Abstract:
Milling and drilling tools and soft tissue management techniques are provided for arthroplasty that facilitate intraoperative and postoperative efficacy and ease of use. In one embodiment, resiliently biased soft tissue protective sleeves surround a side cutting tool and are interposed along the longitudinal axis of the cutting tool, preferably adjacent each side of the bone. The soft tissue protective sleeves are biased to track along the contour of the side of the bone and prevent the cutting tool from being exposed to soft tissue during the resection. In another embodiment, a pilot drill is initially utilized to create an initial bore in the bone to be resected. The pilot drill preferably has an end cutting arrangement and a non-cutting removal channel that minimizes the tendency of the pilot drill bit to drift off-axis as the initial bore in the bone is created. Once the initial bore is created, the pilot drill bit is withdrawn and a second side cutting tool, such as a milling bit, is then inserted into the bore to perform the desired surface resection.

Description:
CLAIM TO PRIORITY 
     The present invention claims priority to U.S. Provisional Application No. 60/551,262, filed Mar. 8, 2004, entitled, “METHODS AND APPARATUS FOR IMPROVED DRILLING AND MILLING TOOLS FOR RESECTION,” and claims priority to U.S. Provisional Application No. 60/551,080, filed Mar. 8, 2004, entitled, “METHODS AND APPARATUS FOR PIVOTABLE GUIDE SURFACES FOR ARTHROPLASTY,” and claims priority to U.S. Provisional Application No. 60/551,078, filed Mar. 8, 2004, entitled, “METHODS AND APPARATUS FOR MINIMALLY INVASIVE RESECTION,” and claims priority to U.S. Provisional Application No. 60/551,096, filed Mar. 8, 2004, entitled, “METHODS AND APPARATUS FOR ENHANCED RETENTION OF PROSTHETIC IMPLANTS,” and claims priority to U.S. Provisional Application No. 60/551,631, filed Mar. 8, 2004, entitled, “METHODS AND APPARATUS FOR CONFORMABLE PROSTHETIC IMPLANTS,” and claims priority to U.S. Provisional Application No. 60/551,307, filed Mar. 8, 2004, entitled, “METHODS AND APPARATUS FOR IMPROVED CUTTING TOOLS FOR RESECTION,” and claims priority to U.S. Provisional Application No. 60/551,160, filed Mar. 8, 2004, entitled, “METHODS AND APPARATUS FOR IMPROVED PROFILE BASED RESECTION,” and is a continuation-in-part of U.S. patent application Ser. No. 11/036,584, filed Jan. 14, 2005, entitled, “METHODS AND APPARATUS FOR PINPLASTY BONE RESECTION,” and is a continuation-in-part of U.S. patent application Ser. No. 11/049,634, filed Feb. 2, 2005, entitled, “METHODS AND APPARATUS FOR WIREPLASTY BONE RESECTION,” which claims priority to U.S. Provisional Application No. 60/536,320, filed Jan. 14, 2004, and is a continuation-in-part of U.S. patent application Ser. No. 11/049,634,filed Feb. 3, 2005, entitled, “METHODS AND APPARATUS FOR WIREPLASTY BONE RESECTION,” which claims priority to U.S. Provisional Application No. 60/540,992, filed Feb. 2, 2004, entitled, “METHODS AND APPARATUS FOR WIREPLASTY BONE RESECTION,” the entire disclosures of which are hereby fully incorporated by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     This invention generally relates to methods and apparatus for bone resection to allow for the interconnection or attachment of various prosthetic devices with respect to the patient. More particularly, the present invention relates to methods and apparatus for improved drilling and milling tools for resection and arthroplasty. 
     2. Background Art 
     Different methods and apparatus have been developed in the past to enable a surgeon to remove bony material to create specifically shaped surfaces in or on a bone for various reasons including to allow for attachment of various devices or objects to the bone. Keeping in mind that the ultimate goal of any surgical procedure is to restore the body to normal function, it is critical that the quality and orientation of the cut, as well as the quality of fixation, and the location and orientation of objects or devices attached to the bone, is sufficient to ensure proper healing of the body, as well as appropriate mechanical function of the musculoskeletal structure. 
     In total knee replacements, for example, a series of planar and/or curvilinear surfaces, or “resections,” are created to allow for the attachment of prosthetic or other devices to the femur, tibia and/or patella. In the case of the femur, it is common to use the central axis of the femur, the posterior and distal femoral condyles, and/or the anterior distal femoral cortex as guides to determine the location and orientation of distal femoral resections. The location and orientation of these resections are critical in that they dictate the final location and orientation of the distal femoral implant. It is commonly thought that the location and orientation of the distal femoral implant are critical factors in the success or failure of the artificial knee joint. Additionally, with any surgical procedure, time is critical, and methods and apparatus that can save operating room time, are valuable. Past efforts have not been successful in consistently and/or properly locating and orienting distal femoral resections in a quick and efficient manner. 
     The use of oscillating sawblade based resection systems has been the standard in total knee replacement and other forms of bone resection for over 30 years. Unfortunately, present approaches to using existing planar or non-planar saw blade instrumentation systems all possess certain limitations and liabilities. 
     Perhaps the most critical factor in the clinical success of any bone resection for the purpose of creating an implant surface on the bone is the accuracy of the implant&#39;s placement. This can be described by the degrees of freedom associated with each implant. In the case of a total knee arthroplasty (TKA), for example, for the femoral component these include location and orientation that may be described as Varus-Valgus Alignment, Rotational Alignment, Flexion-Extension Alignment, A-P location, Distal Resection Depth Location, and Mediolateral Location. Conventional instrumentation very often relies on the placement of ⅛ or 3/16 inch diameter pin or drill placement in the anterior or distal faces of the femur for placement of cutting guides. In the case of posterior referencing systems for TKA, the distal resection cutting guide is positioned by drilling two long drill bits into the anterior cortex across the longitudinal axis of the bone. As these long drills contact the oblique surface of the femur they very often deflect, following the path of least resistance into the bone. As the alignment guides are disconnected from these cutting guides, the drill pins will “spring” to whatever position was dictated by their deflected course thus changing their designated, desired alignment to something less predictable and/or desirable. This kind of error is further compounded by the “tolerance stacking” inherent in the use of multiple alignment guides and cutting guides. 
     Another error inherent in these systems further adding to mal-alignment is deflection of the oscillating sawblade during the cutting process. The use of an oscillating sawblade is very skill intensive as the blade will also follow the path of least resistance through the bone and deflect in a manner creating variations in the cut surfaces which further contribute to prosthesis mal-alignment as well as poor fit between the prosthesis and the resection surfaces. Despite the fact that the oscillating saw has been used in TKA and other bone resection procedures for more than 30 years, there are still reports of incidences where poor cuts result in significant gaps in the fit between the implant and the bone. Improvements in the alignment and operation of cutting tools for resecting bone surfaces are desired in order to increase the consistency and repeatability of bone resection procedures as is the improvement of prosthetic stability in attachment to bone. 
     One technique that has been developed to address these challenges has been the profile based resection (PBR) techniques taught, for example, by U.S. Pat. Nos. 5,514,139, 5,597,397, 5,643,272, and 5,810,827. In a preferred embodiment of the PBR technique, a side cutting tool such as a milling bit or side drill bit is used to create the desired resected surface. While the PBR technique offers many advantages over conventional resection and arthroplasty techniques, it would be desirable to provide enhancements to the PBR technique that improve the ability to address soft tissue management 
     SUMMARY OF THE INVENTION 
     The present invention provides for embodiments of milling and drilling tools and soft tissue management techniques for arthroplasty facilitating intraoperative and postoperative efficacy and ease of use. In one embodiment, resiliently biased soft tissue protective sleeves surround the side cutting tool and are interposed along the longitudinal axis of the side cutting tool adjacent each side of the bone. The soft tissue protective sleeves are biased to track along the contour of the side of the bone and prevent the side cutting tool from being exposed to soft tissue during the resection. In another embodiment, a pilot drill is initially utilized to create an initial bore in the bone to be resected. The pilot drill preferably has an end cutting arrangement and a non-cutting removal channel that minimizes the tendency of the pilot drill bit to drift off-axis as the initial bore in the bone is created. Once the initial bore is created, the pilot drill bit is withdrawn and a second side cutting tool, such as a milling bit, is then inserted into the bore to perform the desired surface resection. 
     The present invention utilizes a number of embodiments of cutting tools to remove boney material to create cut surfaces for prosthetic implant attachment and fixation. The overriding objects of the embodiments are to provide the ability to perform resection in very small incisions, the creation of precise and accurate cut(s), and to provide for soft tissue protection characteristics and features preventing the tool from accidentally harming soft tissue. Specifically, many of the cutting tool embodiments disclosed are either incapable or highly resistant to damaging soft tissue, or are by means disclosed prevented from coming into contact with soft tissue in the first place. 
     The present invention utilizes a number of embodiments of cutting guide technologies loosely or directly based on Profile Based Resection (PBR). The overriding objects of PBR technologies are to provide for significantly improved reproducibility of implant fit and alignment in a manner largely independent of the individual surgeon&#39;s manual skills, while providing for outstanding ease of use, economic, safety, and work flow performance. 
     The present invention utilizes a number of embodiments of alignment or drill guides to precisely and accurately determine the desired cutting guide location/orientation, thus cut surface location(s)/orientation(s), thus prosthetic implant location and orientation. The overriding objects of the embodiments are to precisely and accurately dictate the aforementioned locations and orientations while optionally enabling ease of use in conjunction with manually or Computer Assisted techniques, and while optionally enabling ease of use in minimally invasive procedures where surgical exposure and trauma are minimized. 
     The present invention utilizes a number of methods and apparatus embodiments of soft tissue management techniques and the devices supporting said techniques. The overriding object of these embodiments is to take advantage of the anatomy, physiology, and kinematics of the human body in facilitating clinical efficacy of orthopedic procedures. 
     It is an often repeated rule of thumb for orthopedic surgeons that a “Well placed, but poorly designed implant will perform well clinically, while a poorly placed, well designed implant will perform poorly clinically.” The present invention provides a method and apparatus for reducing implant placement errors in order to create more reproducible, consistently excellent clinical results in a manner that decreases risk to soft tissue, incision or exposure size requirements, manual skill requirements, and/or visualization of cutting action. 
     It should be clear that applications of the present invention is not limited to Total Knee Arthroplasty or the other specific applications cited herein, but are rather universally applicable to any form of surgical intervention where the resection of bone is required. These possible applications include, but are not limited to Unicondylar Knee Replacement, Hip Arthroplasty, Ankle Arthroplasty, Spinal Fusion, Osteotomy Procedures (such as High Tibial Osteotomy), ACL or PCL reconstruction, and many others. In essence, any application where an expense, accuracy, precision, soft tissue protection or preservation, minimal incision size or exposure are required or desired for a bone resection and/or prosthetic implantation is a potential application for this technology. In addition, many of the embodiments shown have unique applicability to minimally invasive surgical (MIS) procedures and/or for use in conjunction with Surgical Navigation, Image Guided Surgery, or Computer Aided Surgery systems. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Other important objects and features of the invention will be apparent from the following detailed description of the invention taken in connection with the accompanying drawings in which: 
         FIGS. 1 ,  2 , and  3  are pictorial representations standard incision sizes or exposure required by the prior art, while 
         FIG. 4  is a pictorial representation or approximation of one form of surgical exposure that is desired. 
         FIGS. 5-98 ,  111 ,  119 , and  125 - 127  show various depictions of embodiments and methods in accordance with alternate embodiments of the present invention. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     It should be noted that, in many of the figures, the cut surface created by the cutting tool in accordance with the techniques of the present invention are shown as having already been completed for the sake of clarity. Similarly, the bones may be shown as being transparent or translucent for the sake of clarity. The guides/pins, cutting tool, bones, and other items disclosed are may be similarly represented for the sake of clarity or brevity 
     
       FIGS. 1 through 4 
     
       FIGS. 1 and 2  show conventional surgical exposures and instrumentation being utilized.  FIG. 4  shows a reduced incision currently utilized in performing the current state of the art in ‘minimally invasive’ Unicondylar Knee Replacement. 
     
       FIGS. 41-60 
     
       FIGS. 41 through 60  represent an embodiment of the present invention the soft tissue protection sleeves  428  and milling/drilling bit  420  management techniques that enable Triple Transcutaneous Transarticular TKA (“TTTKA” or “Triple TKA” or “T Cubed” or “T 3 ” Procedures). The soft tissue protection sleeves  428  shown, for example, in  FIGS. 42 and 43 . One clinical application calling for the benefits of this feature would be where a PBR cutting guide  402 , as generally shown in  FIG. 35  is positioned completely outside of the wound with the exception of fixation features  426  which extend from the externally located guides through skin incisions and into holes or apertures created in bone. As shown in  FIGS. 52 and 53 , the cutting tool  420 , in the case of the present invention a side cutting drill, is extended through the handle  422 , the guide  402 , the skin, fat, capsule, etc (soft tissue), across, across and in front of, through, or beneath the articular surfaces of the joint, and through the soft tissue, guide  402 , and handle  422  on the opposing side of the bone. The soft tissue protection sleeves  428  may be extended through the soft tissue and into contact with the sides of the bone. The retaining lip  430  can be used to maintain the sleeves  428  in contact with the bone and are held there by the edges of the incision through the capsule during cutting. The springs  432  shown in  FIG. 43  can further bias the sleeves  428  into contact with bone in a manner that would maintain that contact as the width of the bone changed along the cutting path of the resected surface. 
     One skilled in the art will note that the thicknesses for the soft tissue through which the sleeves  428  extend change significantly from patient to patient thus requiring the proportions of the sleeve  428 , spring  432  and other components of the present embodiment of the invention to change accordingly. For example, in an obese patient, the fat layer through which the cutting tool  420  extends can be 5 inches thick per side or more. The diameter of the soft tissue protection sleeve  428  can be significantly reduced with respect to what is shown as the side cutting drill diameter is reduced, thus requiring a smaller capsular or other soft tissue incision or ‘stab wound’. 
     In operation, the handle  422  is manipulated to traverse the cutting path  404  of the cutting guide  402  while the tibia is swung through a range of motion about the femur as shown in comparing  FIGS. 54 through 60 . This particular principal of operation takes advantage of the fact that the capsule, the patella, and to a lesser or greater extent the skin, moves with the tibia as it moves through a range of motion with respect to the femur. Thus, a small, perhaps 4 mm to 10 mm long stab wound through skin to the medial side of the posterior femoral condyles (roughly in line with the axis of the pilot drill shown in  FIG. 51 ) with the knee bent in flexion, and then looked at the side of the femur (through the portal created by the stab wound) while moving the tibia through a range of motion, the side of the femur would be observed to be passing by/through the portal. In order to complete all of the resected surfaces on the femur necessary to fix a standard femoral prosthesis, it may be necessary in one embodiment to make two passes with the side cutting drill  420  sweeping about the femur with the tibia as represented in  FIGS. 54 through 60 . 
       FIGS. 44 through 51  represent an embodiment of the present invention for use in creating pilot holes allowing for introduction of a side cutting drill or other cutting tool in Triple TKA or Unicondylar or Bicondylar procedures. Of particular interest, the pilot drill  421  is designed to eliminate or mitigate any deviations of the drill from its intended location and orientation as it is guided to create portals in living bone. Standard drills tend to follow the path of least resistance into and through bone often resulting in either poor drill placement, and thereby poor cutting guide  402  placement, or improperly located and oriented portals or apertures for fixation of a cutting guide resulting in poor cutting guide placement. As shown in  FIG. 44 , the pilot drill  421  possesses cutting teeth  423  that are very aggressive in side cutting. This is critical in that it prevents deflection of the cutting tool when it contacts tissue of varying material properties. This area of very aggressive side cutting teeth  423  is relatively short, and is followed by a longer smooth portion  425  of the shaft of the drill  421  which is designed to be incapable of cutting bone, but may beneficially include smooth flutes  427  allowing for removal of chips during the cutting process. A pilot drill  421  of this kind, optionally used in conjunction with the Surg Nav Drill Guide  190  of  FIGS. 8 through 11 , would be outstanding for use in creating the apertures in bone desired for positioning any number of cutting guides. Specifically, the pilot drill  421  may provide sufficient accuracy and precision of aperture  496  creation to allow for drilling all the way through or across a bone to which a cutting guide  407  will be attached to bone sides of the aperture  496  as shown in  FIG. 68 , where the cancellous bone within the cortical shell is not shown for the sake of clarity. 
     In use with the embodiment of the present invention, with the soft tissue protection sleeves  428  of the milling handle  422  in contact with a bone surface, the pilot drill  421  would be plunged through the bushings  434  of the milling handle  422  and across the joint, as shown in  FIGS. 45 through 51 .  FIG. 51  represents the pilot drill  421  having been plunged entirely across the joint, but with the milling handle not shown for the sake of clarity. Thus, a portal has been created across the entirety of the joint for subsequent insertion of the side cutting drill  420  shown in  FIGS. 52 and 53 , or any other cutting tool. It should be noted that in embodiments adapted for use in Unicondylar knee replacement, it would only be necessary to create the portal in one side of the joint for extension of the cutting tool  420  across only a single condyle (as is seen in comparing  FIGS. 78 and 80 ). An alternative embodiment and method of the milling handle  422  of the present invention represented in  FIG. 54  would be to extend the side cutting drill  420 , or other cutting tool, through a soft tissue portal on one side of the joint, across the entirety of the bone surfaces to be resected or cut, but not extend the tool through the soft tissue on the far side of the joint. As control of the side cutting drill by the milling handle  422  is very robust, even when it supports only one spindle of the side cutting drill, accurate and precise preparation of the distal femur can be performed without necessitating a second soft tissue portal, and the soft tissue trauma associated with it, no matter how minor, on the far side of the joint. 
     Alternatively, a hybrid embodiment of externally and internally located guide surfaces would allow for high precision, high accuracy cutting without necessitating the creation of soft tissue portals for insertion of the cutting tool  420 . This embodiment of the present invention can be attained by positioning one PBR cutting guide surface(s) in the wound (perhaps looking like the medial guide surface of the cutting guide  407  shown in  FIGS. 68 through 70 ) and interconnecting it with an externally located PBR cutting guide surface(s) (for example, looking like the laterally located plate in  FIG. 60 ). This would allow for single spindle guidance of the side cutting drill or other cutting tool in a very robust manner, while minimizing the trauma to soft tissues necessary to implement these embodiments. Furthermore, the use of these single spindle embodiments lend themselves to easy manipulation of the cutting tool in pivotally sweeping (see  FIG. 85 ) a cut surface while manipulating the cutting tool axially with respect to the milling handle. Thus the anterior chamfer cut, distal cut, and posterior cut could be completed by sweeping the cutting tool along the cutting path of the cut surface, and the anterior and/or posterior cuts could be completed by pivotally sweeping the cutting tool as mentioned above while maintaining the stability inherent in guiding the milling handle on guide surfaces on opposing sides of the cut being created. This is beneficial in that the internally located guide surfaces could be truncated or shortened significantly allowing for both easier insertion into the surgical exposure and reduction in the exposure necessary to accommodate the embodiments in clinical use. 
     
       FIGS. 5 through 11 
     
       FIGS. 5 through 11  concentrate on alignment guide and/or drill guide techniques.  FIG. 5  shows a manually operated alignment guide  100  suitable for use with surgical exposures similar to that shown in  FIG. 2  (it should be noted that surgical navigation sensors could be used to assist in determining final drill guide location and orientation).  FIGS. 6 and 7  show an improvement upon the embodiment shown in  FIG. 5  for enabling manual alignment guide use in less invasive incisions by providing soft tissue accommodating contours or reliefs  110 . In other words, for a medial parapatellar incision, the alignment guide  100  is configured to allow for appropriate contact and referencing of the distal and posterior femoral condyles, the IM canal (when not relying on an extramedullary reference or inference of the mechanical axis) or IM Rod  120 , the anterior cortex or anterior runout point of a given or proposed implant size (via a stylus not shown), and the epicondylar axis via palpitation or visual reference while the patellar tendon, patella, and/or quadriceps tendon is draped over the lateral side (right side as shown in the figures) of the alignment guide  100  allowing insertion of the guide when the patella is neither everted not fully dislocated as in conventional techniques. It should be noted that initial alignment indicated by reference of the distal femur may be further adjusted in all six degrees of freedom as a fine tuning for final cut location and orientation. This simply calls for the inclusion of additional adjustment of the location and orientation of the crossbar mechanism  130  and/or rotational alignment arm  140 , with respect to the initial reference provide for by contact between the body  150  of the guide  100  and the bone (optionally including the IM Rod  120 ), in flexion-extension angulation, varus-valgus angulation (rotational angulation and Anterior-Posterior location are already shown), mediolateral location (represented in this embodiment of the current invention by the cross bar mechanism  130  in  FIG. 5  where drill guide mediolateral location is shown as being independently and infinitely adjustable), and proximal-distal location (as shown in  FIGS. 5 ,  6 , and  7 —it should be noted that this adjustment might be best embodied in an infinitely adjustable slide as opposed to the incrementally adjustable slide  160  shown, and that simple marking would be present indicating the relative movement of the slide with respect to the body). It may be desirable to only utilize only a medial drill guide plate  170  with multiple drill guide bushings  180  to create holes extending partially or completely across the femur depending upon the manner in which the guides are to be connected to the femur. 
       FIGS. 8 ,  9 , and  10  show an alternative alignment/drill guide embodiment of the present invention wherein a cannulated surgically navigated handle/drill guide  190  is used to create fixation apertures in the bone for direct or indirect fixation of a cutting guide. As shown in  FIG. 8 , it may be advantageous to include tines  192  for penetrating the bone to obtain initial stabilization of the handle in the location and orientation indicated by the surgical navigation system (“Surg Nav”—this term shall be used interchangeably with Computer Aided Surgical System or Image Guided Surgical System throughout this disclosure) prior to extending the drill  194 , represented in  FIG. 10 , into the bone to create the aperture. It should be noted that the aperture  196 , or hole, thus created could be blind or extended to a specific depth, or optionally extended entirely through the bone and out the furthest side of the bone. Importantly, this process could be utilized transcutaneously through a small stab wound (perhaps 4 mm in length) through the skin to the bone surface, or through a preformed incision through which other instrumentation of the present invention or other devices may be introduced during a procedure. Further, although only one cannulation is shown, a single handle may desirably contain multiple cannulations, some or all of which could be adjustably extended into contact with the bone to reduce any wandering of the drill  194  contacting oblique bone surfaces and improve the precision and accuracy of aperture creation (thus allowing for the creation of apertures  196  in the medial side of the femur, represented in  FIG. 11 , with a single Surg Nav Handle—Also, the apertures  196  may be configured such that the femoral and tibial apertures  196  shown in  FIG. 11  are all created using a single positioning step for the handle). As represented in  FIG. 9 , there is very little distance over which the drill  194  is cantilevered between its guidance within the cannulations and its point of initial contact with the outer surface of the bone. This aspect of this embodiment of the current invention is critical in preserving the potential accuracy of Surg Nav systems, i.e.; the navigation system (the computer and the sensors) may be capable of determining appropriate location and orientation to ±0.1 mm and ±0.5 degrees, but if the location and/orientation of the aperture created represents some path of least resistance in bone which is followed by the drill  194 , the resultant location and orientation of cut surfaces, and thereby the location and orientation of the prosthesis attached thereto, will likely be seriously in error. 
     It should also be noted that the methods described herein are applicable to the methods demonstrated in Provisional Patent Application Ser. No. 60/536,320, entitled “Methods and Apparatus for Pinplasty Bone Resection” and Ser. No. 60/xxx,xxx, entitled “Methods and Apparatus for Wireplasty Bone Resection,” the disclosures of each of which are hereby incorporated by reference. 
     It should also be noted that another embodiment of the present invention, represented in  FIGS. 88-92 , benefits from the apparatus and principles of operation outlined above. As shown in  FIG. 88 , an aperture  202  and a plane  204  are created in bone which actually act as the cutting guide  200  in controlling the location and orientation of the cutting tool  220  within a specific plane during the creation of a cut surface. In this embodiment of the present invention, the cannulated drill guide will, in either manual or Surg Nav techniques, be used to guide a forstner style drill bit (the ‘guide surface’  200  shown in  FIG. 88  could have been created by a modified drill with a leading section 15 mm long by 4 mm in diameter, responsible for the pivot aperture  202 , and a 10 mm diameter following section which was about 10 mm long, responsible for the pivot reference surface  204 ) to create a larger diameter cylindrical aperture the bottom of which would define a pivot reference surface  204  parallel to the cut surface to be created, and a smaller diameter cylindrical aperture to form a pivot aperture  202  for maintaining the body of the bushing  210  shown in  FIGS. 88-91  in the proper location and orientation while cutting. Importantly, the technique outlined above is beneficially applied to tibial resection or any other planar or curvilinear resection technique as well. 
     
       FIGS. 12 through 34 
     
       FIGS. 12-34  disclose embodiments of the present invention for creating planar and/or curvilinear resection surfaces on or in the proximal tibial and other bones and embodiments of the present invention for prosthetic implants. 
       FIGS. 12-15  represents an embodiment of the present invention for cutting guides and cutting tools which substantially comprises a guide  200  with guide pivot aperture(s)  202  and a guide pivot reference surface(s)  204  for mating with a bushing  210  controlling a cutting tool  220 , wherein the bushing  210  possess a bushing reference plane  212  (which mates with the pivot reference surface(s)  204  of the guide  200 ), a bushing pivot pin  214 , best represented in  FIG. 88  (which mates with the guide pivot aperture(s)  202  of the guide  200 ), and a cannulation  216  for articulated and/or axial guidance of the cutting tool  220 . 
     There are a number of optional features that are highly desirable depending on the preferred method of use utilized for these embodiments of the present invention. The soft tissue protection tip  222  of the cutting tool  220  and the integral soft tissue retractor feature  218  of the bushing body  210  are two principal examples represented in  FIG. 20 . The soft tissue protection tip  222  can be integrally formed as a part of the cutting tool  220  during its manufacture, be a separate component attached to it, and may, in one preferred embodiment, be free to rotate with respect to the cutting tool  220  (which would be useful in preventing rotating bearing contact between the tip and soft tissue). The integral soft tissue protector  218  in beneficial in preventing or mitigating contact between soft tissue near the area where the cutting tool  220  enters, cuts, and exits the wound (in other words, to the right and left of the bushing body  210  shown in  FIG. 13 ). If you picture the incision as being a window into the joint which is somewhat elastically moveable from side to side, the integral soft tissue retractor  218  would act to shift that window to mitigate or prevent contact between the soft tissue (specifically the patella tendon, medial or lateral collateral ligaments, the capsule, skin, fat, etc.) and the cutting surfaces of the cutting tool  220 . 
     In operation, the guide is properly positioned with respect to the proximal tibia and the cut to be created thereon and robustly fixed with respect to the tibia or directly to the tibia. This can be accomplished by manual alignment means outlined in U.S. Pat. No. 5,643,272 for manually positioning guides then fixing them in place, or use the &#39;272 apparatus and methods to create the fixation apertures  196  shown in  FIG. 11  or  12 , or use the Surg Nav techniques described herein as shown or in conjunction with the methods described in the &#39;272 patent. The bushing body is then engaged with the guide. Three primary methods of initiating cutting of the proximal tibia are preferred. The first, or ‘Tangent Method’, is initiated by extending the side cutting drill through the bushing body cannulation and into contact with a side of the tibia and then sliding the optional non cutting tip along the face of the bone until the cutting surfaces of the cutting tool were first in contact with the side of the bone. At this point, the cutter could be actuated to begin cutting the boney tissue to create the cut surface. As the non-cutting tip cannot cut bone, its edges would remain at all times immediately beyond and adjacent to the boundary of the cut surface being created. The diameter or size may be greater or less than the diameter or size of cutting surfaces of the cutting tool. Note that although the embodiment of the cutting tool shown is a side cutting drill, a modified rat tail rasp driven by a reciprocating driver could also work well—any cutting tool capable of cutting in a direction orthogonal to its long axis is considered to be within the scope of the present invention. 
     As best represented in  FIG. 15 , the entirety of the resected surface may be prepared in this manner. The second primary method is the ‘Plunge Then Sweep’ method. In this method, the cutting tool or optionally a pilot drill would be plunged completely or partially across the surface to be cut. Then the cutting tool could be swept back and forth in clockwise and counter-clockwise directions while being axially manipulated to complete the cuts. The third primary method is the ‘Chop Then Sweep’ method represented in comparing  FIGS. 88 and 89 . In this method, the cutting surfaces of the cutting tool are positioned over and at least partially across the uncut bone, then chopped down into it by manipulating the bushing. In other words, the bushing pivot pin is engaged with the pivot aperture with the cutting tool positioned over the bone which positions the bushing reference surface at a distance above the pivot reference surface, then the bushing is moved downward along the axis of the bushing pivot pin while the cutting tool is under power until the cutting tool reaches the cut surface to be created (if the cutting tool is a side cutting drill, the cutting surfaces would be tangent to the desired cut surface at that time). The bushing is then manipulated as described hereinabove to complete the cuts. Importantly, the pivot reference surface and pivot aperture could be slidably mounted to a base component fixed with respect to the tibia so that the surgeon may manipulate the bushing body to simultaneously create the cut and move the pivot aperture with respect to the tibia. This embodiment will enable the surgeon to easily compensate for any soft tissue condition encountered clinically while preserving the benefits of the present invention. Methods combining the aforementioned primary methods are considered to be within the scope the present invention. Importantly, most standard or prior art tibial resection cutting guides may be simply modified to include the pivot apertures described herein. 
       FIGS. 16 through 21  describe another embodiment  200  of the present invention. As shown in  FIG. 16 , this embodiment includes a Base  240  and a Rotational/Translational Pivot Arm  242  coacting to allow for infinite manipulation of the bushing  210  pivot pin  214  location within a desired plane during the process of removing material from the proximal tibia or other bone. Movement of the Rotational/Translational Pivot Arm  242  in both rotational and translational degrees of freedom within a desired plane allows for any combination of rotational and translational movement of the axis of the bushing pivot pin  214  within its desired plane. In other words, this embodiment of the present invention allows for infinite and continuous adjustability of cutting tool  220  location and orientation with respect to the bone or bones being cut while providing for accurate and precise cut surface creation. 
       FIGS. 22 through 28  represent another embodiment  200  of the present invention whose principal of operation are similar to previous embodiments, with the exception of including a depth limiting contour  244  which acts as either a definitive limitation for cutting tool  220  depth or as a general guideline for a surgeon to follow as the patient&#39;s clinical presentation and the surgeon&#39;s judgment dictate. Although the embodiment shown is directed toward Unicondylar tibial preparation, it should be noted the any clinical application where such definitive or guideline type depth guidance is desirable. 
       FIGS. 29 and 30  show an embodiment  300  of the present invention directed toward endplate preparation in spinal reconstruction where the endplates are prepared to receive a prosthetic implant. Guide  300  includes a milling handle  302  to which the cutting tool  310  attaches. It is interesting to note that the profile of the cutting path  312  of the guide  300  represented in  FIG. 30 , in this embodiment, is geometrically identical to the cutting path of the resected surface created by the passage of the cutting tool  310  shown. This could be very helpful in clinical application where such a device where inserted into a wound such that, while the surgeon could not visually observe the cutting tool  310  while it removes boney material, he could, by way of the guide geometry, observe where the cutting is with respect to the bone being cut by looking at the position (represented by “POS  1 ” and “POS  2 ”) of ‘Pivot  2 ’, represented in  FIG. 30 , with respect to its location in contact with the guide as it traverses the cutting path of the cutting guide. This embodiment is also highly applicable to tibial resection and could allow for cut geometries that are anatomically curved in both AP and ML profiles to both preserve bone and improve fixation quality and load transfer characteristics between the implant and the bone by converting the shear component load of conventional planar tibial components into compressive loads via geometrically normal or transverse abutment of bone and implant surfaces in the direction of A-P and/or M-L and/or torsional shear loading. An implant design embodying fixation geometries for mating with such cut surfaces is highly desirable. In one embodiment of such a tibial prosthesis design, the fixation surfaces would be intended to mate, directly or indirectly, with cut surfaces represented in  FIGS. 33  and/or  34  (the tibia in the right side of the  FIG. 34 ). In essence, the tibial implant would possess a planar or gently curvilinear ‘rim’ for contacting the ‘cortical skim cut’ surface (represented in  FIG. 32 ), and convex fixation surfaces for direct or indirect fixation to the concave tibial cuts represented in  FIGS. 33 and 34 . Direct fixation to such surfaces could be achieved by high precision resection of both the cortical rim, for attachment of the rim of the tibial prosthesis, and the concave surface(s), for intimate apposition to the convex implant surfaces. Such fixation, specifically of the concave bone cuts to the convex implant surfaces, could be achieved by way of an interference fit between the cuts and the implant along one axis (for instance, a front to back—AP—axis or direction), or along two axes (for instance, AP and Side to Side—ML—axes), or circumferentially (in other words a bit like a pin of a given diameter being forced into a hole of a lesser diameter), or both circumferentially and along an axis at roughly a 90 degree angle or normal to the skim cut surface when viewed in one or two orthogonal planes (an “up and down axis” or superior-inferior or proximal distal direction). It should be noted that an interference fit in a roughly superior-inferior direction may call for a textured surface on the bottom most surface of the convex fixation surfaces presents a small surface area of contact at initial contact with the bottom of the concave cut to allow the implant to compact a reduced area of cancellous bone as the implant is impacted in a superior to inferior direction until it reaches its desired superior-inferior location and/or contact between the rim of the implant and the skim cut of the cortices. As compared to previous methods of achieving implant fixation, these embodiments of the present invention yield superior stability of implant fixation to bone to an extent reminiscent of the difference between riding a horse wearing a deeply dished saddle and riding a very sweaty horse bareback. 
     An alternative fixation paradigm allows for less intensive demands for the precision of the fit between concave tibial cuts and convex fixation surface. In essence, the concave surface may be ‘excavated’ in any desired manner (such as the Cutting Trials shown in  FIG. 31  which cut the proximal tibia while the tibia is moved through at least a portion of its range of motion about the femur), and a morselized or granular osteobiological substance, perhaps tricalcium phosphate, HATCP, or other substances generally described as ‘bone substitutes’ or autograft or allograft cancellous or cortical bone (it would be very useful to use the bone which was removed from the tibia or other patient bone during the creation of the cut(s) in that it is readily available and completely avoids the issues of disease transmission or immune response), is then impacted into the concave surface using a ‘form’ to create a surface of impact material (referred to herein as the “Impacted Surface”) of specific shape and location/orientation with respect to the cortical skim cut and/or the tibia or femur. This form is beneficially shaped in a manner related to the shape of the convex implant fixation surface shape so as to create a specific geometric relationship between the implant fixation surfaces and the Impacted Surface geometry. In one embodiment of the present invention, the fit between the implant and the Impacted Surface would be an interference fit or press fit. As properly impacted morselized cancellous bone is known to achieve stiffnesses (or modulus of elasticity) which approach as much as 80% of the stiffness of cortical bone in compression, robust intraoperative fixation may be achieved in this manner. In another embodiment, the fit would leave a significant gap, perhaps 0.2 mm to 4.0 mm in width, between portions or all of the convex fixation surfaces of the implant and the convex cut(s), into which bone cement or other substance would then be injected or impacted achieving interdigitation with both the surfaces of the prosthesis and the material of the Impacted Surface. This results in what could be described as composite interface of both biologically active and non-living but structurally robust materials to facilitate both immediate intraoperative stability by way of simple mechanics and long term stability by way of improved load transfer between the implant and the bone eliciting a beneficial biological response by the bone to said loading resulting in intimate and mechanically robust apposition between the composite interface and living tissue. It should be noted that such a method prevents excessive micromotion or strain at the interface between the implant (and/or the composite interface) and living tissue during the postoperative healing process, which, in essence, gives the bone a chance to further stabilize its fixation to the implant by way of bone modeling or remodeling in response to load transfer. Specifically, it is highly beneficial to maintain the strain state within living bone at and/or in the general vicinity of the bone implant interface within a range of 50 microstrain to 4000 microstrain so as to elicit the formation of bone tissue at and around the interface—strain levels in excess of 4000 microstrain or less than 50 microstrain are very likely to elicit the formation of fibrocartilagenous tissues at the interface which may lead to aseptic loosening of the implant. In the embodiment where the bone cement is injected, a small hole located at or beneath the skim cut allows for the injection of the material beneath the implant to achieve intimate and controlled interdigitation. 
     Alternatively, the implant could be seated ‘over’ the freshly cut concave surfaces, and a slurry of biologically active and/or mechanically robust material(s) injected into the gaps between the implant and the bone under controlled pressure. Injection could be achieved via the portal  12  shown in  FIG. 34 . Such a slurry may comprise a mixture of substances such as morselized patient bone and bone cement, but alternative or additional materials including bone substitutes, osteobiologicals such as bone morphogenic proteins, antibiotics, or even living cells such as T cells known to promote post-operative healing and long term implant fixation. Beneficially, a fin feature may be added to these embodiments to facilitate additional mechanical stability, and said stem feature could beneficially possess an aperture for cross-pin fixation as described below for use in conjunction with the cross pins  10  represented in  FIG. 111 . 
     Importantly, it is an objective of the embodiments of the present invention to preserve living, structurally viable bone tissue to facilitate the efficacy of any subsequent revision procedures. Further, the location and geometry of the concave tibial cut allows for the use of a bearing insert (conventionally made of materials such as polyethylene or other materials capable of ‘whetting’ or mimicking the benefits of ‘whetting’ during bearing contact; mimicking constituting, in one embodiment, the absence or mitigation of wear debris generation despite the application of significant bearing forces, in TKA in excess of 200 lbs and often as much as 500 lbs or more) whose ‘underside’ is convexly shaped to mate with a concavely shaped mating or accommodating surface in the upper surface of the tibial implant or ‘baseplate’ as it is sometimes referred to. This allows for a tibial insert(s) whose thickness, in the areas beneath where the femoral implant bears against the tibial insert, may be equal to or greater than those insert thicknesses used in the past (those associated with predominantly planar tibial cuts) while require removal of significantly less structurally viable bone from the cortical rim of the proximal tibia than past efforts. Determination of the geometry and location of the baseplate&#39;s concave surface and therefore the areas of greatest insert or bearing surface are easily determined by analysis of the wear patterns of retrieved tibial inserts. These embodiments of the present inventions also facilitate significant clinical benefits when applied to meniscal or rotating platform TKA designs as a high degree of conformity may be achieved while constraint is mitigated while preserving significantly more bone than prior art devices. Further, the reproducibility of the methods and apparatus described herein enable independent attachment of single compartment implants to bone to achieve Unicondylar, Bicondylar, Bicondylar and Patellofemoral, or Unicompartmental and Patellofemoral replacement of damaged bone surfaces while achieving the objectives of bone preservation, robust immediate and short and long term fixation, reproducibility of implant fixation and resulting location and orientation, and intraoperative ease of use. 
     It should be noted that the cutting profile of the cutting tool shown in  FIG. 29  may be curved in manner beneficial to endplate preparation in intervertebral fusion, dynamic disc replacement, and/or nucleus replacement as the cutting profile closely approximately the natural geometry of the endplates and provides for intimate fit with such prostheses fixation surfaces. In adapting this embodiment to tibial resection in either partial or complete knee replacement, the cutting profile of the tool would be shaped as desired to create the aforementioned cut surfaces in either one continuous movement of a single cutting tool, or incremental use of one or more cutting tools to cut bone to the desired shape and in the appropriate location and orientation, in all degrees of freedom, with respect to the tibia and/or femur and/or patella and/or soft tissues of the knee joint. 
     Critically, in many applications of the tibial resection embodiments and methods described herein it is desirable that the Superior-Inferior thickness or diameter of the cutting tools used be less than the thickness of the bone to be removed in the creation of the cut surfaces so that the cutting surfaces of the cutting tool not contact soft tissue surface and bone surfaces located above the bone being removed. Alternatively, the cutting tool could be of such a thickness or diameter as to allow for the resection of both the femur and the tibia, or any such contiguous bones, to be prepared simultaneously with the passage of the cutting surfaces of a single tool across or along cut surfaces being created on both bones. Maintaining the desired geometric relationships between the contiguous or adjacent bone ends would be key in this embodiment of the present invention and could easily be obtained and maintained by use of a bracket fixed to the bones to establish and maintain the geometric relationship between said bones (see  FIG. 30  for one embodiment of such a bracket employed to establish and maintain alignment between adjacent vertebral bodies. 
     
       FIGS. 35 through 40 
     
       FIGS. 35 through 40  show embodiments of the present invention for femoral resection. For the sake of clarity, it should be noted that any combination of the forms of the present invention disclosed herein may be modified or combined to form constructs not specifically disclosed herein, but still within the scope of the present invention. The embodiments represented in  FIGS. 29 and 30  are outstanding examples of this, as one of ordinary skill in the art would clearly recognize the applicability and benefits of this embodiment for tibial and/or femoral resection in Unicondylar or Bicondylar procedures, for bone resection in ankle replacement or arthrodesis (fusion), mandibular advancement procedures, high tibial osteotomy procedures, proximal femoral and acetabular preparation in Hip Arthroplasty, and many other applications where reproducible and safe removal of living tissue during surgical intervention is beneficial. 
       FIGS. 35-40  shows an embodiment  400  of the present invention wherein the guide plates  402  and guide surfaces  404  are located entirely outside the wound, but the side cutting drill  420  and handle  422  construct are not passed through mediolateral soft tissue portals described hereinabove. The side cutting drill controlling portion  424  of the handle is essentially ‘snaked’ into the less invasive wound/exposure/approach/incision and the guide engagement features  426  are engaged to the cutting guide at a location entirely outside the wound. As long as the axis of the engagement feature  426  is maintained as coaxial with the side cutting drill  420 , the desired cut geometries will be attained despite manipulation of the handle  422  with respect to the guide  402 . This method can be utilized to complete some or all of the desired cuts. Also, this embodiment of the current invention can be used to perform the posterior cut, posterior chamfer cut, and distal cut optionally using kinematic resection to reduce exposure requirements, and then removed from the wound and guide, flipped over 180 degrees from the orientation shown in  FIG. 39 , reinserted into the wound and into engagement with the guide  402  to cut the anterior chamfer cut and anterior cut with or without implementation of a kinematic resection technique and, optionally, with the knee in 15 degrees to 45 degrees to facilitate the soft tissue laxity and ease of use previously described. It should be noted that the mechanism for driving the side cutting drill  420  is not represented in these figures and that a number of different options may be used. One way to accomplish drive input is generically represented in  FIG. 40 , where a flexible drive shaft or bevel gear arrangement may be utilized to drive the side cutting form drill  420  shown. Alternatively, chain, belt, or pneumatic drive mechanisms may also be used.  FIG. 40  also represents an embodiment of the present invention which allows for the accurate and precise preparation of curvilinear cut surfaces, beneficially used in conjunction with guides  403  containing curvilinear guide surfaces  405  as represented in  FIGS. 61 and 62 , to create cut surfaces for intimate attachment and fixation to implants  20  represented in  FIGS. 125 ,  126 , and/or  127 . 
       FIGS. 93 through 98  represent an implementation of the side cutting drill  220  embodiment of the present invention for cutting tools. It is of interest to note that the milling handle  211  shown could further be guided by the PBR guides of the present invention to further combine the accuracy and precision benefits of PBR with the soft tissue protection characteristics of tibially embedded femoral cutting tool. It should also be noted that the side cutting drill  220  with a curved cutting profile, similar to that shown in  FIG. 119 , could also be used to attain cut geometries possessing simultaneously curved or curvilinear cutting profiles and cutting paths. In utilizing such, it would be critical that the side to side location of the cutting profile of the cutting tool  220  be tightly controlled with respect to the desired side to side location of the implant as the side to side location of the implant would be dictated by the cut surfaces generated. Alternatively, a cutting tool with a linear cutting profile, as shown in  FIG. 94 , could be utilized to create cut surfaces with a linear cutting profile and a curved cutting path, and then a second cutter with a curved cutting profile could be used to create a second, contiguous or noncontiguous, cut with a curved cutting profile and/or path whose mediolateral location was closely controlled to result in proper fit and location of the prosthesis attached to said cut surfaces. It should be noted that the cutting path of the second cutter could be located within a single plane, such as for a bilateral femoral component design, or could be curvilinearly divergent from the plane containing the cutting path of the first cut surface. This would be useful for unilateral femoral component designs (ones which require separate left and right femoral implants) so as to allow for the implant design to reflect out of plane patellofemoral kinematics and/or out of plane tibiofemoral kinematics most accurately. 
     Interestingly, this embodiment of kinematic resection style resection could be modified to allow the cutting tool to be directly or indirectly linked to the movement of the patella with respect to the femur, or directly connected to the patella, to enable cutting of patellofemoral articular surfaces on the femur while moving the tibia and patella through ranges of motion about the tibia. The embodiments of cutting tools for use in attaining this include curvilinear end cutting mills or face cutters, side cutting drills with linear or non-linear cutting profiles, and other cutting tools capable of cutting the femur while engaged, directly or indirectly, to the patella. The side-to-side location of such cutters could be determined by engagement or adjustment with respect to a PBR or other guide, or simply by the natural kinematic path of the patella about the femur during flexion-extension of the knee joint. 
     The complete disclosures of the patents, patent applications and publications cited herein are incorporated by reference in their entirety as if each were individually incorporated. Various modifications and alterations to this invention will become apparent to those skilled in the art without departing from the scope and spirit of this invention. It should be understood that this invention is not intended to be unduly limited by the illustrative embodiments and examples set forth herein and that such examples and embodiments are presented by way of example only with the scope of the invention intended to be limited only by the claims set forth herein.