Minimally invasive orthopaedic apparatus and methods

Apparatus (20, 120, 300) and methods for use in the performance of minimally invasive orthopedic procedures, including apparatus and methods for use in the performance of such procedures under the visualization of an endoscope (22), are herein disclosed. Such procedures include a minimally invasive intramedullary nailing procedure, a minimally invasive bone graft harvesting procedure, a minimally invasive pelvic osteotomy procedure, an orthopedic implant revision procedure, and a minimally invasive percutaneous bone plating procedure.

FIELD OF THE DISCLOSURE

The present disclosure relates generally to orthopaedic methods and apparatus, and more particularly to methods and apparatus for use in the performance of endoscopic minimally invasive orthopaedic procedures.

BACKGROUND OF THE DISCLOSURE

Minimally invasive surgical techniques have been developed for many different types of surgical procedures. Such techniques attempt to balance the need to achieve the goal of the surgical procedure while minimizing the surgical injury to the patient. As such, surgeries performed by use of minimally invasive techniques generally result in lower postoperative morbidity, shorter postoperative stay, less postoperative pain, decreased cost, and quicker recovery as compared to “open” or conventional surgical techniques. Because of the aforementioned advantages, these minimally invasive techniques are being applied to an increasing variety of surgical procedures. For example, minimally invasive techniques in the form of laparoscopic procedures, such as a laparoscopic colectomy for carcinoma of the colon, have been developed.

However, despite growing use in other surgical fields, minimally invasive techniques have not been significantly developed for use in orthopaedic procedures. In particular, although orthopaedic surgeons have recognized the general principle that maintenance of soft tissue contributes significantly to the postoperative healing process, conventional techniques in which the soft tissue is completely opened in order to gain complete access to the bone structure therein are still in widespread use. One reason for this is the unique nature of many orthopaedic procedures. In particular, orthopaedic procedures often involve the “delivery” and implantation of devices which are relatively large in design compared to the “deliverables” associated with other forms of surgery. In particular, in the case of, for example, an appendectomy, minimally invasive techniques are adaptable since the surgeon may aptly remove the subject tissue (i.e., the patient's appendix) and thereafter deliver and install the necessary sutures through the relatively small confines of a cannula of a trocar. However, in the case of, for example, trauma repair of a heavily fractured long bone (e.g., a femur or tibia), one or more relatively large plates are screwed or otherwise fastened to the fractured bone. The size of such plates has long since been viewed as prohibitive in regard to the use of minimally invasive techniques for the implantation thereof.

Another reason commonly cited in regard to the use of traditional techniques (i.e., “open” incisions) is the surgeon's need to visualize the surgical site. In particular, orthopaedic procedures commonly include complicated fractures which require precision in regard to the installation of fixation devices (e.g., screws and the like) and the reduction of such fractures. As such, surgeons have heretofore preferred to open the soft tissue surrounding the bone to be treated in order to completely expose the surgical site.

As a result of such continued use of “open” procedures, soft tissue surrounding the bone continues to be compromised thereby impairing normal blood circulation to the treated bone, potentially delaying fracture healing, and potentially increasing the risk of infection. Indeed, although the majority of patients treated with such procedures heal without complication, there are certain occasions in which complications such as infection or non-union occur thereby prolonging healing rates and, in certain cases, increasing the rates of secondary revisions.

As a result of the aforedescribed shortcomings associated with traditional orthopaedic surgeries, along with the promise associated with minimally invasive techniques, a number of attempts have been made to provide certain of the advantages associated with minimally invasive techniques to a limited number of orthopaedic procedures. For example, plate fixation assemblies have heretofore been developed for use in fracture repair of femurs. However, such assemblies suffer from a number of drawbacks. For example, such assemblies rely heavily on the use of fluoroscopy as the manner by which the surgeon “visualizes” the surgical site. In addition to the fundamental limitations relating to the resolution associated with fluoroscopy, many surgeons may also be reluctant to embrace the use of large amounts of fluoroscopy in order to minimize radiation exposure to themselves, the other members of the surgical staff, and the patient.

SUMMARY OF THE DISCLOSURE

The concepts of the present disclosure provide apparatus and methods for use in the performance of minimally invasive orthopaedic procedures. The concepts of the present disclosure also provide apparatus and methods for use in the performance of such procedures under the visualization of an endoscope.

In accordance with one illustrative embodiment of the concepts of the present disclosure, there are provided apparatus and methods for use in the performance of a minimally invasive intramedullary nailing procedure. In accordance with a more specific implementation of this illustrative embodiment, there are provided apparatus and methods for use in the performance of an endoscopic minimally invasive intramedullary nailing procedure.

In accordance with another illustrative embodiment of the concepts of the present disclosure, there are provided apparatus and methods for use in the performance of a minimally invasive bone graft harvesting procedure. In accordance with a more specific implementation of this illustrative embodiment, there are provided apparatus and methods for use in the performance of an endoscopic minimally invasive bone graft harvesting procedure. There are also provided, in accordance with a more specific implementation of this illustrative embodiment, methods and apparatus for use in the performance of a minimally invasive, or even an endoscopic minimally invasive, bone graft material delivery procedure.

In accordance with another illustrative embodiment of the concepts of the present disclosure, there are provided apparatus and methods for use in the performance of a minimally invasive pelvic osteotomy procedure. In accordance with a more specific implementation of this illustrative embodiment, there are provided apparatus and methods for use in the performance of an endoscopic minimally invasive pelvic osteotomy procedure.

In accordance with another illustrative embodiment of the concepts of the present disclosure, there are provided apparatus and methods for use in the performance of an orthopaedic implant revision procedure. In accordance with a more specific implementation of this illustrative embodiment, there are provided apparatus and methods for use in the performance of an endoscopic orthopaedic implant revision procedure.

In accordance with another illustrative embodiment of the concepts of the present disclosure, there are provided apparatus and methods for use in the performance of a minimally invasive percutaneous bone plating procedure. In accordance with a more specific implementation of this illustrative embodiment, there are provided apparatus and methods for use in the performance of an endoscopic minimally invasive percutaneous bone plating procedure.

DETAILED DESCRIPTION OF ILLUSTRATIVE EMBODIMENTS

Referring now toFIGS. 1-53, there is shown a number of apparatus and methods which may be utilized to perform a minimally invasive orthopaedic surgical procedure. Common to many of the concepts disclosed herein is the notion of utilizing endoscopic instruments to provide the surgeon with enhanced viewing capabilities in the form of direct visualization of the surgical site. The concepts of the present disclosure may be utilized in a wide variety of orthopaedic procedures. Indeed, although the concepts of the present disclosure will be described in regard to specific orthopaedic procedures, it should be appreciated that such concepts are not limited to the specific exemplary embodiments described herein, but rather may be utilized in a wide variety of orthopaedic procedures.

As utilized herein, the term “endoscope” is intended to mean any device which is capable of collecting images for display on a display device. As such, the endoscopes of the present disclosure may take the form of a conventional endoscopic “wand” which utilizes conventional endoscopic imaging techniques. Conventional endoscopes are constructed such that an objective lens and an eyepiece are disposed at opposite end portions of optical fibers for transmitting an image. The image of an article to be observed is made to focus at one end face of the optical fibers. A transmitted image of the article is transmitted through the optical fibers and appears on the other end face so as to be observed through the eyepiece.

More recently, endoscopes have been constructed in which an image sensor converts an optical image focused on the sensor into electrical signals. The image sensor typically includes an array of light detecting elements in which each element produces a signal corresponding to the intensity of light impinging on the element when an image is focused on the array. These signals may then be used, for example, to display a corresponding image on a monitor or otherwise used to provide information about the optical image. One common type of image sensor is a charged coupled device (CCD). CCDs have been improved greatly during the last several years, and, as a result, provide images with very good resolution.

Another type of image sensor is formed as an integrated circuit using a complementary metal oxide semiconductor (CMOS) process. In such a CMOS type image sensor, a photodiode or phototransistor (or other suitable device) is used as the light-detecting element in which the conductivity of the element corresponds to the intensity of light impinging on the element. The variable signal thus generated by the light-detecting element is an analog signal whose magnitude is approximately proportional (within a certain range) to the amount of light impinging on the element. Examples of medical devices using a CMOS chip are provided in U.S. Pat. No. 5,817,015 issued to Adair on Oct. 6, 1998 and U.S. Pat. No. 6,139,489 issued to Wampler et al. on Oct. 31, 2000, both of which are hereby incorporated herein by reference.

It is known to form these light-detecting elements in a two-dimensional core array that is addressable by row and column. Once a row of elements has been addressed, the analog signals from each of the light detecting elements in the row are coupled to the respective columns in the array. In some CMOS based systems, an analog-to-digital (A/D) converter may then be used to convert the analog signals on the columns to digital signals so as to provide only digital signals at the output of the image sensor chip. These signals may then be transmitted to a video display for viewing of the image. Examples of this type of video format include the PAL format commonly used for European televisions, and the high resolution S-video format used in, for example, surgical operating rooms. Indeed, most CCD based endoscopic systems also use the S-video format.

Other CMOS based systems send an analog signal to the video display. An example of this type of format is the NTSC format such as the format used for standard television signals in the United States. The latter is a very popular format, therefore, for CMOS based systems, due to the huge number of NTSC formatted televisions available.

CMOS image sensors are generally highly sensitive to light. As a result, the light intensity required to illuminate the image when using a CMOS system (typically less than or equal to one lux) is relatively low. In fact, a very low power light source, such as a tungsten filament, incandescent, penlight bulb, placed near the area being imaged, or used within a short distance of a light transmitting element such as an acrylic rod, is sufficient for the CMOS system to obtain a good image. The low power light source and transmitting element are small enough to be placed inside of a handheld, endoscopic medical instrument. Moreover, CMOS image sensors require very little electrical power and it is practical to use small (in the range of 6-9 VDC) batteries to operate them, although a CMOS image sensor can also be used with a conventional DC power supply connected to a wall outlet.

From the foregoing discussion, it is evident that a CMOS based visualization system may provide a disposable, low cost, high resolution, wireless system. Indeed, one or both the light source and the power source can be integrated into a handheld instrument to operate the CMOS image sensor constructed into the viewing end of the instrument. The output signal of the CMOS image sensor could then be connected to any one of a number of video displays, including conventional televisions or monitors, depending on the video format chosen. Alternatively, the output signal of the CMOS image sensor may be coupled to a “heads up” display such as a commercially available heads up display unit being offered by, amongst others, Sony Corporation.

In any of the above described cases, the image collecting unit (e.g., the camera) may be fixed in position or steerable. Moreover, illumination for operating any of the aforedescribed endoscopes may be provided by the use of commercially available LED's, tungsten bulbs, or a light pipe with an illumination source mounted in the handle or externally to the device. Illumination may also be provided in conventional manners. In the case of when a CMOS pinhole camera is used, the illumination source may be infrared LED's.

Moreover, in the case of utilizing an endoscope to visualize the advancement of an obturator of a trocar, a number of different configurations are available for use in regard to the concepts of the present disclosure. For example, a separate, independent endoscope may be utilized which peers through or even around the tip of the obturator. Alternatively, the endoscope may be integrated into the clear tip of the obturator itself. Examples of an integrated endoscope and obturator are shown in U.S. Pat. No. 5,797,944 which was issued to Nobles et al. on Aug. 25, 1998, and which is hereby incorporated herein by reference.

In one exemplary embodiment of the concepts of the present disclosure, an apparatus and method are provided to allow a surgeon to perform an intramedullary nailing procedure. This concept will be described herein in regard to the nailing of a patient's femur, although it should be appreciated that the concepts of the present disclosure may be utilized in regard to the nailing of other bone structures. For example, the concepts described herein may also be utilized to install intramedullary nails in a tibia or a humerus or supracondylar nails in a distal femur. As will now be discussed in regard to the installation of an intramedullary nail into the intramedullary canal of a femur, the concepts of the present disclosure allow for such installation of intramedullary nails without the use of a large, open incision and without the use of fluoroscopy.

Heretofore utilized intramedullary femoral nailing techniques required the “filleting” of the patient's hip12to expose the greater trochanter14of the femur16(seeFIG. 1). Such filleting of the patient's hip12provides the surgeon with direct visualization of the proximal end of the femur16. Thereafter, such heretofore utilized techniques require that an awl18or other type of instrument be placed on the femur16at the approximate entry point for a guide pin (not shown) which is used in the installation of the intramedullary nail. To confirm that the awl18is at the proper entry point of the guide pin (i.e., a point on the femur16adjacent to the greater trochanter14at the lateral edge of the piriformis fossa), a number of intraoperative anterior-posterior and lateral radiographs are taken for use by the surgeon.

However, procedures utilizing certain of the concepts of the present disclosure avoid such filleting of the hip12and the use of radiographs. In particular, according to one illustrative embodiment of this concept, an endoscopic instrument may be utilized by the surgeon to directly visualize the entry point for the guide pin. In a more specific illustrative embodiment, as shown inFIG. 2, a cannulated instrument such as a trocar20is inserted through a small stab incision58in the skin of the patient. The trocar20has an endoscope22associated therewith. In one exemplary embodiment, the endoscope22is positioned in the cannula24. In such an arrangement, the endoscope22may be of conventional design and is positioned to visualize through a clear tip26of an obturator28associated with the trocar20. However, it should be appreciated that other configurations of the endoscope22are also contemplated. For example, the endoscope22may be secured to an outer portion of the cannula24of the trocar20or may be integrated into the tip26of the obturator28.

Under visualization, the tip26of the obturator28is advanced through the underlying tissue to a location on the proximal end of the femur16adjacent to the greater trochanter14, as shown inFIG. 2. As such, the surgeon may utilize the images generated and returned from the endoscope22to position the tip26of the obturator28on the desired entry point for a guide pin. The surgeon may then remove the obturator28from the cannula24of the trocar20.

Once the obturator28has been removed, the surgeon may then advance instruments through the cannula24, such as an awl or step drill (not shown), to prepare the femur16for the introduction of a guide pin30. The prepared femur16is shown inFIG. 3. Thereafter, as shown inFIG. 4, the guide pin30is advanced through the cannula24of the trocar20until the distal tip32thereof approaches the prepared hole34in the femur16. The tip32of the guide pin30is then advanced under visualization provided by the endoscope22. Specifically, the images of the prepared entry point (i.e., the hole34) of the femur16collected by the endoscope22are utilized by the surgeon to aid the advancement of the distal tip32of the guide pin30into the hole34prepared in the femur16.

Once the guide pin30has been inserted into the femur16, the nailing procedure may be completed. Specifically, the cannula24may be removed so that a tubular shaped skin protector36may be slipped over the guide pin30and thereafter inserted through the incision58in the skin. The skin protector36is then advanced through the underlying tissue to a position proximate to the entry point of the guide pin30into the femur16, as shown inFIG. 5. During such advancement of skin protector36, the skin, along with the underlying tissue, is spread slightly in order to protect the same during subsequent implantation of a cannulated intramedullary nail38. Once the skin protector36is secured in place, the distal tip46of the nail38(seeFIG. 6) may be advanced into the prepared hole34in the proximal end of the femur16.

To do so, the nail38is first secured to a jig42. Specifically, as shown inFIG. 7, a locking bolt44is utilized to threadingly engage a proximal end40of the nail38. Once secured in such a manner, the distal tip46of the nail38is advanced into the prepared hole34in the proximal end of the femur16. Thereafter, a sliding hammer48may be utilized to drive the nail38into the intramedullary canal of the femur16to a desired depth, as shown inFIG. 8.

As shown inFIG. 9, the jig42may then be utilized to guide the placement of a number of cortical screws50into a number of holes52defined in the proximal end40of the implanted nail38. The screws50are advanced through a number of stab incisions54created in the skin of the patient. It should be appreciated that a number of such cortical screws may also be installed in similar holes located on the distal end of the implanted nail38.

As shown inFIG. 10, the jig42may then be removed by removal of the locking bolt44. An end cap56may then be advanced through the incision58and thereafter screwed or otherwise secured to the proximal end40of the implanted nail38. Installation of the end cap56prevents bony ingrowth into the threads of the proximal end40of the implanted nail thereby facilitating subsequent removal of the nail38after the femur16has healed.

Bone Harvesting and Delivery

In another exemplary embodiment of the concepts of the present disclosure, an apparatus and method are provided to allow a surgeon to harvest bone graft material along with the subsequent delivery of the same. This concept will be described herein in regard to the harvesting of bone graft material from the anterior surface of the patient's ilium, although it should be appreciated that the concepts of the present disclosure may be utilized in regard to the harvesting of bone graft material from other bone structures. For example, the concepts described herein may also be utilized to harvest bone graft material from the posteriorsuperior iliac spine of the ilium, a bicortical graft from the anterior aspect of the ilium, the styloid of the radius, the olecranon, the anterior aspect of the greater trochanter, the distal femoral condyle, the proximal tibia, and the distal tibia.

In regard to the specific exemplary embodiment of harvesting of bone graft material from the anterior surface of the patient's ilium, the concepts of the present disclosure allow for such bone harvesting without the use of a large, painful, open incision. In particular, heretofore utilized iliac harvesting techniques have required the filleting of the patient. Specifically, the surgeon cuts a large curvilinear incision along a path that is parallel to the iliac crest. Thereafter, the surgeon must subperiosteally dissect the abdominal musculature and, subsequently, the iliacus from the inner wall of the ilium. The bone graft material is then harvested from the ilium. Once the harvest is complete, the surgical site is closed and sutured.

An improvement to such a technique has been a long felt need. In particular, it has been noted that many patients observe significantly greater amounts of postoperative discomfort (i.e., pain), and are subjected to a significantly longer recovery period, as a result of the harvesting procedure than is generally attributable to the underlying ailment for which the patient is treated (i.e., the ailment at the site of the bone graft delivery).

In one illustrative embodiment of the concepts of the present disclosure, an endoscopic instrument may be utilized by the surgeon to directly visualize the harvest location of the anterior surface114of the ilium116. In a more specific illustrative embodiment, as shown inFIG. 11, a cannulated instrument such as a trocar120is inserted through a small stab incision158in the skin of the patient. The trocar120has an endoscope122associated therewith. In one exemplary embodiment, the endoscope122is positioned in the cannula124of the trocar120. In such an arrangement, the endoscope122may be of conventional design and is positioned to visualize through a clear tip126of an obturator128associated with the trocar120. However, it should be appreciated that other configurations of the endoscope122are also contemplated. For example, the endoscope122may be secured to an outer portion of the cannula124of the trocar120, or, alternatively, may be integrated into the tip126of the obturator128.

Under visualization, the tip126of the trocar120is advanced through the underlying tissue to a location proximate to the anterior surface114of the ilium116, as shown inFIG. 11. As such, the surgeon may utilize the images generated and returned from the endoscope122to position the tip126of the obturator128proximate to the desired harvesting location of the ilium116. The surgeon may then remove the obturator128from the cannula124of the trocar120.

Once the obturator128has been removed, the surgeon may then advance a number of instruments through the cannula124of the trocar120in order to perform the harvesting operation. For example, as shown inFIG. 12, a number of straight and/or curved osteotomes130are advanced through the cannula124of the trocar120and thereafter manipulated or otherwise operated by the surgeon to form an outline of the area to be harvested in the ilium116of the patient. Such outlining of the anterior ilium prevents splitting of the ilium116into the sciatic notch. It should be appreciated that the surgeon performs such outlining of the ilium116under the visualization provided by the endoscope122. Specifically, along with the osteotome130, the endoscope122is present in the cannula124of the trocar120to provide direct visualization of the harvest site during use of the osteotome130.

Once outlined in such a manner, corticocancellous strips or other portions of the ilium116may then be removed. In particular, as shown inFIG. 13, a material removal instrument such as a curette or a gouge132may be advanced through the cannula124of the trocar120and thereafter manipulated by the surgeon in order to harvest bone graft material from the ilium116. Such harvesting of the anterior ilium116is also performed under the visualization provided by the endoscope122. Specifically, along with the material removal instrument (e.g., the gouge132), the endoscope122is also positioned in the cannula124of the trocar120during the harvesting operation. As such, the images collected by the endoscope122are utilized by the surgeon to visualize the surgical site (i.e. the anterior ilium116) during use of the gouge132.

It should be appreciated that other types of instruments may also be utilized to remove the bone graft material from the patient's ilium116. For example, an auger (not shown) may be advanced through the cannula124of the trocar120and thereafter into the cortex of the ilium116. In such an arrangement, rotation of the auger causes removed bone material to be advanced through the cannula124via the helical band of the auger.

It should also be appreciated that the concepts of the present disclosure may also be utilized during delivery of the bone graft material to a delivery site such as a spinal location. For instance, a trocar120having an endoscope122associated therewith may be utilized to access the delivery site. Use of a minimally invasive device such as the trocar120prevents the need for elongated incisions and dissection at the delivery site. Moreover, by utilizing the endoscope122, the delivery operation may be performed under direct visualization thereby allowing the surgeon to implant the graft material without inadvertently contacting other anatomical structures proximate to the delivery site.

It should also be appreciated that other surgical configurations may also be utilized during bone harvesting/delivery. For example, if the number or configuration of the surgical instruments required to harvest or deliver the bone graft material utilizes substantially all of the area within the cannula124of the trocar120, a second trocar120may be utilized. For example, a first trocar120may be utilized to permit visualization of the surgical site with the endoscope122, whereas a second trocar120may be utilized to permit access to the surgical site by providing for advancement of the necessary harvesting instruments (e.g., an osteotome, gouge, or auger).

In another exemplary embodiment of the concepts of the present disclosure, an apparatus and method are provided to allow a surgeon to perform a pelvic osteotomy. As will now be discussed in greater detail, the concepts of the present disclosure allow for the performance of a pelvic osteotomy without requiring a large, open incision. In particular, heretofore utilized techniques for performing a pelvic osteotomy generally require the use of a number of relatively long incisions, along with extensive muscle stripping and tendon division. As a result, patients often suffered from heavy blood loss, lengthy hospitalization stays, and relatively long recovery periods. Moreover, even despite the relatively extensive exposure of the hip during such a procedure, certain portions of the periacetabular osteotomy may still be difficult for the surgeon to visualize.

However, procedures utilizing concepts of the present disclosure avoid such drawbacks of heretofore utilized techniques. In particular, according to one illustrative embodiment of the present disclosure, a pelvic osteotomy may be performed by the surgeon while directly visualizing the bone during sawing thereof. In a more particular illustrative embodiment, a number of trocars, similar in nature to the trocars hereinbefore described (i.e., the trocar20and the trocar120) are inserted through small stab incisions in the skin of the patient to visualize the surgical site. Specifically, as shown inFIG. 14, a first trocar (not shown) may be inserted at a groin insertion location202, whereas a second trocar (not shown) may be inserted at an iliac insertion location204.

One or both of the inserted trocars have an endoscope associated therewith. In one exemplary embodiment, the endoscope is positioned in the cannula of the trocar. In such an arrangement, the endoscope may be of conventional design and is positioned to visualize through a clear tip of an obturator associated with the trocar much in the same way the endoscopes were utilized to visualize the approach to the surgical site in the aforedescribed procedures. It should be appreciated that other configurations of the endoscope are also contemplated for use during performance of a pelvic osteotomy. For example, the endoscope may be secured to an outer portion of the cannula of the trocar, or, alternatively, may be integrated into the tip of the obturator.

Under visualization, the tip of the trocar may be advanced through the underlying tissue to a desired location near the hip bone structures to be treated. As such, the surgeon may utilize the images generated and returned from the endoscope to position the tip of the obturator proximate to the hip bone structures which are to be treated. The surgeon may then remove the obturator from the cannula of the trocar.

Once the obturator has been removed, the surgeon may then advance a number of surgical instruments through the cannulae of the trocars in order to perform the pelvic osteotomy. For example, a number of micro sawing instruments may be advanced through the cannulae and thereafter utilized to saw one or more of the structures of the hip bone in a desired location. It should be appreciated that such sawing of the hip bone is performed under the direct visualization of the endoscopes positioned in one or both of the trocars. As such, the surgeon maintains a direct view of the bone being sawed.

In addition to providing visualization of the bone which is being sawed, use of the endoscopes positioned in the trocars provides a number of other distinct advantages. For example, by directly visualizing the surgical site, inadvertent severing of certain anatomic structures may be avoided. For example, such visualization of the surgical site will prevent the inadvertent severing of the obturator neurovascular bundle or the sciatic nerve.

Implant Revision Procedures

In another exemplary embodiment of the concepts of the present disclosure, an apparatus and method are provided to allow a surgeon to visualize the surgical site during performance of an orthopaedic implant revision procedure. In particular, as will now be discussed in greater detail, the concepts of the present disclosure allow the surgeon to visualize the intramedullary canal of a bone during an orthopaedic implant revision procedure. Such capability is a significant improvement over heretofore utilized techniques in which the surgeon did not possess the ability to “see” into the intramedullary canal beyond his or her ability to “peer” into the canal. The ability to visualize the intramedullary canal has been improved somewhat by the use of illumination instruments which are lowered into the canal, but the surgeon remains constrained by the limitation that he or she can only observe the canal from “outside” the bone.

However, procedures utilizing concepts of the present disclosure avoid such drawbacks of heretofore utilized techniques. In particular, as shown inFIG. 15, according to one illustrative embodiment of the present disclosure, an endoscope222is lowered into the intramedullary canal214of the bone216to directly visualize the bone during the implant revision procedure. In particular, as shown inFIG. 15, a number of cutting instruments220may be utilized to scrape or otherwise remove any residual bone cement218(i.e., the cement218that was utilized to retain the previously removed prosthesis). During such a procedure, the endoscope222may be lowered into the intramedullary canal214such that the images generated by the endoscope222may be utilized to inspect the intramedullary canal214during the implant revision procedure. Such an inspection may be utilized to confirm, amongst other things, adequate bone cement removal and the lack of any spiral fractures in the bone.

In such an arrangement, the endoscope222may be of conventional design and may be positioned to visualize the canal214continuously during the procedure. Alternatively, the endoscope222may be lowered into the canal214only periodically during the procedure.

In a more specific exemplary embodiment, the endoscope222may be provided as part of a “combination” instrument. For example, instruments for use in implant revision procedures have heretofore been designed which provide for irrigation of the canal214, suction of removed material or debris, illumination (i.e., lighting) of the canal214, and cutting of the residual cement218. As such, these irrigation-suction-illumination-cutting instruments have become a useful tool for surgeons since they perform multiple functions within the confines of a single instrument. In order to render such instruments even further useful to a surgeon, the concepts of the present disclosure provide for the bundling of the endoscope222with such a combination instrument.

The resultant instrument would provide for all of the functions described above (i.e., irrigation, suction, illumination, and cutting) while also providing for visualization of the intramedullary canal214. Specifically, the integration of the endoscope222into the device would provide for a device which allows the surgeon to visualize the inner surfaces of the intramedullary canal214, including the residual bone cement218present therein, while also performing one or more of the other associated functions of the instrument (i.e., irrigation, suction, illumination, and cutting).

Percutaneous Plating

In another exemplary embodiment of the concepts of the present disclosure, an apparatus and method are provided to allow a surgeon to perform a bone plating procedure in a percutaneous manner. As will now be discussed in greater detail, the concepts of the present disclosure allow for the performance of a minimally invasive, percutaneous bone plating procedure without requiring a large, open incision. In particular, heretofore utilized techniques for performing such a plating procedure generally require the use of a number of relatively long incisions, along with the associated extensive muscle stripping and tendon division. As a result, patients often suffered from heavy blood loss, lengthy hospitalization stays, and relatively long recovery periods.

However, procedures utilizing concepts of the present disclosure overcome such drawbacks of heretofore utilized techniques. In particular, according to one illustrative embodiment of the present disclosure, an apparatus and method are provided for inserting a bone plate into a relatively small incision and thereafter securing the plate to a desired position on a bone. In doing so, the plate is inserted under visualization provided by an endoscope associated with the apparatus.

Referring now toFIGS. 16-53, there is shown a number of exemplary embodiments of a bone plating instrument300. The plating instrument300includes a housing302(which, in the exemplary embodiment described herein, includes a handle304), an elongated cannulated shaft306, and a tissue expander308. As shown inFIG. 16, in one exemplary embodiment, the tissue expander308may be embodied as a spoon-shaped member310(referred to hereinafter simply as spoon310), whereas in other embodiments, the tissue expander308is embodied as a tunnel-shaped member312(referred to hereinafter simply as tunnel312). It should be appreciated that the tissue expander308is utilized to expand the tissue around the bone314to be treated to provide access to the bone314for both a bone plate316and the instruments necessary for installation of the same. As such, the tissue expander308provides a subcutaneous working space for the positioning and securing (with bone screws) of a bone plate316onto a fractured bone314.

As shown in, for example,FIGS. 16,17, and23, the tissue expanders308of the present disclosure include a body309having a top wall311and a pair of downwardly extending side walls313. It should be appreciated that although the body309of the tissue expanders308are herein described as being generally semi-tubular or otherwise arcuate shaped in cross section, other configurations of the body309are also contemplated for use. For example, the cross sectional shape of the body309of the tissue expanders308(i.e., either the spoon310or tunnel312) may be non-arcuate in shape such as in the case of two longitudinal rails spaced apart and coupled by a number of cross elements.

The aforedescribed embodiments of the tissue expanders308provide for a relatively large degree of flexibility in regard to the design of the plating instrument300. Additional flexibility may be achieved by the use of removable tissue expanders308. In particular, the spoon310may be configured to be removably secured to the elongated cannulated shaft306, whereas the tunnel312may be configured to be removably secured to the handle304. In such an arrangement, different sizes, shapes, or types of spoons and tunnels may be utilized on a common shaft306/handle304assembly thereby allowing the plating instrument300to be adapted to fit the needs of a given patient's anatomy or surgical procedure.

The plating instrument300has an endoscope330associated therewith (see, e.g.,FIG. 25). The endoscope330is provided to allow the surgeon to visualize the bone314along with the plate316being secured thereto. Specifically, as shown inFIG. 19, during installation of the bone plate316, the images generated by the endoscope330are utilized by the surgeon to visualize the surgical site.

The plating instrument300also includes a screw alignment device or jig318. The screw alignment device318is provided to align bone screws320with a number of holes322defined in the bone plate316(see, e.g.,FIG. 39). Specifically, the screw alignment device318, when secured to the housing302of the plating instrument300, may be utilized to guide the screws320during percutaneous advancement thereof into the holes322of the bone plate316. To do so, the surgeon visualizes the location of the individual holes322of the bone plate316by use of the endoscope330. Under such visualization, the surgeon may then align one of the holes322of the plate316with an access hole324defined in the tissue expander308. As shown inFIG. 16, the spoon310has a single hole324defined therein. As such, the surgeon, under visualization, aligns the hole324of the spoon310with one of the holes322of the bone plate316.

Once the holes324,322are aligned with one another, a screw320may be inserted through a stab incision in the skin of a patient by use of the screw alignment device318. Specifically, when the screw alignment device318is secured to the housing302of the plating instrument300, a guide hole326defined therein is aligned with both the hole324in the tissue expander308and the hole322in the bone plate316. As such, a cannulated guide342may be advanced through the hole326in the alignment device318, the stab incision and underlying tissue, and through the hole324in the tissue expander308(see, e.g.,FIG. 39). A bone screw320may then be advanced through the cannulated guide342, the hole324in the tissue expander308, and one of the holes322in the bone plate316and thereafter threadingly engage the fractured bone314

It should be appreciated that the stab incision through which the screw320is advanced may be created in a number of different manners. For example, an obturator (not shown) may first be advanced through the cannulated guide342and into the skin and underlying tissue of the patient. The obturator may be advanced to the point at which the obturator enters the hole324of the tissue expander308. The obturator may then be removed from the cannulated guide342such that the screw320may thereafter be advanced through the guide342. It should be appreciated that an elongated screw driver (not shown) may be advanced through the cannulated guide342(and hence the incision) to drive the screw320into the bone314.

As shown inFIGS. 16-18, the screw alignment device318may take on many different forms. Specifically, the design of the screw alignment device318may be modified to, for example, cooperate with a given design of the tissue expander308. For example, as shown inFIG. 16, the screw alignment device308may take the form of an elongated member with only a single hole326. In such an embodiment, the hole326of the alignment device308is aligned with the hole324in the spoon310. In use, the surgeon utilizes the handle304to pull the instrument300along the length of the implanted plate316in order to successively align the hole324of the spoon310(and hence the hole326of the alignment device318) with the individual holes322of the implanted plate316.

However, in the case of the instrument300being configured with the tunnel312, the alignment device318may be configured with a plurality of the holes326, each of which aligns with one of the plurality of holes324defined in the tunnel312. In such an arrangement, the position of the holes324(and hence the holes326) may be predetermined in order to align with the holes322defined in the plate316. In this manner, the instrument300need not be moved in order to drive successive screws320.

As shown inFIG. 16, the screw alignment device318has an attachment member such as a number of pins332defined in the inner end thereof. The pins332may be positioned in any adjacent pair of holes334defined in the housing302(specifically, the handle304) in order to secure the alignment device318to the housing302. As shown inFIG. 16, the handle304may be configured with a plurality of holes334. In doing so, the height at which the alignment device318is secured to the handle304may be adjusted thereby allowing for variations in the thickness of the tissue surrounding the fracture bone314.

Numerous other manners for adjusting the height of the screw alignment device318are also contemplated for use. For example, the plating instrument300may be configured to include a gear assembly which, upon rotation of a knob or the like, causes the screw alignment device318to be moved upwardly and downwardly. For instance, a rack and pinion gear assembly, similar to the type utilized in the construction of conventional microscopes for moving the specimen tray relative to the lens, may be utilized to adjust the position of the screw alignment device318.

The screw alignment device318may also be secured to the handle304in other manners. For example, the screw alignment device318may be pivotally secured to the handle304to allow the surgeon to pivot the device318out of the way when, for example, operating on tissue. Moreover, as shown inFIG. 22, the screw alignment device318may be arcuate or curved in shape to conform to the arcuate or curved shape of the bone plate316being implanted (which in turn conforms to the bone to which it is being secured). In such an arrangement, the alignment device318may be rotatably secured to the handle304(or removable for rotation) thereby allowing the device318to conform to a plate316with either a right-hand or left-hand curvature (seeFIG. 22). Moreover, the locations of the holes326of the screw alignment device318may be configured to allow for the use of a single design of the alignment device318with a number of different bone plate designs.

A further alternative feature for use in the design of the screw alignment device318is shown inFIG. 33. In this embodiment, the screw alignment device318has a single hole326. The alignment device318of this embodiment includes a pivotal latch358which may be utilized to allow the surgeon to leave an instrument or the like in the stab incision. For example, an instrument, such as the trocar/obturator assembly utilized to create the stab incision for screw insertion, is only removable from the hole326of the alignment device318when the distal tip thereof is external to the body of the patient. However, use of the latch358allows an implanted instrument (i.e., an instrument having a distal end present in the tissue of the patient) to be removed from the hole326thereby allowing the instrument to remain in the body of the patient for subsequent use during the procedure.

As shown inFIG. 38, in an alternate configuration of the plating instrument300, an integrated handle304/screw alignment device318includes a cannulated sleeve368that is pivotally and slidably secured to the alignment device318. In such an arrangement, a number of instruments370may be advanced through the sleeve368in order to perform a desired function. For example, one of the removable instruments370may be an obturator which is advanced through the cannulated sleeve368to create the stab incision. The removable instrument370could also be a drill or tap which is advanced through the sleeve368and thereafter utilized to create a hole in the fracture bone into which a screw will be driven. As shown in phantom lines inFIG. 38, when not in use, the cannulated sleeve368may be slid and pivoted to a substantially horizontal storage position on the upper surface of the alignment device318.

Use of a cannulated sleeve which is integral to the instrument (i.e., the integrated cannulated sleeve368) allows for the elimination of certain instruments which are commonly utilized in plating procedures. For example, as shown inFIG. 40, a tap instrument372having a shoulder portion374and a tap portion376may be utilized in conjunction with the cannulated sleeve368. A similarly configured (i.e., shouldered) drill (not shown) could also be utilized in conjunction with the cannulated sleeve368. By doing so (i.e., utilizing the cannulated sleeve368for operation of both instruments), the need for separate tap and drill guides is eliminated.

The cannulated sleeve368may be transparent in design and thus allow for the instruments advancing therethrough (e.g., the obturator) to be endoscopically viewed. Alternatively, the cannulated sleeve368may have a number of longitudinal slots defined therein for such endoscopic viewing of the passage of an instrument therethrough.

Other embodiments of the screw alignment device318are also contemplated for use. For example, as shown inFIG. 18, the screw alignment device318may be movable relative to the housing302of the instrument300. Specifically, a ratchet mechanism336may be utilized to ratchet or otherwise move the screw alignment device in the general direction of arrows338and340ofFIG. 18. In such an arrangement, the screw alignment device318need only be embodied with a single hole326since the movement of the device318provided by the ratcheting mechanism336is utilized to position the hole326in the appropriate location relative to the holes324in the tunnel312. It should be appreciated that the ratchet mechanism336may be configured such that each incremental movement of the alignment device318generated by the ratchet mechanism336coincides with the placement of the hole326into alignment with one of the holes324of the tunnel312.

The embodiment of the instrument300shown inFIG. 18also includes a coupler344which coordinates the movement of the endoscope330with that of the screw alignment device318. Specifically, the coupler344may be utilized to mechanically couple the endoscope330to the screw alignment device318. As such, as the surgeon operates the ratchet mechanism336to position hole326of the alignment device318over one of the holes324in the tunnel312, the endoscope330is likewise moved in the direction of arrows338,340to a position which allows the endoscope330to collect the desired images of the screw driving operation. Hence, when the surgeon positions the screw alignment device318in a desired location, the endoscope330is likewise positioned in a desired location to observe the associated procedure (e.g., screw insertion).

Referring now toFIG. 53, there is shown another exemplary embodiment of the bone plating instrument300. In lieu of a gear mechanism for re-positioning the tissue expander308and the alignment device318, the plating instrument300ofFIG. 53includes a telescoping shaft306and an alignment device318with a telescoping body. A spring loaded detent319is positionable in any one of a number of locator holes321to position the shaft (and hence the tissue expander308) and the alignment device318in a desired position.

Referring now toFIG. 20, there is shown another exemplary embodiment of a bone plating instrument. In this case, an alignment instrument390provides the screw alignment function and is intended to be utilized in conjunction with the instrument300. The alignment instrument390includes a handle378having a pair of parallel arms380,382extending therefrom. The upper arm380has a hole388defined in that functions essentially the same as the hole326of the screw alignment device318(i.e., aligns with the hole324of the tissue expander308). The lower arm382includes a location feature384in the form of a tab386which aligns with one of the holes322defined in the implanted bone plate316. The dimensions of the alignment instrument390are selected such that when the tab386is positioned in one of the holes322, one of the other holes322(e.g., the adjacent hole322) is aligned with both the hole324of the tissue expander308and the hole388of the upper arm380. As such, the precise location for the stab incisions associated with screw insertion can be enhanced.

It should be appreciated that similar concepts may be incorporated into the design of the tissue expander308. For example, the spoon310or the tunnel312may be configured to include a locating tab similar to the tab386such that when the tab is positioned in one of the holes322of the bone plate316, one of the other holes322(e.g., the adjacent hole322) is aligned with the hole324in the spoon or tunnel (and hence the hole326of the screw alignment device318).

It should be appreciated that there are numerous other manners for aligning the hole324(or holes324) of the tissue expander308(and hence the hole326of the screw alignment device318) with the holes322of the bone plate316. For example, as shown inFIG. 28, a flexible, remotely operable, guide wire408may be extendable and retractable through the cannulated shaft306of the plating instrument300. Once the spoon310(or tunnel312) is located precisely over the plate hole322of interest (as determined by use a locating feature on the spoon or tunnel, or the use of the endoscope330), the surgeon may advance the wire408distally. During such distal movement of the wire408, the tip410of the wire is guided by a ramp412which guides the wire tip410vertically out of the hole324of the spoon310(or tunnel312). Continued vertical advancement of the wire tip410causes it to penetrate through the underlying tissue and eventually puncture the skin (as shown in phantom inFIG. 28). The point at which the tip410of the wire exits the skin may be utilized as an indicator for the location of a stab incision for subsequent screw insertion.

It should be appreciated that the tissue expander308itself may provide the necessary alignment features for screw insertion. For example, the outer surfaces of the spoon310or the tunnel312may have alignment features defined therein which allow the surgeon to tactilely locate the position of the hole324(or holes324) in the spoon or tunnel through the tissue of the patient. Alternatively, a pointer laser may be mounted on the cannulated shaft306, with an associated mirror positioned on the inside surface of the spoon310or tunnel312, so that a laser beam may be reflected or otherwise directed outwardly and upwardly through the hole324(or holes324) of the spoon or tunnel. In this manner, the directed beam would illuminate the location of the stab incision to be utilized to drive a screw320through the hole324in the spoon310or tunnel312and hence the hole322in the plate316positioned thereunder.

Another device392which utilizes certain features of the present disclosure is shown inFIG. 26. This screw alignment device392is embodied as a flexible guide which may be secured or “keyed” off of one of the bone screws320which has been installed in the bone plate316. In doing so, a number of holes394defined in the alignment device392are aligned with the remaining holes322defined in the bone plate316.

One manner of providing a bone screw320for such a “keying” function is shown inFIG. 36in which the bone screw320is provided as an assembly having a threaded component396and a compression component398. The threaded component396is first threadingly implanted into the fractured bone314via a stab incision as described above. The threaded component396is implanted at a location which corresponds to a desired location of the distal tip400of the bone plate316. In particular, the distal tip of the plate316is slid or otherwise advanced through a small incision402and advanced along the bone314to a point in which the threaded component396of the bone screw320is captured or otherwise received into a slot404defined in the bone plate316. Once the threaded component396is positioned in the slot404, the compression component398may be advanced through the hole324in the tissue expander308and into a bore406defined in the head of the implanted threaded component396. Advancement of the compression component398into the bore406of the threaded component396forces the distal tip400of the bone plate316downwardly into contact with the surface of the bone314thereby vertically aligning the plate316. It should be appreciated that the alignment bone screw320may be left in the bone314or removed after the remaining bone screws320have been secured within the holes322of the plate316in one of the numerous manners described herein.

Referring now toFIG. 30, there is shown one of the holes324of the tissue expander308in greater detail. Although the hole324is shown inFIG. 30in the context of the spoon310, it should be appreciated that the holes324of the tunnel312may be constructed in a similar manner. As shown inFIG. 30, the hole324defined in the tissue expander308has a chamfered portion346. Such a feature functions as a “lead-in” which facilitates the advancement of instruments (e.g., drills, taps, or even the screws320) through the hole324. Moreover, the hole324extends through a boss348which, for example, may be integrally molded with the tissue expander308(i.e., either the spoon310or the tunnel312). Use of the boss348provides a structure of sufficient length and rigidity to allow proper alignment of instruments (e.g., drills, taps, or even the screws320) during advancement of the same through the hole324.

As shown inFIG. 21, a remotely controllable (i.e., from a control mechanism (not shown) associated with the handle304) cover350may translate within the elongated cannulated shaft306(which, in this case has a plurality of holes324defined therein). The cover350prevents fat or other types of tissue from entering the workspace inside the tissue expander308. In the specific exemplary embodiment shown inFIG. 21, the remotely controlled cover350is secured to the movable endoscope330.

Such protection from the entry of unwanted tissue may also be provided by other structures. For example, as shown inFIG. 31, a flexible seal352constructed of, for example, silicon may cover the entrance to the hole324. The seal352prevents the entry of fat or other tissue into the hole, but yet may be relatively easily pierced by instruments during advancement thereof into the hole324.

As shown inFIG. 25, the upper surface356of the tissue expander308may be configured to include a number of illumination devices such as light emitting diodes (LED's)354. The LED's354may be utilized to illuminate portions of the workspace (e.g., the holes322in the bone plate316during screw insertion) during a procedure. Such use of the LED's354is particularly useful for use with an endoscope330constructed with a CMOS chipset (such as in the case of the CMOS-based design of the endoscope shown inFIG. 25). It should be appreciated that the upper surface356(or the other inner surfaces of the tissue expander308) may be configured as optical lenses or other similar structures to intensify the light generated by the LED's354in a number of different directions. For example, in addition to directing light onto the workspace, the configuration of the inner surfaces of the tissue expander308may direct intensified light outwardly through the underlying tissue and skin of the patient to provide an external indication of the location of the tissue expander308. Such “trans-illumination” may be useful to supplement or perhaps even replace the use of the screw alignment device318during screw insertion.

The concepts of the present disclosure also provide for the lateral and vertical alignment of the bone plate316prior to securing the plate316to the fractured bone314. For example, as shown inFIG. 23, a leading edge414of the tissue expander308may be configured to conform to the contour of the fractured bone314. Such a feature assists in the centering of the tissue expander308onto the fractured bone314when the plate316is secured thereto. As shown inFIG. 21, extended side wings416may also be utilized in the construction of the tissue expander308in order to provide similar functionality. It should be appreciated that although the spoon310is shown inFIGS. 21 and 23, similar features (i.e., a contoured leading edge414or the use of extended side wings416) may be utilized in the design of the tunnel312.

Other configurations of plate alignment features are also contemplated for use in the design of the tissue expanders308. For example, the spoon310or tunnel312may be adapted to “grab” around the outer periphery of the fractured bone314to assist in aligning the instrument300, and hence the plate316positioned thereunder, over the center axis of the bone314. It should be appreciated that such engagement or “grabbing” of the bone would also allow the surgeon to selectively release the handle304thereby permitting a certain degree of “hands free” operation of the plating instrument300.

As shown inFIG. 19, additional “hands free” operation may be achieved by use of features associated with the housing302, specifically the handle304. For example, a number of lateral extensions444may be provided to support the plating instrument300against, for example, the patient's leg, an operating table, or the like. Such extensions444may take on the form of wings, legs, or any other type of similar structure. During a procedure, the surgeon may utilize the lateral extensions444to engage a support structure thereby allowing the surgeon to release the handle304to perform other tasks.

Other support mechanisms may also be utilized to support the plating instrument300during a procedure (e.g., to provide for “hands free” operation). For example, as shown inFIG. 49, a support block445may be secured to the an outer surface of the patient's body (e.g., the patient's leg). The plating instrument300may be supported by the support block445thereby eliminating the need for the surgeon (or other personnel) to support the plating instrument300. In the exemplary embodiment shown inFIG. 49, the support block445is constructed from a deformable material (e.g., foam) with a channel447formed therein. The housing302of the plating instrument300is positionable in the channel447. A lower surface449of the support block445is secured to the patient (or other surface, if desired) by the use of, for example, an adhesive. In such a way, use of the support block445allows the surgeon to release the handle304of the plating instrument300to perform other tasks.

As shown inFIG. 24, the tissue expander308may also have a slot418defined therein. The slot418extends from the hole324to the outer edge of the tissue expander308. Use of the slot418allows the tissue expander308to be removed from the body of the patient while a K-wire, alignment screw, or the like that is being utilized to align the plate to the bone314is left secured to the bone314. Specifically, the K-wire or alignment screw may be advanced through the hole324in the tissue expander308in the manner described above and thereafter left in place during subsequent movement of the tissue expander308by sliding the implanted K-wire or alignment screw through the slot418.

As shown inFIG. 32, a separate bone clamp assembly420may be provided for use with the tissue expanders308(i.e., the spoon310or the tunnel312). The clamp assembly420includes a pair of arms422pivotally coupled to a frame424. The distal end of each arm422has a barb426defined therein which is capable of penetrating the skin, underlying tissue, and thereafter engaging the outer surfaces of the fractured bone314. A biasing member428threadingly engages the frame424and, as a result, is movable upwardly and downwardly (as viewed in the orientation ofFIG. 32) by rotation of a handle430in one direction or the other.

In order to center the bone plate316over the fractured bone314, the surgeon positions the clamp assembly420externally over the bone314and thereafter advances the arms422inwardly toward one another. The surgeon continues advancement of the arms422such that the barbs426pierce the skin, penetrate the underlying tissue, and engage the outer surfaces of the bone314. The surgeon may then turn the handle430so as to advance the biasing member428downwardly (as viewed in the orientation ofFIG. 32) through the skin and underlying tissue via a previously created stab incision. The distal tip432of the biasing member428is advanced through the hole324in the tissue expander308and into the workspace created thereby. The distal tip432is then advanced into contact with the top of the plate316in order to bias the plate316firmly against the bone314. In a specific exemplary embodiment, an extension portion434of the tip432of the biasing member428may be advanced into one of the holes322in the plate316with a shoulder portion436of the tip432engaging the upper surface of the plate316.

As shown inFIG. 37, the design of the clamp assembly420may be modified to include a pair of flexible, spring biased arms438secured to a frame (not shown) within a tube442. The flexible arms438may be brought together by use of the tube442. Specifically, when the tube442is moved upwardly (as viewed in the orientation ofFIG. 37), the arms438are spread outwardly in a direction away from one another. However, when the tube assembly442is advanced downwardly (as viewed in the orientation ofFIG. 37), the arms438are urged toward one another and, as a result, may be inserted through a stab incision440. The arms438may then be spread away from one another (i.e., by movement of the tube442), advanced around the bone314, and then moved toward one another (i.e., by movement of the tube442in the opposite direction) so as to engage the outer surfaces of the bone314, as shown inFIG. 37.

A biasing member428, similarly to as previously described in regard to the assembly420ofFIG. 32, may then be utilized to bias the bone plate316downwardly into contact with the bone314. Specifically, the distal tip432of the biasing member428may be advanced through the hole324in the tissue expander308and into the workspace created thereby. The distal tip432is then advanced into contact with the top of the plate316in order to bias the plate316firmly against the bone314. In particular, the extension portion434of the tip432of the biasing member428may be advanced into one of the holes322in the plate316with the shoulder portion436of the tip432engaging the upper surface of the plate316.

It should be appreciated that other mechanisms may also be utilized to exert a downward bias on the bone plate316. For example, a number of inflatable bladders may be mounted on the anterior surface of the spoon310or tunnel312. Such bladders are remotely inflatable with air, saline, or other fluids. As such, when the spoon310or tunnel312is positioned over the plate316and the fractured bone314, the inflated bladders exert a bias against the plate316which urges the plate316into firm contact with the bone314.

The concepts of the present disclosure may also be utilized to “deliver” the bone plate316to a desired location along the bone314. For example, as shown inFIGS. 27,29, and35, the tissue expanders308(either the spoon310or the tunnel312) may have a feature defined therein which is utilized to engage the bone plate316near the distal tip400thereof. Such a feature may take the form of a rearwardly facing flange or lip446which is received into a corresponding slot448defined in the bone plate316(seeFIG. 27). Such a feature may also take the form of a forwardly facing flange or lip450which is received into a corresponding slot452defined in the bone plate316(seeFIG. 35). Alternatively, such a feature may take the form of a protrusion, detent, or tab454which is received into a corresponding recess456defined in the bone plate316(seeFIG. 29).

As described, such features support the distal end of the plate316. To support the other end of the plate316(i.e., the proximal end), a removable fastener458is provided (seeFIG. 27). The fastener458is received through a bore defined in the housing302and thereafter threadingly engages the proximal end of the bone plate316thereby allowing the plate316to be removably secured to the plating instrument300.

Once positioned in a desired position, one or more bone screws320may be inserted through the plate316and into the bone314to initially secure the plate316in the desired location. The surgeon may then remove the fastener458and thereafter manipulate the instrument300so as to release the distal tip400of the plate316(i.e., remove the lip from the associated slot or the tab from the associated recess). Once done, the surgeon may then insert the remaining bone screws320in the manner described above.

Other exemplary embodiments of plate attachment and delivery mechanisms are shown inFIGS. 41-48and50-52. As shown inFIG. 41, the plating instrument300may be embodied to include a plate attachment and delivery mechanism470. The mechanism470includes a saddle472that is movably secured to the plating instrument300. In the exemplary embodiment shown inFIGS. 41-43, the saddle472is slidable along the shaft306of the plating instrument300. Such mobility (e.g., slidability) allows the position of the bone plate316to move relative to the plating instrument300during implantation thereof. In such a manner, the bone plate316may be positioned in a temporary delivery position during advancement of the plate316into the body. For example, as shown inFIG. 34, the plate316may be retained in a delivery position (indicated generally at460inFIG. 34) during insertion into the incision and advancement through the underlying tissue to the desired position along the fractured bone314. Positioning the plate316in such a position prevents the plate316from obstructing the view of the endoscope330thereby allowing full use of the endoscope330during navigation of the instrument300to the delivery site.

The saddle472has a thumbwheel474rotatably secured thereto. A first end of a shaft476is secured to the thumbwheel474and extends downwardly therefrom. The other end of the shaft476has a flange478secured thereto. As such, rotation of the thumbwheel474causes rotation of the flange478.

The mechanism470is operable to secure the bone plate316to the plating instrument300. In particular, the flange478may be positioned in a release position which allows the flange478to be advanced through one of the holes322in the bone plate316(the release position of the flange478being approximately 90° from the position of the flange478shown inFIG. 41). Once the flange478is advanced through the hole322(i.e., the shaft474extends through the hole322), the thumbwheel474may be rotated such that the flange478is positioned in a locked position (such as shown inFIG. 41) thereby causing the bone plate316to be secured to the plating instrument300. In such a manner, the bone plate316may be delivered to a desired location proximate to the fractured bone314, and thereafter released prior to, or during, bone screw insertion.

As shown inFIGS. 42 and 43, the mechanism470may also be configured to include a number of alignment features for aligning the bone plate316in a desired lateral and/or longitudinal orientation relative to the bone plating instrument300. For example, as shown inFIG. 42, the attachment mechanism470may be embodied to include a pair of downwardly extending locator tabs480. The plate316is positioned between the locator tabs480when the plate is secured to the plating instrument300thereby maintaining the plate316in a desired lateral orientation. The attachment mechanism470may also be configured to include a downwardly extending flange in the form of a hook482(seeFIG. 43). The hook482is received through one of the holes322in the bone plate316when the bone plate316is secured to the plating instrument300. In such a way, the bone plate316may be maintained in a desired longitudinal orientation. It should be appreciated that the design of the attachment mechanism470may be varied to include any one or more of the afore-described alignment features, or may alternatively, be configured without any of the alignment features (such as shown inFIG. 41).

It should be appreciated that other types of retention mechanisms may also be utilized to secure the plate316to the instrument300during delivery of the plate316. For example, a remotely controllable clasping or gripping assembly may be utilized to engage the plate316during delivery thereof to a desired location. For example, as shown inFIGS. 44-49and50-52, the plating instrument300may be configured to include an attachment and delivery mechanism490.

The mechanism490includes a number of downwardly extending flanges492which, in the case of the exemplary embodiments described herein, are embodied as a pair of hooks494,496. The hooks494,496are movable relative to one another. In particular, as shown inFIGS. 44 and 45, the hooks494,496may be slid or otherwise moved relative to one another. More specifically, as shown inFIG. 44, the hooks494,496may be positioned at a relative close distance to one another, or may be spaced apart from one another as shown inFIG. 45. A spring498(seeFIG. 45) biases the hooks494,496toward one another (i.e., biases the hooks into the position shown inFIG. 44). When a user (e.g., a surgeon) urges a lever500in the general direction of arrow502ofFIG. 44(i.e., in the general direction of the handle304), the bias of the spring498is overcome, thereby urging the hook496away from the hook494in the general direction of arrow502.

Such movement of the hooks494,496relative to one another allows for attachment of the bone plate316to the plating instrument300. In particular, as shown inFIG. 48, the surgeon may first urge the hooks494away from one another (i.e., to the position shown inFIG. 45) and thereafter advance the hooks494,496into respective holes322of the bone plate316. Thereafter, when the surgeon releases the lever500, the bias of the spring498urges the hooks494,496toward one another thereby causing the hooks to engage the bone plate316(as shown inFIG. 48) thereby securing the bone plate316to the plating instrument300. The plate316may be released from the plating instrument300by again urging the lever500toward the handle304and advancing the hooks494,496out of their respective holes322.

As shown inFIGS. 46 and 47, the hooks494,496may be configured to “nest” with one another when positioned in the closed position ofFIG. 44. In such a manner, the hooks494,496are prevented from inadvertently engaging tissue (e.g., snagging) during manipulation of the instrument300in the body of the patient.

As shown inFIGS. 50-52, the attachment and delivery mechanism490may be configured such that the entire mechanism (including both hooks494,496) is movable (e.g., slidable) along the shaft306. To do so, the hook494is defined in one end of an elongated, tubular shaped body504with a first lever506being defined in the opposite end of the body504. The body504is cannulated and slides along the shaft306of the plating instrument300. The hook496, on the other hand, is defned in one end of an elongated, tubular body508with a second lever510being defined in the opposite end of the body508. In a similar manner as the body504, the body508is also cannulated. In such a manner, the body508slides along the body504.

When the two levers506,510are urged toward one another (as shown inFIG. 51), the hooks494,496are urged away from one another. However, when the levers506,510are released, the bias of the spring498urges the hooks494,496toward one another (as shown inFIG. 50). As such the levers506,510may be manipulated to allow the hooks494,496to engage the bone plate316in a similar manner to as described above in regard toFIG. 48.

Moreover, the mobility of the attachment and delivery mechanism490ofFIGS. 50-52allows for the selective positioning of the plate316during implantation thereof in the manner previously described in regard toFIG. 34. By sliding the mechanism490along the shaft306(as shown inFIG. 52), the bone plate316may be positioned in a temporary delivery position during advancement of the plate316into the body. For example, as shown inFIG. 34, the plate316may be retained in a delivery position (indicated generally at460inFIG. 34) during insertion into the incision and advancement through the underlying tissue to the desired position along the fractured bone314. Positioning the plate316in such a position prevents the plate316from obstructing the view of the endoscope330thereby allowing full use of the endoscope330during navigation of the instrument300to the delivery site.

Use of the aforedescribed components (e.g., the attachment and delivery mechanisms described in regard toFIGS. 27,29,35,41-48, and50-52) allows the surgeon to deliver the plate316during insertion of the instrument300. Specifically, prior to insertion of the bone plating instrument300into the body of the patient, the bone plate316is secured to the instrument300in one of the manners described above. Thereafter, under visualization provided by the endoscope330, the instrument300, with the plate316secured thereto, is inserted through a relatively small incision and thereafter advanced beneath the underlying tissue along the length of the bone314.

Once the instrument arrives at the location of the bone314to which the plate316is to be secured, the surgeon may remotely (e.g., by use of a control (not shown) positioned on the handle304) advance the bone plate316distally to its final position against the fractured bone314(indicated generally at462inFIG. 34). It should be appreciated that the plate316may then be secured (e.g., screwed) to the bone314within full view of the endoscope330when positioned in its final position.

In operation, the bone plating instrument300may be utilized to secure the bone plate316to a fractured bone314. To do so, a small incision is made in the skin overlying the fractured bone314to be repaired. A relatively small degree of dissection is performed which extends from the incision in the skin through the underlying incision down to the fractured bone314.

The instrument300is then inserted into the incision and advanced under the visualization provided by the endoscope330. It should be appreciated that, if so desired, the surgeon could insert the instrument300through a secondary incision proximate to the fractured bone314to be treated. In either case, the instrument300is then advanced along the surface of the fractured bone314to allow for imaging of fracture lines, fragments, surrounding tissue, or the like.

The bone plate316is inserted through the incision and positioned along the fractured bone314. As described above, the bone plate316may be delivered to the desired location on the fracture bone314by the instrument300. Alternatively, the bone plate316may be independently advanced to the desired location on the fractured bone once the instrument300is properly positioned. It should be appreciated that when so positioned, the plate316bridges the fracture or fractures in the bone314.

Once the bone plate316has been positioned, instruments and implant devices may be advanced through the holes322in the bone plate316and thereafter into contact with the bone314under the visualization provided by the endoscope330. For example, under the visualization provided by the endoscope330, K-wires, soft tissue cannulated sleeves, drill guides and bits, tap guides and taps, screws and screw drivers may be advanced through the soft tissue and into the holes322of the plate316(and hence the portions of the bone314thereunder).

A number of external devices, such as the screw alignment device318, may be utilized to guide the advancement of such instruments and implants. In addition, an integral or independent clamp assembly420may be utilized to further align the plate316prior to securing the same to the bone314.

In such a fashion, a plurality of bone screws320may be installed on the bone plate316. Once the last of such screws320has been installed, the plating instrument300may be removed. The incision may then be closed in a conventional manner.

Other Orthopaedic Procedures

The concepts of the present disclosure may also be utilized in the performance of other orthopaedic procedures. For example, the concepts of the present disclosure may also be utilized in the performance of procedures to relieve carpal tunnel syndrome. Specifically, a small, portable, preferably disposable version of the endoscopic instruments hereinbefore described may be utilized during the performance of such a procedure. Typically, a surgeon performing a carpal tunnel procedure will utilize relatively large incisions along the wrist and hand of the patient and thereafter dissect a portion of the underlying tissue. This is done, primarily, so that the surgeon may directly visualize the underlying anatomy (such as median nerve in the case of carpal tunnel) thereby preventing inadvertent damage thereto.

However, by use of an endoscopic instrument constructed in accordance with the present disclosure, the affected soft tissues may be dissected subcutaneously while under direct visualization from the endoscope. Specifically, an endoscope may be integrated into the subcutaneous scalpel assembly thereby allowing the surgeon to directly visualize the surgical site.

Similar concepts may also be utilized in regard to the performance of a procedure to relieve compartment syndrome or plantar fasciitis. For example, the concepts of the present disclosure may be utilized to eliminate the need to cut an elongated incision in an extremity of the patient. To do so, an endoscope of the type described herein my be integrated into the hook portion of a hook knife instrument thereby allowing the surgeon to manipulate the relatively long instrument up through a small incision made in the extremity under the visualization provided by the endoscope. Once present at the surgical site, the endoscope provides the visualization necessary to aid the surgeon in the cutting of the desired tissue without damaging surrounding anatomical structures.

The concepts of the present disclosure may also be utilized in regard to orthobiologics. Specifically, the concepts of the present disclosure may be utilized to deliver and place orthobiologic components such as resorbable patches and the like. For example, devices such as those devices sold under the trade names Restore™, Orthosorb™ pins, α-BSM™, and Symphony™ may be placed utilizing the concepts of the present disclosure.

The concepts of the present disclosure may also be utilized to provide direct visualization during skinny wire placement in regard to circular external fixation. Such visualization allows the surgeon to avoid neurological bundles and blood vessels.

The concepts of the present disclosure may also be utilized in the evaluation and removal of a tumor biopsy or an aneurysmal bone cyst. In particular, under the visualization of an endoscope, the surgeon may gain access to the surgical site via a trocar. Thereafter, the surgeon may evaluate the tumor or cyst by use of the endoscope, and, if need be, remove the tumor or cyst via the cannula of the trocar. Moreover, if the procedure so requires, graft material may be implanted into the surgical site via the cannula of the trocar and under the visualization of the endoscope.

Moreover, while a number of the concepts of the present disclosure have herein been described in detail in regard to delivery and installation of a bone plate, it should be appreciated that the instruments and methods described herein may also be utilized to remove a bone plate or other hardware such as screws in an IM nail or the nail itself. For example, the plating instruments described herein may be utilized to locate and remove an implanted bone plate (including the locating and removal of each of the bone screws). More specifically, the tissue expander, under the visualization of the endoscope, may be positioned over each of the bone screws. Then, under the alignment provided by the screw alignment device, the bone screws may then be removed via a series of stab incisions. Once the screws have been removed, the bone plate may then be removed from the body of the patient via the incision through which the plating instrument was inserted.

While the concepts of the present disclosure have been illustrated and described in detail in the drawings and foregoing description, such an illustration and description is to be considered as exemplary and not restrictive in character, it being understood that only illustrative embodiments have been shown and described and that all changes and modifications that come within the spirit of the disclosure are desired to be protected.

There are a plurality of advantages of the present disclosure arising from the various features of the apparatus and methods described herein. It will be noted that alternative embodiments of each of the apparatus and methods of the present disclosure may not include all of the features described yet still benefit from at least some of the advantages of such features. Those of ordinary skill in the art may readily devise their own implementations of apparatus and methods that incorporate one or more of the features of the present disclosure and fall within the spirit and scope of the present disclosure.

For example, in lieu of utilizing the plating instrument300described herein, a trocar alone may be utilized to perform a plating operation. For example, a trocar with embedded CMOS or conventional endoscopic camera may be advanced (with a sheath) through a jig connected to the plate. The holes in the jig are in direct alignment with the holes in the plate. As the trocar/camera is passed through a stab incision, the plate and surrounding areas can be visualized. Once the surgeon is satisfied with the plate placement and proposed screw location, the trocar/camera is removed from the sheath, whereupon drills, taps, depth gauges, and screwdrivers can be used in succession to place screws. The process is repeated for each screw.

Moreover, although the endoscope330of the bone plating instrument300is herein described as being advanced through the handle304of the instrument300, it should be appreciated that other configurations are also contemplated. For instance, the endoscope330may be advanced into the workspace created by the tissue expander308via a stab incision which is distinct from the incision through which the tissue expander308enters the body.

In a specific implementation of this exemplary embodiment, the endoscope330may be advanced into the body in a similar nature as the bone screws320. Specifically, the endoscope330may be advanced through one of the holes326in the screw alignment device318and thereafter through one of the holes324in the tissue expander308. For example, both the screw alignment device318and the tissue expander308may be configured to include a pair of holes326,324, respectively. The endoscope330may be advanced through the first hole326of the device318and the first hole324of the expander308so as to visualize the insertion of a screw driver and bone screw320through the second hole326of the device318and the second hole of the expander308.

It should be appreciated that the incisions through which the endoscope330is advanced may be later utilized for screw insertion to avoid the creation of additional stab incisions. Specifically, the stab incision through which the endoscope330is advanced to visualize insertion of a first bone screw320may be later utilized for the insertion of a second bone screw320. The endoscope330may then visualize the insertion of the second bone screw320from a third stab incision which is later utilized for insertion of a third bone screw, and so forth.