Abstract:
An apparatus and related method for controlling a load on a human hip joint during normal gait while preserving motion. The approach is intended to treat osteoarthritis of the hip without substantially resisting an angular displacement associated with full mobility of the pelvis and femur bones.

Description:
BACKGROUND 
     The present disclosure is directed toward apparatus and methods for treating joints and in particular, to treating hip joints affected with osteoarthritis. 
     A joint is the location at which two or more bones make contact. Joints are constructed to allow movement and provide mechanical support, and are classified structurally and functionally. Structural classification is determined by how the bones connected to each other, while functional classification is determined by the degree of movement between the articulating bones. In practice, there is significant overlap between the two types of classifications. 
     There are three structural classifications of joints, namely fibrous or immovable joints, cartilaginous joints and synovial joints. Fibrous/Immovable bones are connected by dense connective tissue, consisting mainly of collagen. The fibrous joints are further divided into three types:
         sutures which are found between bones of the skull;   syndesmosis which are found between long bones of the body; and   gomphosis which is a joint between the root of a tooth and the sockets in the maxilla or mandible.       

     Cartilaginous bones are connected entirely by cartilage (also known as “synchondroses”). Cartilaginous joints allow more movement between bones than a fibrous joint but less than the highly mobile synovial joint. Cartilaginous joints include the artificial discs of the spine. 
     Synovial joints have a space between the articulating bones for synovial fluid. This classification contains joints that are the most mobile of the three, and includes the hip, knee and shoulder. These are further classified into ball and socket joints, condyloid joints, saddle joints, hinge joints, pivot joints, and gliding joints. 
     Joints can also be classified functionally, by the degree of mobility they allow. Synarthrosis joints permit little or no mobility. They can be categorized by how the two bones are joined together. That is, synchrondoses are joints where the two bones are connected by a piece of cartilage. Synostoses are where two bones that are initially separated eventually fuse together as a child approaches adulthood. By contrast, amphiarthrosis joints permit slight mobility. The two bone surfaces at the joint are both covered in hyaline cartilage and joined by strands of fibrocartilage. Most amphiarthrosis joints are cartilaginous. 
     Finally, diarthrosis joints permit a variety of movements (e.g. flexion, adduction, pronation). Only synovial joints are diarthrodial and they can be divided into six classes: 1. ball and socket—such as the shoulder or the hip and femur; 2. hinge—such as the elbow; 3. pivot—such as the radius and ulna; 4. condyloidal (or ellipsoidal)—such as the wrist between radius and carps, or knee; 5. saddle—such as the joint between carpal thumbs and metacarpals; and 6. gliding—such as between the carpals. 
     Synovial joints (or diarthrosis, or diarthroidal joints) are the most common and most moveable type of joints in the body. As with all other joints in the body, synovial joints achieve movement at the point of contact of the articulating bones. Structural and functional differences distinguish the synovial joints from the two other types of joints in the body, with the main structural difference being the existence of a cavity between the articulating bones and the occupation of a fluid in that cavity which aids movement. The whole of a diarthrosis is contained by a ligamentous sac, the joint capsule or articular capsule. The surfaces of the two bones at the joint are covered in cartilage. The thickness of the cartilage varies with each joint, and sometimes may be of uneven thickness. Articular cartilage is multi-layered. A thin superficial layer provides a smooth surface for the two bones to slide against each other. Of all the layers, it has the highest concentration of collagen and the lowest concentration of proteoglycans, making it very resistant to shear stresses. Deeper than that is an intermediate layer, which is mechanically designed to absorb shocks and distribute the load efficiently. The deepest layer is highly calcified, and anchors the articular cartilage to the bone. In joints where the two surfaces do not fit snugly together, a meniscus or multiple folds of fibro-cartilage within the joint correct the fit, ensuring stability and the optimal distribution of load forces. The synovium is a membrane that covers all the non-cartilaginous surfaces within the joint capsule. It secretes synovial fluid into the joint, which nourishes and lubricates the articular cartilage. The synovium is separated from the capsule by a layer of cellular tissue that contains blood vessels and nerves. 
     Various maladies can affect the joints, one of which is arthritis. Arthritis is a group of conditions where there is damage caused to the joints of the body. Arthritis is the leading cause of disability in people over the age of 65. 
     There are many forms of arthritis, each of which has a different cause. Rheumatoid arthritis and psoriatic arthritis are autoimmune diseases in which the body is attacking itself. Septic arthritis is caused by joint infection. Gouty arthritis is caused by deposition of uric acid crystals in the joint that results in subsequent inflammation. The most common form of arthritis, osteoarthritis is also known as degenerative joint disease and occurs following trauma to the joint, following an infection of the joint or simply as a result of aging. 
     Unfortunately, all arthritides feature pain. Patterns of pain differ among the arthritides and the location. Rheumatoid arthritis is generally worse in the morning; in the early stages, patients often do not have symptoms following their morning shower. 
     Osteoarthritis (OA, also known as degenerative arthritis or degenerative joint disease, and sometimes referred to as “arthrosis” or “osteoarthrosis” or in more colloquial terms “wear and tear”), is a condition in which low-grade inflammation results in pain in the joints, caused by wearing of the cartilage that covers and acts as a cushion inside joints. As the bone surfaces become less well protected by cartilage, the patient experiences pain upon weight bearing, including walking and standing. Due to decreased movement because of the pain, regional muscles may atrophy, and ligaments may become more lax. OA is the most common form of arthritis. 
     The main symptoms of osteoarthritis is chronic pain, causing loss of mobility and often stiffness. “Pain” is generally described as a sharp ache, or a burning sensation in the associated muscles and tendons. OA can cause a crackling noise (called “crepitus”) when the affected joint is moved or touched, and patients may experience muscle spasm and contractions in the tendons. Occasionally, the joints may also be filled with fluid. Humid weather increases the pain in many patients. 
     OA commonly affects the hand, feet, spine, and the large weight-bearing joints, such as the hips and knees, although in theory, any joint in the body can be affected. As OA progresses, the affected joints appear larger, are stiff and painful, and usually feel worse, the more they are used and loaded throughout the day, thus distinguishing it from rheumatoid arthritis. With progression in OA, cartilage looses its viscoelastic properties and it&#39;s ability to absorb load. 
     Generally speaking, the process of clinical detectable osteoarthritis is irreversible, and typical treatment consists of medication or other interventions that can reduce the pain of OA and thereby improve the function of the joint. According to an article entitled  Surgical Approaches for Osteoarthritis  by Klaus-Peter Günther, MD, over recent decades, a variety of surgical procedures have been developed with the aim of decreasing or eliminating pain and improving function in patients with advanced osteoarthritis (OA). The different approaches include preservation or restoration of articular surfaces, total joint replacement with artificial implants, and arthrodesis (fusion). 
     Arthrodesis are described as being reasonable alternatives for treating OA of small hand and foot joints as well as degenerative disorders of the spine, but were deemed to be rarely indicated in large weight-bearing joints such as the hip due to functional impairment of gait, cosmetic problems and further side-effects. Total joint replacement was characterized as an extremely effective treatment for severe joint disease. Moreover, recently developed joint-preserving treatment modalities were identified as having a potential to stimulate the formation of a new articular surface in the future. However, it was concluded that such techniques do not presently predictably restore a durable articular surface to an osteoarthritic joint. The correction of mechanical abnormalities by osteotomy and joint debridement are still considered as treatment options in many patients. 
     Joint replacement is one of the most common and successful operations in modern orthopaedic surgery. It consists of replacing painful, arthritic, worn or diseased parts of the joint with artificial surfaces shaped in such a way as to allow joint movement. Such procedures are a last resort treatment as they are highly invasive and require substantial periods of recovery. Joint replacement is sometimes called total joint replacement indicating that all joint surfaces are replaced. This contrasts with hemiarthroplasty (half arthroplasty) in which only one bone&#39;s joint surface is replaced and unincompartmental arthroplasty in which both surfaces of the knee, for example, are replaced but only on the inner or outer sides, not both. Thus, arthroplasty as a general term, is an operative procedure of orthopaedic surgery performed, in which the arthritic or dysfunctional joint surface is replaced with something better or by remodeling or realigning the joint by osteotomy or some other procedure. These procedures are also characterized by relatively long recovery times and are highly invasive procedures. 
     The currently available therapies are not condro-protective. Previously, a popular form of arthroplasty was interpositional arthroplasty with interposition of some other tissue like skin, muscle or tendon to keep inflammatory surfaces apart or excisional arthroplasty in which the joint surface and bone was removed leaving scar tissue to fill in the gap. Other forms of arthroplasty include resection(al) arthroplasty, resurfacing arthroplasty, mold arthroplasty, cup arthroplasty, silicone replacement arthroplasty, etc. 
     Osteotomy is a related arthroplasty procedure involving cutting of bone to improve alignment. The goal of osteotomy is to relieve pain by changing the anatomy and equalizing forces across the joint. This procedure is often used in younger, more active or heavier patients. Hip osteotomy involves removing bone from the femoral head or from the acetabulum of the hip joint and moving the bones slightly within the joint. This changes the position of the bones of the hip joint to shift the brunt of the patient&#39;s weight from damaged joint surfaces to healthier cartilage. A metal plate or pin is inserted to keep the bone in the new position. 
     Other approaches to treating osteoarthritis involve an analysis of loads which exist at a joint. Both cartilage and bone are living tissues that respond and adapt to the loads they experience. If a joint surface remains unloaded for appreciable periods of time the cartilage tends to soften and weaken. Further, as with most materials that experience structural loads, particularly cyclic structural loads, both bone and cartilage begin to show signs of failure at loads that are below their ultimate strength. However, cartilage and bone have some ability to repair themselves. There is also a level of load at which the skeleton will fail catastrophically. Accordingly, it has been concluded that the treatment of osteoarthritis and other conditions is severely hampered when a surgeon is not able to precisely control and prescribe the levels of joint load. Furthermore, bone healing research has shown that some mechanical stimulation can enhance the healing response and it is likely that the optimum regime for a cartilage/bone graft or construct will involve different levels of load over time, e.g. during a particular treatment schedule. Thus, there has been identified a need for devices which facilitate the control of load on a joint undergoing treatment or therapy, to thereby enable use of the joint within a healthy loading zone. 
     Certain other approaches to treating osteoarthritis contemplate external devices such as braces or fixators which control the motion of the bones at a joint or apply cross-loads at a joint to shift load from one side of the joint to the other. Various of these approaches have had some success in alleviating pain but suffer from lack of patient compliance or lack an ability to facilitate and support the natural motion and function of the diseased joint. Notably, the motion of bones forming a joint can be as distinctive as a finger print, and thus, each individual has his or her own unique set of problems to address. Some prior approaches to treating osteoarthritis have also been remiss in acknowledging all of the basic functions of the various structures of a joint in combination with its unique movement. 
     Osteoarthritis is the most common type of hip arthritis. As the protective cartilage is worn away by hip arthritis, bare bone is exposed within the joint. 
     Hip arthritis typically affects patients over 50 years of age. It is more common in people who are overweight, and weight loss tends to reduce the symptoms associated with hip arthritis. There is also a genetic predisposition of this condition, meaning hip arthritis tends to run in families. Other factors that can contribute to developing hip arthritis include traumatic injuries to the hip and fractures to the bone around the joint. 
     It has been reported that thirty-five percent of all osteoarthritis is found in the hips. In fact, it has been estimated that more than ten million American adults suffer from hip osteoarthritis and more than $6 billion is spent per year treating hip osteoarthritis. Hip osteoarthritis is particularly debilitating. Generally, it is believed that osteoarthritis of the hip is the most disabling of all joint osteoarthritis. 
     The most common symptoms of hip arthritis are pain with activities, limited range of motion, stiffness of the hip, walking with a limp, and decreased function, strength, activities and quality of life. Hip arthritis symptoms tend to progress as the condition worsens. Interestingly, hip arthritis symptoms do not always progress steadily with time. Often, patents report good months and bad months or symptom changes with weather accurately represent the overall progression of the condition. 
     Evaluation of a patient hip arthritis should begin with a physical examination and x-rays to determine which course of treatment should be followed. Weight loss is probably one of the most important, yet least commonly performed treatments. The less weight the joint has to carry, the less painful activities will be. Also, limiting certain activities may be necessary, and learning new exercise methods may be helpful. Strengthening of the muscles around the hip joint may help decrease the burden on the hip. Preventing atrophy of the muscles is an important part of maintaining functional use of the hip. Anti-inflammatory pain medications (NSAIDs) are prescription and nonprescription drugs that can help treat pain and inflammation. In more intrusive approaches, hip replacement surgery can hip resurfacing surgery have also been employed to treat hip osteoarthritis. In the most common hip replacement surgery, the cartilage is removed and a metal and plastic ball and socket hip replacement implant is placed in the hip. As an alternative to hip replacement, some patients are opting to pursue hip resurfacing surgery. 
     However, there is a need for a treatment modality which bridges the gap between the more conservative approaches such as weight loss, physical therapy and anti-inflammatory medicine and a decision to seek major surgical intervention. Such a treatment modality should be minimally invasive yet sufficiently effective to reduce the pain of osteoarthritis. The treatment should also be compatible with hip anatomy taking into consideration the many muscles overlaying the hip joint without hindering motion and avoiding the major arteries and nerves which are present. 
     SUMMARY 
     Briefly and in general terms, the present disclosure is directed towards apparatus and methods for treating the hip. Various structures are presented to specifically treat osteoarthritis of the hip joint. 
     In one aspect, there is disclosed an apparatus for controlling a load on a human hip joint during normal gait while preserving full range of motion. The apparatus includes a rail component for attachment to a pelvis, in which the rail component includes a bearing surface. The apparatus also includes a follower component having a first end and a second end. The first end is connected to a femur and the second end contacts the bearing surface of the rail component during a portion of the normal gait to reduce the load on the human hip joint. 
     In another aspect, the apparatus for controlling loads includes a rail component having a bearing surface that is attached to a femur. The apparatus also includes a follower component having a first end and a second end. The first end of the follower component is connected to a pelvis, and the second end of the follower component contacts the bearing surface of the rail component during a portion of the normal gait to reduce the load on the human hip joint. 
     Further, in one embodiment, the apparatus for controlling loads in a hip joint includes a first circular bumper fixed to a first position on a pelvis, and a second circular bumper fixed to a second position on a femur. In this embodiment, the first circular bumper engages the second circular bumper during a portion of the normal gait to reduce the load on the human hip joint. 
     Other features and advantages of the present disclosure will become apparent from the following detailed description, taken in conjunction with the accompanying drawings, which illustrate, by way of example, the principles of the invention. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a front view, depicting a hip joint; 
         FIG. 2  is a partially exploded and enlarged view, depicting details of the hip joint; 
         FIGS. 3A and 3B  are front views, depicting the arteries and nerves of the hip joint; 
         FIG. 4  is a perspective view, depicting angles of forces typically found in a hip joint; 
         FIG. 5  is a chart, depicting a force and motion relative of a hip joint during gait; 
         FIG. 6  is a front view, depicting a healthy hip joint and a hip joint suffering from osteoarthritis; 
         FIG. 7A  is a side view, depicting a first embodiment of a load controlling device placed across a hip joint; 
         FIG. 7B  is a front view of the embodiment of  FIG. 7A ; 
         FIG. 8  is a side view, depicting a second embodiment of a load controlling device placed across a hip joint; 
         FIG. 8A  is an exploded view of one embodiment of a follower component used in the load controlling device of  FIG. 8 ; 
         FIG. 9  is a front view, depicting a third embodiment of a load controlling device placed across a hip joint; 
         FIG. 10  is a front view, depicting a fourth embodiment of a load controlling device placed across a hip joint; 
         FIGS. 11A-B  are perspective views, depicting fourth and fifth embodiments of a load controlling device placed across a hip joint; 
         FIG. 11C  is a perspective view of an alternate linkage between the components of the load controlling device of  FIGS. 11A-B ; 
         FIG. 12  is a front view, depicting a sixth embodiment of a load controlling device placed across a hip joint; 
         FIG. 13  is a front view, depicting a seventh embodiment of a load controlling device placed across a hip joint; and 
         FIGS. 14A-14B  are front views, depicting eighth and ninth embodiments of a load controlling device placed across a hip joint. 
     
    
    
     DETAILED DESCRIPTION 
     Referring now to the drawings, which are provided by way of example and not limitation, the present invention is directed towards apparatus and methods for treating the hip joint. The present disclosure seeks to alleviate pain associated with the function of diseased or malaligned members forming the hip joint. Whereas the present disclosure is particularly suited to address issues associated with osteoarthritis, the energy manipulation accomplished by the disclosed apparatus and methods lends itself well to broader applications. 
     In one particular aspect, the present disclosure seeks to permit and complement the unique articulating motion of the members defining a hip joint of a patient while simultaneously manipulating energy being experienced by both cartilage and osseous tissue (cancellous and cortical bone). Approaches involving varying energy absorption and transfer during the pivoting of the joint and selecting a geometry for the energy absorption assembly to provide necessary flexibility are implemented into various embodiments of the present disclosure. Certain of the embodiments include geometry which accomplishes variable energy absorption designed to minimize and complement the dampening effect and energy absorption provided by the anatomy of the body, such as that found at a hip joint. In certain specific applications, distraction is employed in the energy manipulation approach. 
     In one particular approach, a bending spring assembly is contemplated to manipulate or absorb forces between body parts. Thus, an assembly utilizing an element or elements which respond to bending or changes in elongation may be desirable to treat afflictions such as osteoarthritis. Certain of the assemblies can incorporate features which insure correct device alignment as the member transitions between compressed and uncompressed states. 
     With specific reference to  FIGS. 1-3C , certain features of typical hip anatomy are presented. The hip joint is a ball-and-socket joint. This arrangement gives the hip a large amount of motion needed for daily activities like running, walking, sitting, and climbing stairs. The deepest layer of the hip includes the bones and the joints. The next layer is made up of the ligaments of the joint capsule. Tendons and the muscles overlay the ligaments and joint capsule. 
     The structures of the hip can be divided into several categories. These include bones and joints, ligaments and tendons, muscles and blood vessels. The bones of the hip are the femur (the thighbone)  100  and the pelvis  102 . The top end of the femur is shaped like a ball. This ball is called the femoral head  104 . The femoral head  104  fits into a round socket on the side of the pelvis referred to as the acetabulum  106  ( FIG. 2 ). Structure extending below and lateral to the acetabulum  106  is the portion of the pelvis called the ischium  107 . 
     The femoral head  104  is attached to the rest of the femur  100  by a short section of bone called the femoral neck  108 . A large bump juts outward from the top of the femur  100 , next to the femoral neck  108 . This bump, or the greater trochanter  110 , can be flat along the side of your hip. Large muscles connect to the greater trochanter  110 . 
     Articular cartilage  112  is the material that covers the ends of the bones of any joint ( FIG. 2 ). Articular cartilage is about one-quarter of an inch thick in the large, weight-bearing joints like the hip. Articular cartilage has a rubbery consistency and is slippery, which allows the joint surfaces to slide against one another without causing damage. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to make motion easier. In the hip, articular cartilage covers the end of the femur  100  and the socket portion of the acetabulum  106  in the pelvis. The cartilage is especially thick in the back part of the socket, as this is where most of the force occurs during walking and running. 
     A cone  140  depicted in  FIG. 4  exhibits the direction of the majority of forces applied to the hip socket during the gait cycle. A goal of the load controlling apparatus for the hip is to off-load some of these forces while maintaining as much natural motion as is possible. It has been found that moderate cyclic loading on the hip joint is beneficial and necessary to biological health. 
     There are several ligaments in the hip. Ligaments are soft tissue structures that connect bones to bones. A joint capsule is a watertight sac that surrounds a joint. In the hip, the joint capsule is formed by a group of three ligaments that connect the femoral head to the acetabulum. These ligaments are the main source of stability for the hip and help hold the hip in place. A special type of ligament forms a unique structure inside the hip called the labrum  116  ( FIG. 2 ). The labrum is attached almost completely around the edge of the acetabulum  106 . The shape and the way the labrum  116  is attached create a deeper cup for the acetabulum socket. This small rim of cartilage can be injured and cause pain and clicking in the hip. 
     The hip is surrounded by thick muscles. The gluteals make up the muscles of the buttocks on the back of the hip. The inner thigh is formed by the adductor muscles. The main action of the adductors is to pull the leg inward toward the other leg. The muscles that flex the hip are in front of the hip joint. These include the iliopsoas muscle. This deep muscle begins in the low back and pelvis and connects on the inside edge of the upper femur. Another large hip flexor is the rectus femoris. The rectus femoris is one of the quadriceps muscles, the largest group of muscles on the front of the thigh. Smaller muscles going from the pelvis to the hip help to stabilize and rotate the hip. The load controlling apparatus can be located beneath the muscles and ligaments of the hip or can be positioned between the muscles and tendons. 
     All of the nerves that travel down the thigh pass by the hip (See  FIG. 3A ). The main nerves are the femoral nerve  124  in front and the sciatic nerve  126  in back of the hip. A smaller nerve, called the obturator nerve (not shown), also goes to the hip. These nerves carry the signals from the brain to the muscles that move the hip. Traveling along with the nerves are the large vessel that supply the lower limb with blood (See  FIG. 3B ). The large femoral artery  128  begins deep within the pelvis. It passes by the front of the hip area and goes down toward the inner edge of the knee. The femoral artery has a deep branch, called the profunda femoris  130 . The profunda femoris sends two vessels that go through the hip joint capsule. These vessels are the main blood supply for the femoral head. Other small vessels form within the pelvis and supply the back portion of the buttocks and hip. 
     The hip joint has the greatest range of movement of any joint, second only to the shoulder. The full range of motion of the hip is much larger than used in daily routine activities. For example, in flexion and extension this maximum range of motion is 150° and 15° respectively while during normal gait, there is typically only 45° of flexion and 10° of extension. For abduction/adduction, the maximum range of motion is 45°/30° whereas during normal gait, the range of motion is closer to 7°/10°. Further, as to internal/external rotation, the maximum range of motion can be 60°/60° and only 4°/3° during normal gait. Interestingly, however, in patients suffering from hip osteoarthritis normal gate changes and the range of motion increases in some motions and decreases in other motions. That is, flexion/extension or an osteoarthritic hip during walking has been observed to be 25°/18°, abduction/adduction at 4°/7° and internal/external rotation at 10°/7°. 
     Referring now to  FIG. 5 , a force-motion relationship of a hip joint during gait is presented. Of particular interest to treatment, it is noted that peaks in load occur between 40° and 10° flexion during the stance portion of the gate cycle. It is further noted that vertical forces dominate in the hip joint. It has also been observed that forces of 2.4 times body weight are common during normal walking. Higher forces of up to about 9 times body weight are observed in the hip when running, stumbling or walking down stairs. Lower forces exist when sitting or standing. 
     As shown in  FIG. 6 , showing a healthy hip  102   a  and an osteoarthritic hip  102   b , osteoarthritis can be exhibited as osteophytes and deteriorated cartilage. Often, changes in the femur head  104  and the acetabulum  106  mirror each other or are similar. Various overlapping steps in osteoarthritis include initial articular cartilage degeneration, osteophyte formation in areas of low or no load causing decreases in range of motion and the flattening of the femoral head. Eburnation where bared bone and cartilage are worn away occurs as does necrosis, sclerosis and cyst formation. 
     Aside from ostephyte formation, osteoarthritis develops primarily in regions of high load. As shown by the schematic cone  140  in  FIG. 4 , the majority of forces in the hip joint are through anterior, superior and medial regions of the femoral head  104 . Thus, devices for manipulating such loads are contemplated to fight the degeneration of the hip joint. 
     The load manipulation devices of the present disclosure are contemplated to be placed across a hip joint. Fixation structures for fixing the load manipulation structures to the bone may be attached, for example, to the femur and pelvis. These are linked together with an absorber, the linking structure being configured to accommodate natural motions of the hip joint. The absorber is designed to absorb or off-load some portion of the load normally carried by the hip joint. The device itself is positioned such that the resultant force/unloading vector corresponds to a desired direction of off-loading. In particular, unloading is contemplated to occur in directions relating to the force cone  140 . It is also contemplated that multiple load manipulation devices can be placed at various locations across the hip joint to thereby balance out and/or decrease moment forces being accommodated. 
     In various approaches, on the femur side of a hip joint, the load manipulation devices can be attached at inferior and superior positions, to the greater trochanter, the lesser trochanter, at ostephytes on the femur, or along a bend in the neck of the femur. The device can also be affixed all around the neck and head of the femur including the base and underside of the femur head. Also, it is contemplated that on the femur side, the fixation point be beneath, within, above or in place of muscle. On the pelvis side, fixation of the absorber can be at the top or bottom of the acetabulum, along a ridge defining the acetabulum or along surrounding areas. Additionally, various surfaces on and around the ischium are also contemplated for fixation. Muscle may need to be displaced to gain sufficient access to the ischium to effect a proper fixation. 
     With reference now to  FIGS. 7-16 , there is shown various embodiments of load manipulation assembly implanted across a hip joint. Generally, the load manipulation assembly includes a rail component and a follower component. In some embodiments, the rail component and/or the follower component include one or more springs, absorbers, unloaders or actuators to absorb or off-load forces on the hip joint. Alternatively, the rail and/or follower components may be made from flexible materials and/or one or more materials having different physical properties. The follower component moves relative to the rail component during a gait cycle and absorbs or off-loads some portion of the load normally carried by the hip joint. In some embodiments, the follower and rail components are in contact with one another throughout the gait cycle. Alternatively, the follower and rail components are only engaged for a portion of the gait cycle. 
       FIGS. 7A-7B  illustrate one embodiment of a load manipulation assembly  150  in which the rail component  152  is fixed to the femur  100  and the follower component  154  is fixed to the pelvis  102 . As shown in  FIGS. 7A-7B , the rail component  152  is attached about the neck of the femur  100  to the medial and anterior surfaces of the neck. In alternate embodiments, the rail component  152  can be attached to the greater trochanter, the lateral cortex of the femur  100 , the distal surface of the femur neck or to combinations of these. 
     The rail component  152  is generally arch shape with a top surface  156  (also referred to as a bearing surface) that engages the follower component  154 . As shown in  FIGS. 7A-7B , the bearing surface  156  is in the shape of a flat arch shaped band. That is, a flat surface is a surface having no elevation change when moving across the bearing surface from one edge to an opposite edge of the bearing surface. In other embodiments, the top surface  156  can be convex, concave, or grooved in other embodiments. 
     The shape of the arch of the top surface  156  may be shaped or configured to maximize unloading of the hip joint during various positions of a gait cycle. For example, an arch shape with a high medial portion will maximize unloading when the hip is at a neutral or standing position. 
     As shown in  FIG. 7A , two spring elements  158  engage the base of the rail component  152  and connect the rail component to the femur  100 . The spring elements  158  can furnish the flexibility and force-carrying capacity of the rail  152 . Alternatively, the rail component  152  is made from a flexible material, such as a resilient material or a spring material, to provide these characteristics. In other embodiments, the rail component  152  can be directly fixed to the bone. Although two spring elements  158  have been shown, any number of spring elements may be provided between the rail component  152  and the bone surface to which the rail is attached. In one embodiment, each of the spring elements  158  are separately attached to the bone by one or more fasteners or bone screws. In another embodiment, a base member (not shown) is secured to the bone and the spring elements  158  are movable thereon. 
     The follower component  154  is fixed to the pelvis  102 , for example, the acetabelum with one or more locking screws. The follower component  154  is shaped to avoid certain bone structures and in combination with the rail component  152  to absorb or off-load forces on the hip joint. The distal end  160  of the follower component  154  may be shaped (e.g., rounded) to allow the follower component to move freely with respect to the rail component  152 , as shown in  FIGS. 7A-7B . Alternatively, one or more balls, rollers, or wheels  160  are provided at the distal end of the follower component  154  to facilitate movement over the top surface  156  of the rail component  152 . The bearing surface  156  of the rail component  152  may be contoured, i.e. concave, to correspond in shape to the distal end  160  of the follower component  154 . In some embodiments, the follower component  154  and/or the rail component  152  may be finished, polished, coated or made from materials to facilitate movement of the follower component  154  relative to the rail component  152  during the gait cycle and/or which reduce wear. 
       FIG. 8  illustrates another embodiment of a load manipulation assembly  170  in which a rail component  172  is fixed to the pelvis  102 , and two follower components  174  are coupled to the femur  100  via a base  176 . The rail component  172  is fixed to the pelvis by bone screws and is formed in an arc shape which generally follows the cure of the superior edge of the acetabular cup. While  FIG. 8  shows a load manipulation assembly  170  having two follower components  174 , any number of follower components may be used with the rail component  172 . 
     In one embodiment, the follower component  154  in  FIG. 8  includes an arbor/piston  178  surrounded by a spring  180 , as shown in  FIG. 8A . Alternatively, the load absorbing arm can include other flexible elements such as, but not limited to, polymers, resilient materials, gas/fluid pistons, or any combination thereof. A ball  182  is provided at one end of the follower component  174 . The ball  182  engages the rail component  172 . In one embodiment, the rail component includes a partially enclosed track and the ball  182  is captured by and slides within the track. Alternatively, the ball contacts  182  the rail component  172  for at least a portion of the gait cycle. In other embodiments, the ball  182  may be replaced with a wheel, bearing, or other rotating or non-rotating device. The end  184  of the follower component  174  that is opposite the ball  182  engages and is secured to a base component  176 . In other embodiments, the end  184  of the follower component  174  can include a ball, socket, ridge, groove, recess, or is otherwise shaped to engage the base component  176  in a movable manner. 
     As shown in  FIG. 8 , the base component  176  includes two openings  186  that receive the ends  184  of the follower component  174 . The openings  186  on the base component  176  and the ends of the follower component  174  may be a ball and socket connection. Alternatively, the connection between the base component  176  and the follower component  174  may be any pivoting connection known or developed in the art. 
     The rail and base components  172 ,  176  can be fixed to the bones with locking screws or other attachment means known or developed in the art. As shown in  FIG. 8 , the base component  176  is fixed to the medial and anterior neck of the femur  100 . Alternatively, the base component  176  can be fixed on the lateral cortex of the femur  100 , the greater trochanter or on the posterior surfaces of the neck of the femur. 
     The rail component  172  has a surface  188  that interacts with a portion the follower components  174 . In one embodiment, the surface  188  of the rail component  172  may be shaped (e.g., concave or have a track or groove) to capture a portion of the follower components  174 . That is, the follower component  174  is shaped so that the follower component is not easily removed from the rail component  172 . 
       FIG. 9  illustrates another embodiment of a load manipulation assembly  190 . The load manipulation assembly  190  includes a rail member  192  fixed to the neck of the femur  100  with bone fixators such as, but not limited to, locking screws. The rail  192  includes a flat bearing surface  200  as shown in  FIG. 9 . Alternatively, the rail  192  has a cam-like surface (not shown) having raised and/or lowered areas to provide varying resistance as the follower members  194  move along the top surface  200  of the rail  192 . As shown in  FIG. 9 , three follower members  194  are mounted to the pelvis  102  via fixation screws at locations spaced around the acetabular cup. However, other numbers of followers may also be used and their position can be selected depending on the particular disease and anatomy of a patient being treated. 
     The follower members  194  include a spring  196  supported on a rigid, telescoping piston arrangement that allows the follower member to extend and compress without bending while transferring forces from the hip to the femur. The follower members  194  also include a rotating component  198  such as, but not limited to, wheel, roller, bearing or other component that is able to rotate about a fixed axle and/or axis. The rotating component  198  contacts the surface  200  of the rail  192  during one or more portions of a gait cycle. In one embodiment, the loading members may have the same structure as the follower member shown in  FIG. 8A . Forces on the hip joint may be unloaded during the gait cycle as the follower member moves along (and pushes against) the rail surface  200 . 
     While the follower member  194  in  FIG. 9  is illustrated with a single spring  196 , multiple springs may be used to provide load bypass or absorption. Additional absorber designs which may be used in place of the follower member  194  are shown in U.S. Published Patent Application No. 2008/275558, which is incorporated herein by reference in its entirety. 
       FIG. 10  illustrates yet another embodiment of a load manipulation assembly  210  having a rail member  212  fixed to the femur and a follower member  214  fixed to the pelvis. In an alternate embodiment, the rail member  212  may be fixed to the pelvis and the follower member  214  is coupled to the femur. The rail member  212  is secured on the neck of the femur or the greater trochanter adjacent the neck. The rail member  212  includes a superior or superior and medially oriented surface  220  that is generally flat as shown in  FIG. 10 . Alternatively, the rail  212  may have a cam-like surface (not shown) having raised and/or lowered areas to provide varying unloading of the hip joint as the follower member  214  moves along the top surface. 
     As shown in  FIG. 10 , the follower member  214  is coupled to the pelvis by one or more fasteners (not shown). The follower member  214  includes a body  216  having a bearing surface  218  and is either in the form of a flexible leaf spring or is generally rigid. The body is shaped to avoid the anatomy in the hip. In yet another embodiment, a portion of body  216  is flexible and a portion is rigid, which allows the body to be flexible to a certain degree. In various embodiments, the body  216  may be entirely rigid or it can be flexible. Alternatively, the body  216  can be rigid with flexible portions, or vice versa. The bearing surface  218  of the body  216  contacts the top surface  220  of the rail member  212 . The bearing surface  218  can be finished, polished, coated or made from materials to facilitate movement of the follower member relative to the rail member during the gait cycle. In alternate embodiments, the bearing surface  218  may include one or more rotating members to facilitate movement of the follower member  214  over the top surface  220  of the rail member  212 . The follower member  214  can contact the top surface  220  of the rail member  212  during the entire gait cycle or only a portion thereof. 
       FIGS. 11A-C  show two embodiments of a load manipulation assembly  220  having an arc shaped rigid loop  222  (e.g., wire or band) fixed to the femur  100 . As shown in  FIG. 11 , a follower member  224  includes a rigid bar  226  having an opening  228  at one end. The loop  222  passes through the opening  228  of the rigid bar  226  to link the rigid loop and the follower member  224  together. Additionally, the rigid bar  226  is able to slide along the rigid loop  222  during motion of the hip joint to partially or fully unload the hip joint during some or all of the hip motion. In another embodiment, the rigid bar  226  can be coupled to the rigid loop  222  by a ball and socket joint  231  (or ball and track) as shown in  FIG. 11C . 
     Opposite the opening  228 , the rigid bar  226  may be coupled to the pelvis  102  via a base. The rigid bar  226  can be coupled to the base in a fixed or a movable manner, such as by a ball and socket joint. In one embodiment, the ball is provided at the end of the rigid bar  226  and the socket is provided on a base that is mounted to the pelvis. Alternatively, the socket is provided on the end of the rigid bar and the ball is provided on the base. In another embodiment, a pivot joint can be used to mount the rigid bar  226  to the pelvis  102 . In the embodiment, depicted in  FIGS. 11A-C , pressure against the rigid loop  222  transmits load from the hip to the femur and functions to at least partially unload the hip joint. The load manipulation assembly  220  may support sufficient forces in some embodiments to move the head of the femur  100  slightly out of the acetabulum. The rigidity and/or flexibility of the loop may be varied in order to vary the force off-loaded from the hip joint. Optionally, the length and rigidity of the bars  226  can also be varied to further cause the load manipulation assembly  220  to be active in a specific loading or motion range. 
       FIG. 11B  illustrates another embodiment of the load manipulation assembly  220  having two follower members  230  coupled to the rigid loop  222 . In other embodiments, there can be more than two follower members slidingly coupled to the rigid loop  222 . For example, there may be four follower members (not shown) spaced around the rigid loop  222 . As shown in  FIG. 11B , the follower members  230  include a spring  196  supported on a rigid, telescoping piston arrangement that allows the follower member to extend and compress without bending. The spring  196  can be supported on a rigid telescoping piston arrangement which allows the absorber to extend and compress without bending. Although the absorber  230  is illustrated with a single spring  196 , multiple springs may be used to provide load absorption. Additional examples of absorber designs which may be used in place of the absorber  230  are shown in U.S. Published Patent Application No. 2008/0275558, which is incorporated herein by reference in its entirety. 
       FIG. 11C  illustrates another embodiment of a load manipulation assembly  220  having a ball-socket  232  connection between the rigid loop  222  and an absorption member  230 . 
       FIG. 12  illustrates a load manipulation assembly  240  in which the rail assembly  242  includes a raised surface  244  that engages a follower member assembly  246  of the load absorption assembly. The follower assembly  246  can be directly or indirectly coupled to the pelvis. Alternatively, the follower assembly  246  can be anchored within the pelvis. The follower assembly  246  includes a spacer element  250  to adjust the position of the end of the follower assembly  246  that engages the rail assembly  240 . In one embodiment, the spacer element  250  is adjustable (i.e., the spacer may be shortened or lengthened). Alternatively, the spacer element (not shown) has a fixed length and shape, but the spacer element may be swapped out for other spacer elements having different lengths and/or shapes. 
     As shown in  FIG. 12 , the end  248  of the follower assembly  246  is concave and the rail assembly  242  has a convex surface  244 . Alternatively, the end of the follower assembly  246  is convex and the rail assembly has a concave surface. In yet another embodiment, the rail assembly (not shown) may be configured to capture the end  248  of the follower assembly  246 , as in a track. The mating surfaces between the follower assembly  246  and rail assembly  242  can be shaped to provide different points of contact or different amounts of load transfer during different phases of the gait cycle. 
       FIG. 13  illustrates another embodiment of a load manipulation assembly  250  in which the follower assembly  252  is anchored within the pelvis. The load absorption assembly may include a spring  254  or other force transmission device to push the follower assembly  252  into to the bearing surface  258  of the rail member  256 . In one embodiment, the spring is placed within or partially within a bore formed in the pelvis, preferably superior of the acetabular cup. In another embodiment, the spring is attached to the end of the load absorption assembly. 
       FIG. 14A  illustrates yet another load manipulation assembly  260  in which the rail assembly  262  is fixed to and entirely surrounds the neck of the femur. The follower component  264  is a circular bumper that spans the space between the rail assembly  262  and the ilium. The follower  264  and the rail  262  may be continuous or discontinuous.  FIG. 14B  illustrates another embodiment in which circular bumpers  266 ,  268  are provided on femur and the acetabulum. The circular bumpers  266 ,  268  can include a plurality of internal springs or a resilient material which provide compliance to the system. The thickness and/or durometer of the material of the bumpers (e.g., a portion of the bumper and/or entire bumper) can be varied to tailor the follower of the hip joint and/or avoid the anatomy adjacent/surrounding the rail assembly. 
     To implant the load manipulating assemblies, conventional surgical or minimally invasive approaches can be taken to gain access to a body joint or other anatomy requiring attention. Arthroscopic approaches are contemplated when reasonable to both implant the energy manipulation assembly as well as to accomplish adjusting an implanted assembly. Biologically inert materials of various kinds can be employed in constructing the energy manipulation assemblies of the present invention. The materials can include titanium or titanium alloy, cobalt chromium alloy, ceramic, high strength plastic such as polyetheretherketone (PEEK) or other durable materials. Combinations of materials can also be used to maximize the properties of materials for different parts of the device. At the wear surfaces, the material may include a combination of metal-on-poly, metal-on-metal, metal-on-ceramic or other combinations to minimize wear. 
     In one embodiment, the various elements can be comprised of silicone, silicone ePTFE, or other elastomeric materials which permit lengthening but resist compression beyond a given amount. Soft and hard segments can be disbursed along the elastomeric absorber to provide the desired compression and lengthening. On compression beyond a neutral position of the absorber, the hard segments provide resistance to compression and restrains the soft sections. The lengthening as well as flexibility of the absorber elements and the positioning of the rails is set such that the full or nearly full range of motion of a hip joint is maintained. Although the rail and follower elements are shown arranged primarily on the anterior and superior surfaces of the hip joint, they can also be arranged on the posterior, medial and lateral sides of the hip joint. They can be at converging or diverging angles with respect to one another or crossing arrangements. 
     As with each of the disclosed embodiments, a plurality of load controlling devices can be positioned across a hip joint. For this and other embodiments, the fixation points of the device are contemplated to be outside of the hip capsule and the absorber is positioned along natural planes and lines of the hip ligaments and away from major arteries and nerves. On the femur side, fixation of terminal ends of the load controlling device can for example, be configured to be placed along the greater trochanter and the neck of the femur. 
     It is to be borne in mind that each of the disclosed various structures can be interchangeable with or substituted for other structures. Thus, aspects of each of the assemblies can be employed across approaches. Moreover, the various manners of engaging energy absorbing structures, rails, followers with attachment structures and attachment structures to body anatomy can be utilized in each approach. Also, one or more of the various disclosed assemblies can be placed near a treatment site and at various angles with respect thereto. Pressure sensing and drug delivery approaches can also be implemented in each of the various disclosed embodiments. 
     Certain components of most embodiments can be designed for easy removal and, if necessary replacement while others are intended for permanent fixation. The devices can also be implanted encased within a sheath. The permanent components are fixation components which can have bony in-growth promoting surfaces and are responsible for fixation of the system to the skeletal structure. The removable components include the mobile elements of the system such as the link members and/or the pivots or ball joints. 
     The disclosed embodiments permit the exchange of key components of the system due to device failure, patient condition change or newer improved systems being available. Additionally if the patient subsequently requires further surgery the links may be removed to facilitate the additional procedure. 
     Further, certain of the contemplated mechanisms can be made to be completely disengaged mechanically and then brought into action under various conditions and during certain phases of the gait cycle. This discontinuous functionality—and the ability to tune that functionality to a particular patient&#39;s gait or pain is consequently a feature of one or more of the disclosed embodiments. 
     Location of the permanent fixation components is important to fixation strength, ability to complete subsequent procedures, and location of pivots or ball joints. The fixation strength of the system, and therefore load bearing capacity, is dependent on the integrity of the bone onto which the plate is fixed. To ensure strong fixation, in one embodiment, the fixation components span along the cortical bone and cancellous (or trabecular) bone. The system may utilize fixation on two cortical surfaces using through pins or bicortical screws. 
     A common joint procedure is joint replacement as previously described. The procedure of replacing a diseased joint includes resection of the surfaces of the joint and replacement with synthetic materials. To enable implantation of the energy absorbing system without impacting the potential to complete subsequent procedures (e.g., joint replacement) the permanent fixation components in a preferred embodiment are positioned at a location that does not compromise the total joint zone. 
     Many articulating joints are not simply pivot joints but involve complex multi-axis rotation and translation movements. To achieve its intended purpose, the energy absorber must accommodate these movements but also absorb and transfer energy during the required range of motion. To do so the joints on the device may be either located at points on the bones of least motion, or the joint mechanism must incorporate motion beyond simple uni-axial rotation or a combination of both. 
     Further, the fixation components can be positioned such that they orientate the attached device joint locations to preferred locations described by minimal or known motion characteristics. The device joint locations may be finely adjusted within a defined region on the fixation component to further optimize the device joint location. The device joint mechanism can also be configured to accommodate the positional changes and therefore can be placed on any distal point on the fixation component. 
     Therefore, the present invention provides a number of ways to treat body tissues and in particular, to absorb energy or manipulate forces to reduce pain. The disclosed devices can be used throughout the body but have clear applications to articulating body structures such as joints. 
     Thus, it will be apparent from the foregoing that, while particular forms of the invention have been illustrated and described, various modifications can be made without parting from the spirit and scope of the invention.