# Patent

## Title
Instruments and methods for reducing and stabilizing bone fractures

## Abstract

Instruments and methods for reducing and stabilizing bone fractures are presented. One method provides for cutting a portion of a bone having a fracture to create a cavity, wherein the cavity is substantially axisymmetric, and expanding the volume of the cavity thereby reducing the fracture. The fracture may be further reduced and/or stabilized by adding a material, such as an implant, in-situ curable material and/or in-situ hardenable material.

## Background
CROSS-REFERENCE TO RELATED APPLICATION
This application claims the benefit of U.S. Provisional Patent Application No. 60/575,635 filed May 28, 2004.


BACKGROUND OF THE INVENTION
The present invention generally relates to instruments and methods for application with skeletal disorders, and, in particular relates to instruments and methods for the reduction and stabilization of skeletal fractures.
Fracture reduction and/or stabilization are generally practiced to substantially restore or repair skeletal structures to their pre-fractured state. In practice, materials, such as in-situ curable materials (e.g., bone cements) and/or implants are often used to help stabilize fractured bone. In one clinical procedure known as vertebroplasty, bone cement is injected into a fractured vertebral body to stabilize bone fragments. This and other procedures may also additionally use one or a number of devices for reduction and stabilization of a fracture. For vertebroplasty, a device is used to assist in the formation of a cavity in the vertebra prior to injection of the in-situ curable material. Another device used with some procedures is a bone tamp used to reduce the fracture. To date, however,
SUMMARY OF THE INVENTION
The present invention solves many problems associated with current methods and devices for reduction, stabilization, restoration, and repair of skeletal fractures.
Generally, and in one form of the present invention provides for methods of reducing and/or stabilizing a fracture in bone. The method includes cutting a portion of the bone having a fracture to create a cavity. The cavity may be substantially axisymmetric and may be cut using any suitable device, such as a tissue cavitation device. The cavity is then expanded to reduce the fracture. A suitable expanding device includes a medical balloon as an example. The expanding device is typically positioned proximate to cortical bone. The fracture may be further reduced by filling the cavity with a material. The material may fully or partially fill the cavity. Examples of suitable materials include implants and in-situ materials that are curable or hardenable. Such materials may be permanent, resorbable, penetrating and combinations thereof. The material filling the cavity offers stabilization to the fracture. Any bone fragments near the fracture may also be stabilized. When suitable, the cutting of a portion of the bone having a fracture is preceded by the formation of at least one passage to the fracture site. Depending on the type of bone having the fracture, the passage(s) may be intracortical, extracortical, intrapedicular, extrapedicular, and combinations thereof.
Those skilled in the art will further appreciate the above-noted features and advantages of the invention together with other important aspects thereof upon reading the detailed description that follows in conjunction with the drawings.



BRIEF DESCRIPTION OF SEVERAL VIEWS OF THE DRAWINGS
For a more complete understanding of the features and advantages of the present invention, reference is now made to the detailed description of the invention along with the accompanying figures in which corresponding numerals in the different figures refer to corresponding parts and in which:
FIG. 1 is a superior view of a human bone;
FIG. 2A is another superior view of a human bone showing the bone a working channel;
FIG. 2B is a cross-sectional view of the bone in FIG. 2A or FIG. 1 showing a fracture;
FIG. 3 is a schematic of a device useful with the present invention showing (A) a side view, (B) a perspective view, and (C) a detailed perspective view of a portion of the device;
FIG. 4A is a superior view of the bone of FIG. 1 with a fracture site and after performing a step of the present invention;
FIG. 4B is a cross-sectional view of the bone of FIG. 4A showing the step of FIG. 4A and a cavity within the bone;
FIG. 5A is a superior view of the bone of FIG. 4A when performing another step of the present invention;
FIG. 5B is a cross-sectional view of the bone of FIG. 5A showing the step of FIG. 5A and an expanding device in the cavity of the bone;
FIG. 6A is a superior view of the bone of FIG. 5A when performing yet another step of the present invention;
FIG. 6B is a cross-sectional view of the bone of FIG. 6A showing the step of FIG. 6A and a restored bone;
FIG. 7A is a superior view of the bone of FIG. 5A when performing still another step of the present invention; and
FIG. 7B is a cross-sectional view of the bone of FIG. 7A showing the bone with an in-situ material in the cavity.



DETAILED DESCRIPTION OF THE INVENTION
Although making and using various embodiments of the present invention are discussed in detail below, it should be appreciated that the present invention provides many inventive concepts that may be embodied in a wide variety of contexts. The specific aspects and embodiments discussed herein are merely illustrative of ways to make and use the invention, and do not limit the scope of the invention
In the description which follows like parts may be marked throughout the specification and drawing with the same reference numerals, respectively. The drawing figures are not necessarily to scale and certain features may be shown exaggerated in scale or in somewhat generalized or schematic form in the interest of clarity and conciseness.
Instruments and methods will be disclosed for reducing and stabilizing bone fractures. The method may be useful for fractured bone, including vertebral bone. Typically, vertebral bone fractures in compression. This type of fracture is most common in the thoracic and/or lumbar regions of the spine and may coincide with regions of osteoporotic bone.
Common medical nomenclature may be used when describing aspects of the present invention. As used herein, superior is nearer the head in relation to a specific reference point, inferior is nearer the feet in relation to a specific reference point, anterior is forward in relation to a specific reference point and posterior is rearward in relation to a specific reference point. The midsagittal plane is an imaginary plane dividing the body into a right side and left side. A frontal plane is any imaginary vertical plane orthogonal to the midsagittal plane.
Referring not to FIG. 1, the figure shows anatomical structures of a human bone. In this example, the bone is vertebra 1 in a superior view. Vertebra 1 is comprised of body 2 and posterior elements 3. Posterior elements 3 include pedicle 4. An edge view of midsagittal reference plane 18 is shown in FIG. 1 as line X-X. Body 2 is generally comprised of two types of bone: cortical bone 12 and cancellous bone 14. In contrast to cortical bone, cancellous bone has a substantial degree of porosity. In addition there are transition regions of varying porosity between cancellous and cortical bone. For the present invention, the bone does not necessarily require all the above-identified elements. For example, some bone do not comprise pedicle 4; other bone may be more symmetrical in shape when shown in superior view. All bone, however, will include a body with some degree of cancellous bone and some degree of cortical bone.
Vertebral 1 of FIG. 1 is shown in a superior view in FIG. 2A. FIG. 2B shows relevant cortical bone 12 structures including superior endplate 8, inferior endplate 8′, and side wall 10. As a possible site of fracture, fracture 16 is shown to include side wall 10 and cancellous bone 14. Fractures may also occur in locations such as superior endplate 8 and inferior endplate 8′, as examples.
Continuing to refer to FIG. 2A and FIG. 2B, passage 70 is formed within body 2 using any of a number of methods and surgical instruments known to one of ordinary skill in the art. Examples of possible surgical instruments used to create passage 70 include a bone biopsy needle, guide pin, stylet, stylus, drill-bit instrument, and obturator. Referring again to FIG. 2A, working channel 20 is typically used to pass instruments into and out of body 2. While body 2 will typically have a working channel, the formation of passage 70 may not be essential. In some instances, a drill-bit instrument is used within working channel 20 to create passage 70, wherein the diameter of passage 70 is similar to the inner diameter of working channel 20. Other appropriate instruments may also be used with the working channel. Working channel 20 typically remains in position for additional steps of the present invention. As shown in FIG. 2A, access to body 2 is thru pedicle 4 (intrapedicular); however access may also include one or a number of posterior elements 3 or may be outside pedicle 4 (extrapedicular). The surgical approach typically depends on the site of the fracture, the patient, and/or surgeon preferences.
The term “tissue cavitation device” as used herein will refer to a device useful with the present invention. This device is capable of separating a portion of bone having a fracture and providing a cavity in the portion of the bone including or near the site of the fracture. By use of such a device, the device may separate the bone by cutting, shearing or scraping the bone, as examples. The separation creates a cavity that is typically substantially larger in diameter than the access passage, as shown in FIG. 2A as passage 70. A suitable device and use of such a device is described in U.S. Pat. No. 6,746,451 to Middleton et. al, which is hereby incorporated by reference. The Middleton device is comprised of a rotatable shaft interconnected to a flexible cutting element. The flexible cutting element has a first shape suitable for minimally invasive passage into tissue, and the flexible cutting element has a means to move toward a second shape suitable for forming a cavity in the tissue, such as bone. Several embodiments of the Middleton device may also be adapted to a powered and/or a manual surgical drill, as needed.
Referring now to FIG. 3A, FIG. 3B, and FIG. 3C, examples of a suitable device are shown. Device 30 comprises a flexible cutting element 32, a shaft 34, a serration 36, and a T-handle 38. T-handle 38 allows the user (e.g., surgeon) to rotate device 30 during use or in the formation of a cavity.
Referring now to FIG. 4A and FIG. 4B, vertebra 1 is shown with cavity 72 provided after use of a device, such as device 30 shown in FIG. 3. Here, cavity 72 was created by using a device, such as device 30, within passage 70 to cut a portion of the bone, the bone being cancellous bone 14 and/or cortical bone 12. Although passage 70 is useful to position device 30, it is contemplated that a cavity 72 can be made without requiring passage 70. Cavity 72, as shown in FIG. 4A and FIG. 4B, is generally spherical, although other shapes are also contemplated, such as cylindrical and elliptical shapes, as examples. In general, it is desirable to extend the boundary of cavity 72 so that it at least partially includes, or is in proximity of, superior endplate 8 and inferior endplate 8′. Hence, cavity 72 is typically in proximity to cortical bone 12. Accordingly, cavity 72 may be bound, in part, by cortical bone 12. Cavity 72 is initially formed by device 30; in which device 30 cuts, shears, and/or scrapes a portion of bone near the fracture. Cavity 72 is not initially formed by compacting the bone using an expanding device.
Often, it is desirable to have the height and width of cavity 72 be of similar or equal dimensions. Therefore, an axisymmetric shape of cavity 72 is useful, although non-axisymmetric shapes are also contemplated. For example, device 30, shown in FIG. 3, may be designed, through the use of available materials and geometry, to effectively cut cancellous bone but ineffectively cut cortical bone which may lead to a non-axisymmetric bone cavity, despite complete rotation of shaft 34 during use of device 30. Alternatively, both cancellous and cortical bone may be cut by device 30. Thus, the boundaries of the cavity may be cortical and/or cancellous bone. Various elements of the present invention, to include position and size of the bone cavity, will become apparent to one of ordinary skill in the art.
A further step to reduce the fracture includes expansion of the cavity with an expanding device. The expanding device is one that expands the shape of the cavity in at least one dimension. The device, itself may be involved in the expansion. Alternatively, one or more materials may be used with the device for such expansion. Example of expanding devices are a medical balloon or SKy Bone Expander (Disc Orthopaedic Technologies Inc., N.J., USA). Other suitable expandable means may also be used. Referring now to FIG. 5A and FIG. 5B, expanding device 40 is positioned within cavity 72. For FIGS. 5A and 5B, expanding device 40 is a medical balloon which is inflated with working substance 46, such as a fluid or saline. Readily available surgical inflation devices, including a syringe and syringe-like devices, are suitable for pressurizing the expanding device. Not every expanding device, however, will require pressurization. Each expanding device will have components and functions known to those skilled in the art. For example, expanding device 40 as shown in FIG. 5A and FIG. 5B, typically comprises an expandable portion 41, inner cannula 42, and outer cannula 44. The expandable portion 41 may be constructed of a number of materials, such as a non-compliant or semi-compliant material (e.g., poly(ethylene terephthalate) or Nylon). For any expanding device, the expanding portion may be resorbable, nonresorbable, porous or nonporous.
In general, because cortical bone is stiffer and stronger as compared with cancellous bone, expanding device 40 may be positioned initially at or in proximity to cortical bone 12. The position of expanding device 40 is typically based on the size, shape, and location of cavity 72. For example, with expanding device 40 as a medical balloon, the top and bottom surface of expandable portion 41 may be initially positioned at or in proximity of cortical bone 12 upon initial pressurization of expandable portion 41. Therefore expandable portion 41 may provide relatively direct distraction forces against superior endplate 8 and inferior endplate 8′ upon pressurization of expandable portion 41. The width of expandable portion 41 relates to the vertical distraction forces expandable portion 41 provides for a given pressure. Relative to passage 70, cavity 72 is typically larger, allowing pressurization of a relatively large expandable portion 41. Thus, for a given pressure, a larger expanding expandable portion 41 would generally provide greater distraction forces. Or, for a required distraction force, a larger expanding portion 41 generally requires lower pressure. Typically, a larger expanding device provides greater surface area for distraction and provides broader, more uniform distraction, while avoiding local pressure concentrations. Referring to FIG. 5B, H1 represents the height of body 2 prior to reduction of the fracture. Inflation of expandable portion 41 is intended to reduce the fracture in the form of an increased body height of the bone in at least one dimension.
Referring now to FIG. 6A and FIG. 6B, body 2 is shown following inflation of expanding device 40 of FIG. 5 and removal of expanding device 40. An expanding device may include an implantable portion subsequently left in the patient to become permanent or later resorbed. In suitable embodiments, an expandable portion of expanding device 40 may remain in cavity 72′ and be filled with a material further described below. The material and/or the expandable portion may remain permanently in cavity 72′ or be later resorbed.
Referring specifically to FIG. 6B, a new vertebral body height, H2, is established in the cavity, reflecting partial or significant restoration toward the pre-fractured height of body 2. In addition, cavity 72, as initially shown in FIG. 4, is now enlarged or otherwise modified, as represented in FIG. 6A and FIG. 6B by cavity 72′. Cavity 72′ may, thus, be associated with a reduction of the fracture. This may include, for example as described above, a change in the spatial relationship between endplate 8 and endplate 8′.
The fracture may be further reduced and/or stabilized by any of a number of means, including introduction of a material. Some examples of suitable materials include an implant, a support, an in situ material that is hardenable or curable, and other equivalents. An example of a material used for further reduction is shown in FIG. 7A and FIG. 7B. Here, cavity 72′ is filled with in-situ material 50 to provide stability and strength to body 2. The in-situ material 50 may fully or partially fill the volume of cavity 72′, including between any bone fragments and any related fractures, especially fracture fissures interconnected directly to cavity 72′. In-situ curable material 50 may also penetrate the pores of cancellous bone 14. The in-situ material may be a permanent material or may be resorbable. Alternatively, the Suitable in-situ materials that be hardened or curable include polymethylmethacrylate-based bone cements and bone substitute materials, such as calcium sulfate compounds, calcium phosphate compounds, demineralized allografts, hydroxyapetites, carbonated apetites (e.g., Synthes' Norian Bone Void Filler), collagen mixtures, mineral and cytokine mixtures, terpolymer resins, difunctional resins (e.g., Orthovita's CORTOSS®), and combinations thereof, as examples. Any passage to cavity 72 and 72′, if present, such as working channel 20 or passage 70, is either filled or allowed to heal. Any components used for the introduction of material 50 (or its equivalents) are similarly removed.
The instruments and methods presented in this disclosure are used as examples of the present invention. Those skilled in the art will be able to develop modifications and variants that do not depart from the spirit and scope of the present invention. Variations include using a porous expanding device. Alternately, an expanding device may be filled with a material (e.g., implant or in-situ material that is curable or hardenable) and subsequently left in the patient to become permanent or later resorbed. It is also understood that the expanding device may be an implant or include an implant and, thus, all or part of the device may remain in cavity 72′. Such implants may be metallic or nonmetallic, coated or noncoated.
Alternate surgical approaches are also within the scope of the present invention. For example the instruments and methods may be used on the right side and left side of a body of a bone, such as in a bipedicular approach for vertebral bone. The present invention is applicable to the reduction and stabilization of any bone or fracture site, including fractured vertebra. Accordingly, the present invention offers restoration and repair of a fractured bone comprising cortical and/or cancellous bone.
Additional objects, advantages and novel features of the invention as set forth in the description, will be apparent to one skilled in the art after reading the foregoing detailed description or may be learned by practice of the invention. The objects and advantages of the invention may be realized and attained by means of the instruments and combinations particularly pointed out here.

## Claims

1. A method treating bone comprising the steps of:
forming a passage in a vertebra;
forming a cavity in the vertebra by cutting cancellous bone, wherein a first portion of the cavity is defined by a first exposed vertebral endplate, wherein the first exposed vertebral endplate is exposed by cutting cancellous bone, and a second portion of the cavity is defined by a second exposed vertebral endplate, wherein the second exposed vertebral endplate is exposed by cutting cancellous bone;
providing an inflatable device configured for expansion;
introducing the inflatable device configured for expansion into the cavity; and
expanding the inflatable device configured for expansion to provide a distraction force sufficient to reduce a bone fracture.

2. The method of claim 1, wherein the distraction force is applied to the first endplate and the second endplate.

3. The method of claim 2, wherein the distraction force is applied to reduce a vertebral compression fracture.

4. The method of claim 1, wherein the first endplate is a superior endplate and the second endplate is an inferior endplate.

5. The method of claim 1, wherein the step of forming the cavity comprises a method of cutting bone selected from the group consisting of shearing, cutting, scraping, and combinations thereof.

6. The method of claim 1, wherein the inflatable device configured for expansion is a balloon.

7. The method of claim 6, wherein the inflatable device is non-compliant.

8. The method of claim 6, wherein the inflatable device is semi-compliant.

9. The method of claim 1, wherein the step of expanding the inflatable device to provide a distraction force is configured to manipulate cortical bone.

10. The method of claim 9, wherein cortical bone is manipulated to reduce a fracture.

11. The method of claim 1, further comprising a step of filling the cavity with a material.

12. The method of claim 11, wherein the material is a filling material selected from the group consisting of implant material, in-situ curable material, in-situ hardenable material, permanent material, resorbable material, penetrating material, and combinations thereof.

13. The method of claim 1, wherein the step of forming a passage comprises forming a pilot hole about which the cavity is formed.

14. The method of claim 1, wherein the step of forming a cavity by cutting bone further comprises forming the cavity with a flexible cutting element.

15. The method of claim 1, wherein the cavity is substantially axisymmetric.

16. The method of claim 1, wherein the cavity is substantially non-axisymmetric.

17. The method of claim 1, further comprising a step of increasing the volume of the cavity with the device configured for expansion.

18. The method of claim 1, wherein the cavity is formed with rotational actuation of a tissue cavitation device.

19. The method of claim 1, wherein the step of forming a passage in bone precedes the step of forming a cavity.

20. The method of claim 1, wherein the step of forming a passage in bone occurs substantially concomitantly with the step of forming a cavity.

21. A method for treating bone comprising the steps of:
forming a passage in a vertebra along a linear axis;
providing a tissue cavitation device;
forming a cavity in the vertebra with the tissue cavitation device by cutting bone, the cavity including a first exposed region of a vertebral endplate, wherein the first exposed region is centrally located on the vertebral endplate;
providing an inflatable device configured for expansion; and
expanding the inflatable device configured for expansion within the cavity to provide a distraction force sufficient to reduce a bone fracture.

22. The method of claim 21, wherein the distraction force is applied to a region of cortical bone.

23. The method of claim 22, wherein the distraction force is applied directly to the region of cortical bone.

24. The method of claim 21, wherein the cavity is proximate a first region of cortical bone.

25. The method of claim 24, wherein the cavity is proximate a second region of cortical bone, wherein the first region of cortical bone is a superior endplate and the second region of cortical bone is an inferior endplate.

26. The method of claim 24, wherein the cavity is separated from the first region of cortical bone by a layer of cancellous bone.

27. The method of claim 21, wherein a portion of the boundary of the cavity is cortical bone.

28. The method of claim 21, wherein a portion of the boundary of the cavity is cancellous bone.

29. The method of claim 21, wherein the step of forming the cavity is further selected from the group consisting of shearing, scraping, and combinations thereof.

30. The method of claim 21, wherein the inflatable device configured for expansion is a balloon.

31. The method of claim 30, wherein the inflatable device is non-compliant.

32. The method of claim 30, wherein the inflatable device is semi-compliant.

33. The method of claim 21, wherein the step of expanding the inflatable device to provide a distraction force is configured to manipulate cortical bone.

34. The method of claim 33, wherein cortical bone is manipulated to reduce a fracture.

35. The method of claim 21, further comprising a step of filling the cavity with a material.

36. The method of claim 35, wherein the material is a filling material selected from the group consisting of implant material, in-situ curable material, in-situ hardenable material, permanent material, resorbable material, penetrating material, and combinations thereof.

37. The method of claim 21, wherein the step of forming a passage comprises forming a pilot hole about which the cavity is formed.

38. The method of claim 21, where the step of forming a cavity by separating bone further comprises forming the cavity with a flexible cutting element.

39. The method of claim 21, wherein the cavity is substantially axisymmetric.

40. The method of claim 21, wherein the cavity is substantially non-axisymmetric.

41. The method of claim 21, further comprising a step of increasing the volume of the cavity with the device configured for expansion.

42. The method of claim 21, wherein the cavity is formed with rotational actuation of the tissue cavitation device.

43. The method of claim 21, wherein the step of forming a passage precedes the step of forming a cavity.

44. The method of claim 21, wherein the step of forming a passage occurs substantially concomitantly with the step of forming a cavity.

45. A method for treating bone comprising the steps of:
forming a passage in a vertebra;
providing a tissue cavitation device, wherein the tissue cavitation device includes a deformable cutting element;
inserting the tissue cavitation device into the passage;
forming a cavity in the vertebra along cortical bone within a central portion of the vertebra, wherein the cavity is formed with the flexible cutting element of the tissue cavitation device;
providing an inflatable device configured for expansion;
inserting the inflatable device into the cavity formed along cortical bone within the central portion of the vertebra; and
expanding the inflatable device to provide a distraction force.

46. The method of claim 45, wherein the distraction force is applied to a region of cortical bone.

47. The method of claim 46, wherein the distraction force is applied directly to the region of cortical bone.

48. The method of claim 45, wherein the cavity is proximate a first region of cortical bone.

49. The method of claim 48, wherein the cavity is proximate a second region of cortical bone, wherein the first region of cortical bone is a superior endplate and the second region of cortical bone is an inferior endplate.

50. The method of claim 48, wherein the cavity is separated from the first region of cortical bone by a layer of cancellous bone.

51. The method of claim 45, wherein a portion of the boundary of the cavity is cortical bone.

52. The method of claim 45, wherein a portion of the boundary of the cavity is cancellous bone.

53. The method of claim 45, wherein the step of forming the cavity comprises a method of separating bone selected from the group consisting of shearing, cutting, scraping, and combinations thereof.

54. The method of claim 45, wherein the inflatable device configured for expansion is a balloon.

55. The method of claim 54, wherein the inflatable device is non-compliant.

56. The method of claim 54, wherein the inflatable device is semi-compliant.

57. The method of claim 45, wherein the step of expanding the device to provide a distraction force is configured to manipulate cortical bone.

58. The method of claim 57, wherein cortical bone is manipulated to reduce a fracture.

59. The method of claim 45, further comprising a step of filling the cavity with a material.

60. The method of claim 59, wherein the material is a filling material selected from the group consisting of implant material, in-situ curable material, in-situ hardenable material, permanent material, resorbable material, penetrating material, and combinations thereof.

61. The method of claim 45, wherein the step of forming a passage comprises forming a pilot hole about which the cavity is formed.

62. The method of claim 45, wherein the cavity is substantially axisymmetric.

63. The method of claim 45, wherein the cavity is substantially non-axisymmetric.

64. The method of claim 45, further comprising a step of increasing the volume of the cavity with the device configured for expansion.

65. The method of claim 45, wherein the flexible cutting element is transformable between a first shape for passage into tissue and a second shape for cavity formation.

66. The method of claim 45, wherein the tissue cavitation device comprises:
a shaft having a diameter and a longitudinal axis, wherein the flexible cutting element is associated with the shaft, wherein the flexible cutting element is configured to assume a first shape for insertion and configured to assume a second shape suitable for forming a tissue cavity having a diameter greater than the diameter of the shaft when the shaft is rotated about the longitudinal axis of the shaft.

67. The method of claim 45, wherein the cavity is formed with rotational actuation of the tissue cavitation device.

68. The method of claim 45, wherein the step of forming a passage in bone precedes the step of forming a cavity.

69. The method of claim 45, wherein the step of forming a passage in bone occurs substantially concomitantly with the step of forming a cavity.

70. A method for treating bone comprising the steps of:
forming a passage in a vertebra along a linear axis;
providing a tissue cavitation device;
forming a cavity in the vertebra with the tissue cavitation device by separating bone, wherein the cavity is formed with rotational actuation of the tissue cavitation device, the cavity including a first exposed region of a vertebral endplate, wherein the first exposed region is centrally located on the vertebral endplate;
providing an inflatable device configured for expansion; and
expanding the inflatable device configured for expansion within the cavity to provide a distraction force sufficient to reduce a bone fracture.

71. The method of claim 70, wherein the distraction force is applied to a region of cortical bone.

72. The method of claim 71, wherein the distraction force is applied directly to the region of cortical bone.

73. The method of claim 70, wherein the cavity is proximate a first region of cortical bone.

74. The method of claim 73, wherein the cavity is proximate a second region of cortical bone, wherein the first region of cortical bone is a superior endplate and the second region of cortical bone is an inferior endplate.

75. The method of claim 73, wherein the cavity is separated from the first region of cortical bone by a layer of cancellous bone.

76. The method of claim 70, wherein a portion of the boundary of the cavity is cortical bone.

77. The method of claim 70, wherein a portion of the boundary of the cavity is cancellous bone.

78. The method of claim 70, wherein the inflatable device configured for expansion is a balloon.

79. The method of claim 78, wherein the inflatable device is non-compliant.

80. The method of claim 78, wherein the inflatable device is semi-compliant.

81. The method of claim 70, wherein the step of expanding the inflatable device to provide a distraction force is configured to manipulate cortical bone.

82. The method of claim 81, wherein cortical bone is manipulated to reduce a fracture.

83. The method of claim 70, further comprising a step of filling the cavity with a material.

84. The method of claim 83, wherein the material is a filling material selected from the group consisting of implant material, in-situ curable material, in-situ hardenable material, permanent material, resorbable material, penetrating material, and combinations thereof.

85. The method of claim 70, wherein the step of forming a passage comprises forming a pilot hole about which the cavity is formed.

86. The method of claim 70, where the step of forming a cavity by separating bone further comprises forming the cavity with a flexible cutting element.

87. The method of claim 70, wherein the cavity is substantially axisymmetric.

88. The method of claim 70, wherein the cavity is substantially non-axisymmetric.

89. The method of claim 70, further comprising a step of increasing the volume of the cavity with the device configured for expansion.

90. The method of claim 70, wherein the cavity is formed with rotational actuation of the tissue cavitation device.

91. The method of claim 70, wherein the step of forming a passage precedes the step of forming a cavity.

92. The method of claim 70, wherein the step of forming a passage occurs substantially concomitantly with the step of forming a cavity.