers.
All circles marked on
targeting device indicate
static locking. Dynamic/
compression locking
options are marked
accordingly.
5
3
1
4 2

Proximal locking hole options - side views

1
2
5
3
4

Proximal locking hole options - front view

27
Operative technique
Guided proximal locking

Option 1
Static locking mode
All four indicated holes
may be used.
1 Oblique static
2 Oblique static
3 ML static
4 ML static

Option 2:
Controlled dynamization
or appostion / compression
mode
The dynamic hole is used to
lock the nail in the controlled
dynamization or apposition/
compression modes.
The dynamic hole is indicated on
the targeting arm.
Dynamic
5

CAUTION
Dynamic locking might be
associated with bone
shortening during the healing
period.

28
Operative technique
Guided proximal locking

Option 3:
Internal apposition/
compression
In the internal apposition/
compression mode, use of the
dynamic hole is required.
Use of an additional ML static
screw and/or the most proximal
oblique screw is recommended.
In the internal apposition/
compression mode, the more
distal oblique screw cannot be
used as the compression screw
blocks this hole in the nail.
Dynamic
5

4 ML static (recommended)

1 Oblique static (optional)

Option 4:
External apposition/
compression
In the external apposition/
compression mode, use of the
dynamic hole is required.
Use of an additional ML static
screw is recommended.
Dynamic
5

4 ML static (recommended)
1 Oblique static (optional)
2 Oblique static (optional)

All circles marked on targeting

device indicate static locking.
Dynamic/compression locking
options are marked accordingly.

29
Operative technique
Static locking mode

For static locking of the

T2 Alpha Tibial Nail, both
proximal oblique screws
and both proximal M/L locking Fig. 38a

screws may be used. If secondary

dynamization is planned, the
M/L screw may be inserted in
the dynamic position of the
oblong hole of the Targeting
Arm, Tibia. This allows
controlled dynamization of the
fracture. Insert the Tissue
Protection Sleeve together with
the Locking Drill Sleeve and
Locking Trocar through the
appropriate hole of the
Targeting Arm Tibia
(fig. 38a, 38b). Make a small
Fig. 38b
skin incision at the sleeve
entry point.
Advance the sleeve assembly
through the incision until it is in
contact with the cortex. Fully
seat the Tissue Protection Sleeve
on the cortex. This will drive
the head of the Locking Trocar
from the sleeve assembly (fig. 39).

CAUTION
Ensure sleeve assembly is
seated on bone prior to
drilling and screw length Fig. 39
measuring. Verify correct
position of sleeve under
imaging prior to drilling. The CAUTION
gray friction lock mechanism
is designed to maintain the Applying excessive force may Drilling past the far cortex
position of the drill sleeves. result in breakage of the drill may damage soft tissue.
To remove the sleeve assembly which could require recovery.
from the Targeting Arm Tibia, Recovery could result in an
press the gray mechanism iatrogenic fracture and/or
while pulling the sleeves and bone damage may occur.
trocar.

30
Operative technique
Static locking mode

Advance the Locking Drill,

4.2 x 360mm through the
Locking Drill Sleeve, Long and
onto the cortex. Drill both
cortices (fig. 40a, 40b).
Position the drill tip at the
desired final position of the
screw tip. Determine screw
measurement by rotating the
grip of the Locking Drill Sleeve,
Long and pulling the sleeve
towards the drill attachment
until the sleeve hits the stop.
Fig. 40a Fig. 40b
Read the measurement on the
Locking Drill Sleeve, Long at the
junction of the Tissue Protection
Sleeve, Long (fig. 41)
Alternatively, the Guided Depth
Gauge can be used through the
Tissue Protection Sleeve, Long to
read off the length at the end of
the sleeve (fig. 42).

5.0mm Locking Screws and

Advanced Locking Screws
require the 4.2mm drill Fig. 41
(green color-coded drill).

Damage of the nail during

drilling may reduce the
fatigue strength of the
implant which could
cause the nail to fail.

Fig. 42

31
Operative technique
Static locking mode

Remove the Locking Drill and

Locking Drill Sleeve, Long and
insert the selected Locking
Fig. 43
Screw through the Tissue
Protection Sleeve, Long using
the Screwdriver Bit, Long and
Quick-Lock Delta Handle
(fig. 43, 44a). Advance the screw
through both cortices until the
screw is fully seated. When the
marking on the screwdriver Fig. 44b
(fig. 44b) nears the head of the
Tissue Protection Sleeve, Long,
the screw is close to its final
position. Use imaging to confirm
placement of the screw.
The paddle tip of the Tissue
Protection Sleeve, Long allows
the user to visually verify that
the screw head is seated on
the bone under X-ray without
retracting the sleeve from Fig. 44a
the bone.
Alternatively, the sleeve can be
pulled away from the bone to
verify that the screw is fully
seated.
Repeat the locking procedure for
the second oblique screw (fig. 46)
and/or the static or dynamic ML
screws as appropriate. Fig. 45

Dynamic locking mode After distal locking has been

When the fracture pattern performed, place a locking screw
permits, dynamic locking may in the dynamic position of the
be utilized for transverse, axially ML oblong hole following the
stable fractures. Controlled aforementioned steps for screw
dynamization is performed by insertion.
statically locking the nail distally Do not insert the two proximal
Fig. 46
(see Guided Distal Locking oblique or the static ML screws
or Freehand Distal Locking as this prevents nail movement T2 Alpha Tibial Nail with two oblique
Sections). screws
relative to the locking screw
and the fracture to settle while
maintaining torsional stability.
32
Operative technique
Internal apposition/compression mode

In transverse, axially stable

fracture patterns, active
mechanical apposition/
compression may be desired.
The Compression Screw Tibia
can be used to apply apposition /
compression.
When compressing the nail,
the implant must be inserted
at a safe distance from the entry
point to accommodate for the
7mm of active compression.
The three grooves on the
insertion post help attain
accurate insertion depth
of the implant.
After distal locking has been
performed, insert a Locking
Screw proximally in the dynamic
position of the oblong hole.
To apply compression, attach
the Compression Screw Tibia
to the Compression Screwdriver
and Quick-Lock Delta Handle Fig. 47 Fig. 48
assembly. Insert the Compression
Screwdriver through the Nail
Holding Screw Tibia / Femur PF
or Nail Holding Screw Tibia SPI CAUTION
and apply apposition/compression
Initial signs of screw bending The Compression Screw Tibia
(fig. 47).
indicate that sufficient must be screwed in correctly
Once apposition/compression has compression has been and with reasonable forces to
been applied, the compression achieved. provide desired function and
screwdriver may be removed to avoid damage of implants
(fig. 48). Insertion of a second
CAUTION / instruments. Deformation of
proximal ML screw or the most Apposition / compression must the locking screw may
proximal oblique screw is be carried out under X-ray indicate unreasonable force.
recommended. control. Over-compression
may cause the nail or screw
When using the Compression
to fail.
Screw Tibia, the more distal
of the two proximal oblique
locking screws cannot be used.

33
Operative technique
External apposition/compression mode

As an alternative to internal
compression, the External
Compression Device Tibia can
be used to apply apposition /
compression.
After two static screws have
been inserted distally, insert a
Locking Screw proximally in
Fig. 49
the dynamic position of the
oblong hole.
To apply compression, attach
the External Compression
Device Tibia to the Quick-Lock
Delta Handle (fig. 49) and insert
the External Compression Device
Tibia through the Nail Holing
Screw Tibia / Femur PF or Nail
Holding Screw Tibia SPI to
engage the internal threads of
the nail. Rotate to apply
compression (fig. 50, 51).
When compressing the fragments,
the implant must be inserted at
a safe distance from the entry
point to accommodate up to
7mm of active compression. The
three grooves on the insertion Fig. 50 Fig. 51
post help attain accurate
insertion depth of the implant.
The lines marked on the shaft of Once the second black line is at
the External Compression the same height as the Nail
Device, Tibia are designed to aid Holding Screw, 7mm of
in determining the amount of compression has been achieved
compression that has been and no additional forces should
achieved. The two distal lines be applied.
are used in the infrapatellar
Once apposition / compression
approach, and the two proximal
has been applied, insertion
lines are used for the suprapatellar
of a second proximal ML screw
approach. When the first black
is recommended. Once the
line passes the proximal end of
second screw has been inserted,
the nail holding screw,
the External Compression
compression is being applied.
Device Tibia can be detached.
Fig. 52
34
Operative technique
Guided distal locking

Guided distal locking

Use of the T2 Alpha Tibia Adapter Tibia
Distal Targeting Device is / Femur Retrograde
recommended when performing Nail Adapter
distal locking of the ML screws. Tibia
The distal AP screw requires
freehand distal locking.

Distal Targeting
Arm Tibia

Adjusting
Device Tibia

Fig. 53

35
Operative technique
Assembly

Pre-operative assembly is
recommended prior to nail
insertion. Assembly steps
are as follows:

1. Attach the Adapter

Tibia / Femur Retrograde
to the Distal Targeting
Arm Tibia
The length of the selected nail
determines the attachment Fig. 54
point. Insert the center pin of
the Adapter Tibia / Femur
Retrograde into the hole of the
Distal Targeting Arm Tibia that
corresponds with the selected
nail. Turn knob to secure
(fig. 54, 55).

Fig. 55

2. Attach Adjusting
Device, Tibia to the Distal
Targeting Arm, Tibia
Insert the center pin of the
Adjusting Device Tibia through
the appropriate hole of the Distal
Targeting Arm Tibia. Left/Right
markings on the targeter
indicate which hole should be
used (fig. 56, 57). Once inserted,
turn knob to secure.

Fig. 56 Fig. 57

36
Operative technique
Pre-operative assembly

3. Attach Distal Targeting

Arm Assembly to Nail
Adapter, Tibia/ Nail
Adapter Tibia SPI
Slide the Adapter Tibia / Femur
Retrograde down the shaft of
Nail Adapter Tibia or Nail
Adapter Tibia SPI (fig. 58a),
tibia until the stop is felt.
Turn knob to secure (fig. 58b).
Insert the Tissue Protection
Sleeve, Long into the most
proximal of the distal locking Fig. 58a
holes of the Adjusting Device
Tibia to confirm that the
device has been assembled to
accommodate the selected nail
length (fig. 59).
If the sleeve is properly
positioned, remove the sleeve
from the Adjusting Device Tibia
and disassemble the distal
targeting assembly from the Nail
Adapter Tibia or Nail Adapter
Tibia SPI and place on the back
table. Do not disassemble the
Fig. 58b
Adjusting Device Tibia or
Adapter Tibia / Femur
Retrograde from the Distal
Targeting Arm Tibia.

Fig. 59

37
Operative technique
Distal drilling and locking

Proceed with nail and screw The following three steps must
insertion as described in this be taken prior to drilling:
operative technique. Once the
nail insertion has been 1. Oblique positioning of C-arm
performed, re-attach the Distal 2. Height and orbital rotation
Targeting Arm Tibia to the Nail adjustment of the C-arm
Adapter Tibia or Nail Adapter
Tibia SPI as described in the 3. Sleeve adjustment to the
preassembly steps. Depending nail position
on the preferred locking
configuration, proximal screw
insertion may be performed prior
to distal locking.

Insert the sleeve assembly

through the appropriate hole of
the adjusting device (fig. 60).
The sleeves should not contact
the skin of the patient. Do not
make an incision until the C-arm
and sleeves are correctly
positioned as described in the
following steps.

Fig. 60

38
Operative technique
Distal drilling and locking

1. O
 blique positioning
of the C-arm
To perform guided distal
locking, it is essential to place
the X-ray beam of a C-arm
approximately 30º oblique to the
axis of the drill sleeve assembly.

As an option, the K-wire

3x285mm can be inserted into
the more proximal K-wire hole
of the adjusting device (fig. 61).
This wire indicates 30º oblique
to the axis of the drill sleeve
assembly and helps to adjust
the C-arm.

30º

Fig. 61

39
Operative technique
Distal drilling and locking

2. H
 eight and orbital
rotation of the C-arm
In this step, it is important to
position the C-arm so that the
nail tip and the sleeve tip are
seen parallel on the fluoroscopic
image. 1
After oblique C-arm positioning,
adjust the height and orbital
rotation of the X-ray beam at the

2
same plane as the Drill Sleeve
assembly (fig. 62). Take an X-ray.
Fig. 62
If the sleeve and nail tip are
parallel (fig. 63a) or colinear
(fig. 63b) in the X-ray image, the
C-arm is correctly positioned
and no adjustments to the C-arm
position are necessary (fig. 63).
If the sleeve and nail are not
parallel or colinear, the C-arm is
incorrectly positioned.
Adjust the C-arm rotation as per
the following instructions until Fig. 63a Fig. 63b
the correct position is achieved.
This step requires appropriate
C-arm positioning only. Do not
turn the Adjusting Device Tibia
before the nail and the sleeve are
parallel.

40
Operative technique
Examples of incorrect C-arm positioning

Example 1: When the tip of

the sleeve and nail point down
(fig. 64a), move the X-ray tube up
(fig. 64b) until the nail and sleeve
are seen in parallel.

Fig. 64a Fig. 64b

Example 2: When the tip of

the sleeve and the tip of the nail
point up (fig. 65a), move the
X-ray tube down (fig. 65b) until
the nail and sleeve are seen in
parallel.

Fig. 65a Fig. 65b

41
Operative technique
Distal drilling and locking

3. Sleeve adjustment
to the nail position
Once the C-arm has been
adjusted so that nail and sleeve
are shown parallel, the deviated
image may show the sleeve
either above or below the nail
(fig. 66a and fig. 66b). If the
sleeve and the nail tip are shown
colinear, (fig. 66c) no further Nail tip and sleeve parallel but not in Nail tip and sleeve parallel but not in
adjustment of the Adjusting the same axis. Turn the knob of the the same axis. Turn the knob of the
adjusting device counterclockwise to adjusting device clockwise to move
Device Tibia is needed. move the sleeve up. the sleeve down.
If the sleeve and nail tip Fig. 66a Fig. 66b
are not colinear on the same axis
(fig. 66a, 66b) sleeve adjustment
is required by turning the
adjusting screw of the Adjusting
Device, Tibia (fig. 67). By turning
the adjusting screw, the sleeve
moves anteriorly or posteriorly.

Sleeve and nail tip are Fig. 67

colinear. No adjustment of the
adjusting device is needed.
Fig. 66c.

42
Operative technique
Distal drilling and locking

Once the nail and sleeve are

colinear, make a small skin
incision at the sleeve entry
point. Ensure that the incision
is straight to avoid forces on the
sleeve.
Advance the Locking Tissue
Protection Sleeve Long, Locking
Drill Sleeve Long and Locking
Trocar Long assembly through
the incision until the sleeve tip
is close to the cortex. Do not
force the chamfers of the sleeve
into the bone as this could cause
deviations. Take an X-ray to Fig. 68
confirm correct position of the
sleeve as sleeve alignment could
be compromised by soft tissue
or slippage on the bone. Adjust
sleeve position if needed.
Once sleeve position has been
confirmed, commence distal
drilling and screw insertion
(fig. 68, 69) as outlined in the
proximal locking section. Repeat
these steps for the insertion of
the second ML screw.

Patient anatomy, entry point

Fig. 69
or other factors may result in
excessive nail bending that CAUTION
cannot be compensated with
Take care to avoid capturing 4mm Locking Screw or 4mm
the adjusting device. In these
soft tissue during freehand Advanced Locking Screws are
instances, freehand distal
drilling. used exclusively for distal
locking must be performed.
locking of the 8mm T2 Alpha
Tibial Nails.
CAUTION
8mm T2 Alpha Tibia Nails
4mm Locking Screw and 4mm Avoid applying soft tissue require the use of 5.0mm
Advanced Locking Screw pressure to the sleeve screws proximally.
require the 3.5 drill (orange assembly; do not make a
color-coded drill). skin incision.

43
Operative technique
Freehand distal locking

As an alternative to guided distal

locking, the freehand technique
may be used to insert the distal
ML screws, and must be used to
insert the distal A / P screw.
The critical step with any
freehand locking technique
is to adjust the C-arm until a
perfectly locking hole is Locking hole is not perfectly circular. Locking hole is perfectly circular.
visualized with the C-arm. The C-arm is incorrectly positioned. The c-arm is correctly positioned.
Fig. 70a Fig. 70b
Once the C-arm is correctly
positioned, Make an incision
(fig. 70c) and hold the freehand
drill at an oblique angle to
the center of the locking hole
(fig. 70d). Upon X-ray verification,
the drill is placed perpendicular
to the nail and drilled through
the lateral and medial cortex.
Confirm in both the anterior and
lateral planes by X-ray that the Fig. 70c Fig. 70d
freehand drill passes through the
hole in the nail.
Use the Screw Scale with the
drill to read off the screw length
directly at the color coded
marking (fig. 71) Alternatively, the
Freehand Depth Gauge, Long or
Freehand Depth Gauge Short
may be used after drilling to
determine the required screw
length (fig. 72). Fig. 71
Repeat steps as needed
to insert additional screw(s).

Fig. 72
44
Operative technique
Freehand distal locking

The self-retaining screwdriver

assembly may be used to facilitate
freehand locking. To use,
assemble the Self-Retaining
Screwdriver Sleeve to the Self-
Retaining Screwdriver Bit/
Quick-Lock Delta Handle Fig. 73
Assembly (fig. 73) and attach the
screwdriver to the screw and
secure the connection by
turning the screwdriver sleeve
counterclockwise.
Routine screw insertion is
employed to insert the screw
(fig. 74).

Fig. 74

45
Operative technique
Advanced locking screws

Advanced Locking Screws can

be used as an alternative to the
IMN Locking Screws. Ø5.7mm

The Advanced Locking Screws

are designed with oversized
threads (fig. 75, 75a) that engage Ø5.3mm
with the internal threads of
the T2 Alpha Tibial Nail while
maintaining bicortical purchase.
Overdrilling of the near cortex
must be performed to create a
path for the screw. Ø4.5mm

Advanced Locking Screws may Fig. 75

be preferred in instances of
poor bone quality and in other
instances when axial stability
is desired.
Advanced Locking Screws may Ø4.7mm
be inserted in any circular hole
of the nail. They cannot be used
in the dynamic / oblong holes
(fig. 76). Ø4.3mm

The Advanced Locking Screws

are inserted in a guided locking
technique via the Targeting Arm
Tibia and/or the Distal Targeting
Arm Tibia or using a distal Ø3.5mm
freehand technique.

Guided technique: Fig. 75a

When using a guided technique,

drilling and insertion of the
Advanced Locking Screws is
performed through the sleeve(s)
Fig. 76
of the proximal targeting arm
tibia or distal targeting arm.
Colored screws indicate where
CAUTION Advanced Locking Screws can
be utilized. Advanced Locking
Overdrilling with the Screws are not accepted in the
Counterbore Drill must be oblong hole.
performed prior to Advanced
Locking Screw Insertion.

46
Operative technique
Advanced locking screws

Drill both cortices and determine

screw length in a guided or
freehand manner as previously
described in this operative
technique (fig. 77). Once screw
length has been determined,
open the near cortex using the
Counterbore Drill. Freehand
locking requires use of the
Counterbore Drill, Short, and
guided locking requires use of
the Counterbore Drill, Long.
Fig. 77
Ensure that the counterbore
drill is centered within the
pre-drilled hole and the hole
of the nail prior to insertion,
and then drill until the stop
is felt (fig. 78). Verify under
imaging.
The Counterbore Drill widens
the near cortex to allow for
insertion of the Advanced
Locking Screw (fig. 79).
In some instances, thick cortex
or strong trabecular bone stock Fig. 78
may prevent the counterbore
drill from fully clearing the
pathway to the nail. When this
occurs, use the Counterbore Drill
Manual in combination with
Ø5.5mm Ø4.2mm
the Delta Quick-Lock Handle
to ensure that the passage to
the nail is sufficiently widened
(fig. 80). To use, insert the drill
into the path created by the first
counterbore drill and turn the
drill in a gentle clockwise motion
with moderate axial pressure
until the pathway to the nail has Upon completion of drilling, the near cortex is over-drilled to 5.5mm
while the far cortex is drilled to 4.2mm (pictured). If using the 4.0mm
been opened.
Advanced Locking Screws, the near cortex is Over-drilled to 4.5 while
the far cortex is drilled to 3.5mm.
Fig. 79
Do not use the Counterbore
Drill, Manual with the power
tool. 47
Operative technique
Advanced locking screws

Once drilling has been completed,

insert the Advanced Locking
Screw with gentle axial
force using the appropriate
screwdriver through the near
cortex without turning the
screw while ensuring that the
axis of the screw is aligned with
the corresponding locking hole.
Push the screw until the leading
tip is engaged with the nail hole.
X-ray verification can be used to
Fig. 80
confirm position.
To confirm correct starting
point and axial alignment of
the screw, rotate the screw
counterclockwise while applying
gentle axial force (fig. 81).
A click sound or snapping of the
thread indicates that the screw
is in the correct position.
Once position has been confirmed,
insert the screw by rotating
clockwise until the screw is fully
seated (fig. 82). Use X-ray to Fig. 81

confirm.

CAUTION
The Advanced Locking
Screw must be inserted
using reasonable force.
to provide desired function
and to avoid damaging the
screw. If unreasonable
insertion torque is noticed,
stop insertion, turn the screw
counterclockwise and then
Fig. 82
attempt to insert the screw. If
unreasonable insertion torque
is still noticed, remove the
screw and proceed with a
Locking Screw.

48
Operative technique
End cap insertion

After removal of the Targeting

Arm Tibia, the End Cap Tibia
(+5, +10, +15, +20, +25) or
End Cap Lower Extremity is
available to adjust nail length
and/or protect the threads
of the nail. After imaging
confirms satisfactory reduction Fig. 83
and hardware implantation, an
end cap can be inserted with the
Screwdriver Bit and Quick-Lock
Delta Handle assembly. If using
the +5, +10, +15, +20, +25 End
Caps, the Compression
Screwdriver may also be used.
(fig. 83, 84).
Ensure that the end cap is fully
seated to minimize the potential
risk for loosening.

Fig. 84

49
Operative technique
Nail removal

The End Cap Tibia or End Cap

Lower Extremity is removed
with the Screwdriver Bit Long
and Quick-Lock Delta Handle
assembly. To remove the nail,
first assemble the Extraction
Shaft and the Delta Strike Plate
by threading the Delta Strike
Plate into the Extraction Shaft.
The cannulated Extraction Shaft
is inserted into the driving end
of the nail (fig. 85). If the most
proximal oblique screw was
used, it must be removed prior
to assembling the Extraction
Shaft to the nail.
All IMN Screws are removed
with the Screwdriver Bit (fig.
86). If the Compression Screw
Tibia was used, it must be Fig. 85 Fig. 86
removed prior to assembly of
the Extraction Shaft. Unlock
and remove the Compression
Screwdriver.
Use the Slotted Hammer to
extract the nail in a controlled The T2 Alpha Tibial nail
manner (fig. 87). Alternatively, is not intended for full weight
the T2 Universal Rod may be bearing in patients with
connected to the Extraction complex unstable fractures
until bone consolidation is
Shaft.
confirmed in the follow-up
X-rays.
CAUTION
Stryker offers a universal
implant extraction set that is
not compatible with the T2 The T2 Alpha Tibial nail
Alpha Tibial Nail. Use of the is designed for temporary
T2 Alpha Extraction Shaft is implantation until bone
Required for removal. The consolidation occurs. If bone
universal implant extraction consolidation does not occur
set may be used for removal of or if the consolidation is
IMN Screws or other internal insufficient, the implant may
fixation systems. break. The aim of post-
Fig. 87
operative care must be to
ensure the promotion of bone
consolidation.

50
Notes

51
This document is intended solely for the use of healthcare professionals. A surgeon must always rely on his or her own professional clinical 0123
judgment when deciding whether to use a particular product when treating a particular patient. Stryker does not dispense medical advice
and recommends that surgeons be trained in the use of any particular product before using it in surgery. Manufacturer:

The information presented is intended to demonstrate a Stryker product. A surgeon must always refer to the package insert, product label Stryker Trauma GmbH
and/or instructions for use, including the instructions for cleaning and sterilization (if applicable), before using any Stryker product. Products Prof.-Küntscher-Str. 1-5
may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. 24232 Schönkirchen
Please contact your Stryker representative if you have questions about the availability of Stryker products in your area.
Germany
Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service
stryker.com
marks: Stryker, T2 Alpha. All other trademarks are trademarks of their respective owners or holders.

The devices listed above are CE marked.

Content ID: T2-ST-20, Rev 4, 10.2019

Copyright © 2019 Stryker