Abstract:
A technique for accessing extra articular lesions or abnormalities or intra osseous lesions or abnormalities or bone marrow lesions or all has the step of positioning the localizing pinning member onto cartilage or subchondral bone to define a virtual pathway through the cartilage or subchondral bone towards or into or through the lesion or abnormality or a desired target to create the virtual pathway utilizing an intra articular localizing pinning member to determine a location of the lesion or abnormality wherein the utilization of the localizing pinning member includes the step to locate or stabilize or both and thereafter using the virtual pathway to create an entry access.

Description:
RELATED APPLICATIONS 
       [0001]    This application is a continuation of co-pending U.S. application Ser. No. 15/080,947 filed on Mar. 25, 2016 entitled, “A System And Technique For Accessing Extra Articular Lesions Or Abnormalities Or Intra Osseous Lesions Or Bone Marrow Lesions”. 
     
    
     FIELD OF THE INVENTION 
       [0002]    The present invention relates to the field of addressing lesions of bone marrow. A system and technique for accessing extra articular lesions or abnormalities or intra osseous lesions or bone marrow lesions is taught. 
       BACKGROUND OF THE INVENTION 
       [0003]    Surgical procedures to repair bone defects such as lesions or abnormalities typically involve scooping out the damaged tissue material. One such procedure is called curettage. In these procedures, the bone is removed or opened to provide access to the lesion or cancerous tumor. This effectively weakens the bone structure because not only has the damaged tissue been removed, but also some of the load bearing solid bone structure. This is particularly problematic in the spine, the knees and the shoulder and articulating joints. 
         [0004]    Ideally the surgeon would prefer to attack the problematic tissue without damaging the surrounding load bearing bone tissue. This is particularly difficult, however, because the damaged tissue material to be removed is hidden behind the joint. The current state of the art does not allow for accessing as well as addressing lesions of bone distant to the entry point of the localizing site. 
         [0005]    The presently available systems and techniques do not adequately address this concern. The present invention described below provides an improved technique to remove the lesion, tumor or other abnormality without damaging the outer joint bone structure, and the surrounding cartilage, and soft tissue. This enables the healing and functionality of the repaired joint to be faster and far less painful. 
       Definitions 
       [0006]    Bone cement: The bone cement PMMA (polymethylmethyacrylate) starts out as a liquid and hardens over time. It can be put into a hole in the bone in liquid form. As PMMA hardens, it gives off a lot of heat. The heat helps kill any remaining tumor cells. This allows PMMA to be used without cryosurgery for some types of bone tumors. 
         [0007]    Bone Lesions: Various disorders can damage bones and result in bone lesions. Symptoms include bone pain or tenderness, and the injury can only be seen using special imaging tests. Bone lesions are abnormal areas of bone typically identified using an X-ray or MRI. Lucent bone lesions are caused by rapidly progressing bone injuries. Sclerotic lesions are bone injuries that develop more slowly, which allows the bone to attempt to wall off the damaged bone tissue. Bone lesions typically have cancerous and non-cancerous causes. 
         [0008]    Bone Marrow Lesions: (BMLs), common osteoarthritis-related magnetic resonance imaging findings, are associated with osteoarthritis progression and pain. 
         [0009]    Curettage: In this procedure, the doctor scoops out the tumor from the bone without removing a section of the bone. This leaves a hole in the bone. In some cases, after most of the tumor has been removed, the surgeon will treat the nearby bone tissue to kill any remaining tumor cells. This can be done with cryosurgery or by using bone cement. 
         [0010]    Cryosurgery: For this treatment, liquid nitrogen is poured into the hole that is left in the bone after the tumor was removed. This extremely cold material kills tumor cells by freezing them. This treatment is also called cryotherapy. After cryosurgery, the hole in the bone can be filled by bone grafts or by bone cement. 
         [0011]    Osteoarthritis: is the most common form of arthritis, affecting millions of people worldwide. It occurs when the protective cartilage on the ends of your bones wears down over time. 
         [0012]    Osteochondritis dissecans: (OCD or OD) is a joint disorder in which cracks form in the articular cartilage and the underlying subchondral bone. OCD usually causes pain and swelling of the affected joint which catches and locks during movement. OCD is caused by blood deprivation in the subchondral bone. This loss of blood flow causes the subchondral bone to die in a process called avascular necrosis. The bone is then reabsorbed by the body, leaving the articular cartilage it supported prone to damage. The result is fragmentation (dissection) of both cartilage and bone, and the free movement of these bone and cartilage fragments within the joint space, causing pain and further damage. OCD can be difficult to diagnose because these symptoms are found with other diseases. However, the disease can be confirmed by X-rays, computed tomography (CT) or magnetic resonance imaging (MRI) scans. 
         [0013]    Subchondral bone: bone located beneath or below the cartilage. 
       SUMMARY OF THE INVENTION 
       [0014]    A technique for accessing extra articular lesions or abnormalities or intra osseous lesions or abnormalities or bone marrow lesions or all has the step of utilizing an intra articular localizing pinning member to determine a location of the lesion or abnormality wherein the utilization of the localizing pinning member includes the step of inserting the localizing pinning member through cartilage or subchondral bone into the lesion or abnormality to locate or stabilize or both creating a first entry access. In a first embodiment, the localizing pinning member enters the bony lesion or abnormality penetrating at least into or through the lesion or abnormality to set the localizing pinning member to the desired depth. 
         [0015]    In a second embodiment, the localizing pinning member does not enter into the subchondral bone, but rather is positioned onto the cartilage or subchondral bone to define a virtual pathway through the cartilage or subchondral bone towards or into or through the lesion or abnormality or desired target to create the virtual pathway. In this embodiment, the surgeon selects a desired depth along the virtual pathway to establish the desired target. No physical penetration through the bone or cartilage is required by the virtual pinning member. 
         [0016]    The localizing pinning member can be a graduated or calibrated depth scale. The pinning member can be a trocar, a drill bit or a pin with a shank marked to indicate the distance to the tip or end. The technique optionally can include fluoroscopy to confirm the localizing pinning member location. 
         [0017]    In the technique of the first embodiment, the step of securing a guide component to an exposed portion of the localizing pinning member at a predetermined position on a shank of the localizing pinning member allows manipulating the guide component about the localizing pinning member to establish a desired location for the creation of a second entry access based on the relevant anatomy thus forming a blind angled osteal tunnel or channel. In the second embodiment, the localizing pinning member may employ a pointed end or short pin that fixes the location of the localizing pinning member exterior of the subchondral bone so the surgeon can manipulate the guide component held at the position as he selects the desired entry access. The guide component is preferably held in place, set or fixed at the desired entry access point. The technique then utilizes the held in place, fixed or set guide component passing a drill, a trocar or a punch through the guide component to the entry access to a desired depth within or in the proximity of the lesion or abnormality thus forming an angled osteal tunnel or channel. The entry access alignment is directed by the position of the localizing pinning member or virtual pathway and the guide component wherein straight lines, one line extending along a track of the localizing pinning member and one line extending along a track of the drill, trocar or punch forming the entry access intersect. The first entry access of the first embodiment has an end in or through the lesion or abnormality and the second entry access has an end at least in proximity to, in or through the lesion or abnormality wherein the first access end is located short of the line extending from the track of the second access entry, beyond or an intersection. In the second embodiment, the pointed end is exterior of the cartilage or subchondral bone on a line extending parallel to the localizing pinning member creates a virtual pathway to a desired depth on the virtual pathway. Either technique allows utilizing the access entry to do one or more of the following steps: a) delivering a substance or material to the proximity or location of the lesion or abnormality; b) modifying the lesion or abnormality; and c) introducing devices to modify or visualize the lesion or abnormality. 
         [0018]    Both techniques further can include securing a guide component to an exposed portion of the localizing pinning member at a predetermined position on a shank of the localizing pinning member manipulating the guide component about the localizing pinning member to establish a desired location for the creation of one more additional entry access point based on the relevant anatomy. If desired, 3 or more entry access points can be used with this technique. In fact, one of the formed entry accesses can have the localizing pinning member or the virtual pathway moved into an entry to allow the guide to form the additional entry accesses. 
         [0019]    A system of the first embodiment allows for accessing extra articular lesions or abnormalities or intra osseous lesions or abnormalities or bone marrow lesions or all and has an intra articular localizing pinning member to determine a location of the lesion or abnormality by inserting the localizing pinning member through cartilage or subchondral bone into the lesion or abnormality to locate or stabilize or both creating a first entry access. The localizing pinning member can be a graduated or calibrated depth scale wherein the localizing pinning member physically enters the bony lesion or abnormality penetrating at least into or through the lesion or abnormality to set the localizing pinning member to the desired depth, the desired depth can be the distance to the tip or end of the pinning member or the system can use the second embodiment and can employ a virtual pathway where the localizing pinning member rests on the cartilage or subchondral bone to define a virtual pathway and does not penetrate through the bone. 
         [0020]    Both the systems further have a guide component attachable to an exposed portion of the localizing pinning member at a predetermined position on a shank of the localizing pinning member wherein manipulating the guide component about the localizing pinning member establishes a desired location for the creation of an entry access based on the relevant anatomy. The guide component is preferably held in place, set or fixed at the desired entry access point. The fixed or set guide component has an opening for passing a drill, a trocar or a punch through the guide component to form the entry access to a desired depth within or in the proximity of the lesion or abnormality. The entry access alignment is directed by the position of the localizing pinning member and the guide component, the first and second entry access of the first embodiment are oriented in the same plane and wherein straight lines, the lines L 1 , L 2  extending along tracks or virtual pathway  11 V extending from the localizing pinning member and one line L 1  extending along a track of the drill, trocar or punch forming the entry access intersect at a point L PT . 
         [0021]    The guide component has a first arm portion for attachment to the localizing pinning member and a second arm portion for guiding a drill, a punch or a trocar wherein the first arm portion is a straight bar having an attachment feature for securing to the localizing pinning member at or near an end and the second arm portion extends arcuately from an end of the first arm portion to an end of the second arm portion, the second arm portion can have an arcuate slotted opening for holding a moveable guide with an opening for passing the drill, punch or trocar. The moveable guide can be configured anywhere along the arcuate second arm portion at any angle between 0° up to 90° relative to the track of the localizing pinning member. 
         [0022]    In a preferred embodiment, the movable guide has a tubular sleeve and the tubular sleeve is linearly moveable relative to the second arm portion to set the guide component when an end of the sleeve abuts tissue at the desired access entry location. The guide component has a clamping attachment to fix the tubular sleeve to the second arm portion. Once fixed, the drill, punch or trocar can be used to form an entry access. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0023]    The invention will be described by way of example and with reference to the accompanying drawings in which: 
           [0024]      FIG. 1  shows a plan or frontal view of a relatively normal joint with the bone marrow lesion from osteochondritis dissecans with the femur above and the tibia below. 
           [0025]      FIG. 2  shows the normal joint of  FIG. 1  with the system of the present invention. 
           [0026]      FIG. 3  demonstrates the normal joint with the first entry access and second entry access formed and the system device removed. 
           [0027]      FIG. 3A  is a plan view of an exemplary syringe filled with a bone putty or similar material for injection through the second entry access. 
           [0028]      FIG. 3B  is an exemplary camera or imaging scoping device for visualizing the lesion through the second entry access. 
           [0029]      FIG. 3C  is an example of an expandable reamer for cleaning the lesion material during repair through the second entry access. 
           [0030]      FIG. 4  demonstrates the guide system of the first embodiment of the present invention. 
           [0031]      FIG. 5  is a second view of the joint of  FIG. 1  showing an additional entry access with the guide system of the first embodiment in place. 
           [0032]      FIG. 6  shows the second view with the guide system of the first embodiment removed. 
           [0033]      FIG. 7  shows a camera in the second entry access. 
           [0034]      FIG. 8  is an example of a prior art lesion fixation. 
           [0035]      FIG. 9  shows a bone lesion. 
           [0036]      FIGS. 9A, 9B and 9C  show diagrammatically how the lesion can be separated exposing the bone marrow. 
           [0037]      FIG. 10  is a joint showing fixation anchors or pins pre-set through the subchondral bone and cartilage with the second access extending toward the end of the pins. 
           [0038]      FIG. 11  shows how a bone cement can be injected with a filled syringe into the lesion or abnormality cavity to encapsulate the pins or bone anchors. 
           [0039]      FIG. 12  shows the repair structurally cemented and fully supported lesion or abnormality repair. 
           [0040]      FIG. 13  shows a second embodiment of the invention wherein a virtual pathway is used when positioning the localizing pinning member which does not penetrate through subchondral bone or the cartilage as illustrated, but rather is located on the cartilage. 
           [0041]      FIG. 14  shows the created second entry access to the lesion without a physical access through the subchondral bone or cartilage when performing the method of the second embodiment. 
           [0042]      FIG. 15  is a plan view of the guide system of the second embodiment. 
           [0043]      FIG. 16  is a second view of the joint of  FIG. 15  showing an additional entry access with the guide system of the second embodiment in place. 
           [0044]      FIG. 17  shows the second view with the guide system of the second embodiment removed. 
           [0045]      FIG. 18  shows a camera in the second entry access. 
           [0046]      FIG. 19  is a use of either guide component wherein the localizing pining member is moved to the second access entry to create additional access entry. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0047]    With reference to  FIGS. 1-7 , a first embodiment of the present invention is illustrated. The first embodiment of the present invention provides for a pinning member access  11 , which is the first entry access, to be created through the cartilage  5  and subchondral bone  7  using a guide component  21  which further enables a localizing pinning member  30  to penetrate into the first entry access  11  and by utilizing the guide component  21  allows for a precise location for a second entry access  12  location to be created. 
         [0048]    With reference to  FIGS. 10-12 , pins or anchoring devices  90  can be inserted through cartilage  5  and subchondral bone  7  into a lesion  10  or abnormity and the creation of a second entry access  12  location provides a means through which the pins or anchors  90  can be structurally supported by the addition of bone cement  62 . A syringe  60  can be placed into the second entry access  12  through which the bone cement  62  or other fixing agents can be syringed through the second entry access portal  12  into the lesion  10  to encapsulate the bone screw  90 , as shown in  FIG. 11 . In  FIG. 12 , the residual cement  62  that is packed into the cavity where the abnormality or lesion was and the second entry access is filled as illustrated sealing the opening wherein the anchors  90  are firmly secured. This structurally supporting cementing of the pins or anchors  90  works equally well with the second embodiment of the present invention wherein the entry access  12  is used to fill the lesion cavity  10 ,  10 A and seal the angled tunnel or track entry access  12  to support the pins or anchors  90 . 
         [0049]    With reference to  FIGS. 13-18 , the second embodiment of the invention is illustrated. This second embodiment is very similar to the first embodiment. However, the localizing pinning member  30  creates a virtual pathway  11 V through the cartilage  5  and subchondral bone  7  without requiring a pinning member  30  entry access  11  whereby an entry access  12  can be created that intersects a line L 1  projected along the virtual pathway  11 V from an end of the localizing pinning member  30  in such a way that the entry access L 2  when projected along a track will intersect at a target location along the virtual pathway  11 V. In this embodiment, as will be discussed later, the subchondral bone and cartilage need not be penetrated and no pinning member entry access opening is created. However, the virtual pathway  11 V is created projecting to a lesion allowing the surgeon to precisely direct and create one or more than one entry access portals or openings  12 ,  14  using the guide component  21  of the present invention. 
         [0050]    The present invention addresses lesions  10  of bone, as shown in  FIG. 1 , which may or may not be visualized arthroscopically. This could be in situations where the patient has intact articular cartilage  5 , such as the situation with osteochondritis dissecans. The surgeon can tell where the lesion  10  is by probing. There can be situations dealing with osteoarthritis or other lesions of the bone marrow where the subchondral bone  7  is intact. In either case, the surgeon wants to be able to locate where the lesion  10  of the bone is that can&#39;t be visualized, it is essentially extra articular, it is within the bone. This could be termed a bone marrow lesion, but in this technique, the surgeon uses intra articular techniques to access the lesion. 
         [0051]    The current art on this is very limited because generally it would be utilizing fluoroscopy or other means to vaguely localize where that lesion might be. Sometimes the lesion can&#39;t even be seen on fluoro. One may argue that a pin can be placed in through it, but there are no localizing techniques other than fluoro and imaging which have significant limitations. 
         [0052]    In the first embodiment of the present invention, as shown in  FIG. 2 , the provided device or system  20  of the present invention allows the surgeon to actually put a pinning member  30  into the lesion  10  through articular cartilage  5 , or in a situation of the osteochondritis dissecans lesion, the surgeon can place the pinning member  30  through the subchondral bone  7  to address a bone marrow lesion  10 . The surgeon applies a guide component  21  to that localizing pinning member  30 . The guide component  21  has a movable guide  40  forming a system that allows for extra articular access to the end or point of the localizing pinning member  30  which is something that is not visualized, but rather is something within that bone marrow lesion  10  or within the bone at a point  10 A distal from the intra articular visualized entry point  11 A and access to it occurs from outside the joint  2 . The surgeon could actually access it from even inside the joint  2 , but coming from a different point or direction. And now by accessing the lesion  10  and removing the damaged tissue, the surgeon can introduce substances into it, such as bone mineral grafting, calcium phosphate, etc. or you can even put a camera system  70 , as shown in  FIG. 3B , through the second entry access track or portal  12  that was created to look at or modify the lesion  10  by putting different types of reamers  80 , shown in  FIG. 3C , into it and selected substances using a syringe  60  filled with a material  62  such as putty or bone allograft or bone cement, as shown in  FIG. 3A . Then one can, after that has been done, put fixation pins  90  additionally into it from the intra articular utilizing the initial pinning member  30  access  11 , one can put pins and fixation devices  90  around it to help further fix the lesion, as shown in  FIG. 3 . 
         [0053]    The limitation of the prior art techniques is that they allow for no precise localization of lesions which cannot be seen. It may be argued that when one uses the prior art guide systems, the problem is that these create straight tracks. The prior art in line devices don&#39;t create angled tunnels, this inventive technique requires an angled tunnel to be created because the surgeon wants the extra articular point of entry to be somewhere remote from the pinning member  30  entry point  11 A which is the intra articular localizing point  11 A. The best way to do that is to create an angled tunnel or an angled track. If using the standard prior art in-line guides, with its exit point at the intra articular point coming in from outside in, one does not create an appropriate track and can actually violate that subchondral bone and the lesion. Furthermore, this does not provide an appropriate methodology for introducing substances in a sophisticated manner or in a precise manner. The present invention is a complete and different approach to it and introduces and provides an entirely new system of devices and instruments to be used for these purposes. Limitations of the prior art as mentioned before is there are no methodologies for addressing and accessing lesions one cannot see when one wants to visualize or repair remote from the initial entry localizing point. That is a big difference. 
         [0054]    The present invention allows for precise localization of a lesion  10  and a way to access it while minimizing load bearing bone structure damage caused by the surgical repair by essentially leveraging the inventor&#39;s angled osteal tunnel concept of creating blind tunnels. In the first embodiment, the surgeon is now able to drill a hole  11  into subchondral bone  7  of the femur  6  and from another angled entry point create an access track or portal  12  so the tip of that pinning member  30  and the drill  50  extend along intersecting lines L 1  and L 2  so that the location  10 A is triangulated. This allows for precise localization of the lesion  10  and access to it. 
         [0055]    One example where this is most useful is to access the lesion  10  from within the joint  2  such as the knee joint  2 . This is called intra-articular. The surgeon can drill a pinning member  30  from within the joint  2  into the bone even going through intact cartilage it necessary. Then, from coming outside of the joint  2  with another drill  50 , he or she can then articulate to a blind spot or point  10 A within bone knowing it is accurate based on the precision of the guide system  20  instruments. Often times, the lesion  10  being addressed maybe a cystic lesion. The surgeon can then introduce other reamers  80  into this second access portal  12 , the reamer  80  is configured to expand once it gets to that desired lesion spot to clean this out. The removed lesion tissue forms a cavity which can then be filled with bone grafting material substance  62  through a cannula  61  that came in from outside of the joint  2 . This technique uniquely allows for blind targeting a point or location  10 A within bone. The invention in an earlier angled osteal tunneling technique, was for retrieving sutures. In this technique, the surgeon is using the angled tunnels as portals  12 ,  14  for delivering material  62  to that spot. Additionally, he can also place a camera  72  through one of the portals  14 , see  FIG. 7 , which will then allow for him to directly visualize what is taking place within the lesion  10  using one portal  14  for the camera  72  and another portal  12  for instruments. As shown, the camera  72  is connected by a flexible cable or tube  71  to a display monitor  78  for real time viewing. 
         [0056]    One of the best examples of utilization of this technique is in the case of osteochondritis dissecans. This is a serious lesion in children and young adults where the cartilage  5  can be intact within the joint  2 , but the bone  7  behind it essentially cystic or a vascular. The surgeon knows where the lesion  10  is from looking inside the joint  2 , but he can&#39;t access the dead bone without violating the cartilage  5 . Hence, with this inventive technique, he simply drills up in through the intact cartilage to help stabilize it using the pinning member  30 . Then coming from outside the joint  2  he can address the diseased bone, clean it out and put material  62  using the second entry access portal  12 . He can then, from inside the joint  2 , further stabilize the lesion  10 . 
         [0057]    There are a number of key points the inventor would like to emphasize regarding the present invention. First, the access to a bony lesion  10  from within a joint (intra-articular) or from outside the joint (extra articular) is greatly enhanced. The ability to use the tunnel portal tracks  12 ,  14  either for retrieval or for delivery of materials  62  is achieved. The ability to use the tracks  12 ,  14  to place cameras  72  and working instruments  80  to look inside of the bony lesions  10  is accomplished. The precise targeting of bony lesions  10  blindly using a technique of triangulation with the guide system  20  instruments or devices of the present system is available. 
         [0058]      FIG. 1  shows a relatively normal joint  2  with the bone marrow lesion  10  from osteochondritis dissecans, as shown the joint  2  has the femur  6  above and the tibia  4  below. The figure outlines the articular cartilage  5  and right behind the cartilage is subchondral bone  7 . Also drawn is the capsule  3 , anything outside the capsule  3  is what is called extra articular; inside the capsule  3  is called intra articular space  9 . The bone marrow lesion  10  which is hidden from view because it is behind that cartilage  5 . It may be behind subchondral bone  7  in a situation where you have arthritis and don&#39;t actually have that cartilage over it. The point is one can&#39;t see the lesion  10  behind what they are looking at from the scope. 
         [0059]      FIG. 2  shows how this would be addressed. The surgeon would put a pinning member  30  through the cartilage  5  and the subchondral bone  7  or just the subchondral bone  7  if there was no cartilage  5 , so it actually goes into the bone marrow lesion  10 . This pinning member  30  can go into it or it can go all the way through the lesion  10 . Then, utilizing the guide system  20 , coming from outside in a generally extra articular approach, but it may not be if it just comes in from a different direction to form a second or even more access portals  12 ,  14 . In any event, these second and one or more additional portals  12 ,  14  do not go through the articular cartilage  5 . The key is that the surgeon is accessing this lesion  10  within the bone from a safe area that doesn&#39;t damage the joint  2 . The access doesn&#39;t damage the other anatomical structures; that is why he has to have the variability of a range of depth and the variability of a range of angles combined with the ability to rotate the guide component  21  around the axis of the pinning member  30 . One can&#39;t have a fixed point of entry because that can be dangerous. This adjustment capability allows the surgeon to access the lesion  10  from a different location, generally an extra articular location, that&#39;s what&#39;s demonstrated how the guide  20  works on this example as shown in  FIG. 2 . 
         [0060]      FIG. 3  demonstrates what is done when you have that track formed on an angled osteal tunnel access portal  12 . Once that separate track  12  is created, the surgeon can enlarge the track  12  with reamers  80 , can put different types of reamers  80  in, which are small going in, then they expand once they get to the lesion  10 , flip cutters, or other types that can be utilized in that situation. The surgeon can use the track or access portal  12 ,  14  to fill the cavity created when the lesion tissue is removed with different substances  62  including bone mineral matrices, stem cells, or can even put cameras  72  inside. As illustrated, a putty filled syringe  60 , a camera system  70  or an expandable reamer  80  can be used, as shown in  FIGS. 3A, 3B and 3C  respectively. Once filled in, these different substances can set, then the surgeon can go back into the joint  2  and can put multiple pins  90 , and fixation devices  90  which can now be better fixed because there is some substance within the lesion  10  cavity which to fix them to. 
         [0061]      FIG. 4  demonstrates what the guide system  20  looks like. It demonstrates how an intra articular guide pinning member  30  is placed, how the guide component  21  then attaches to the pinning member  30  at an appropriate depth. The guide component  21  has a swinging arcuate arm  24  that comes around and allows the precise localization and alignment tip to tip even though one can&#39;t see what is essentially a blind tip  10 A. This allows access for things you can&#39;t see. Again, completely eclipses any type of current prior art using poor techniques such as fluoro, etc. for visualization. With the present invention, the surgeon knows exactly where he is with precise localization for addressing the lesion in a completely different way of practicing medicine. 
         [0062]    As shown in  FIG. 4 , the guide system  20  has a guide component  21 . The guide component  21  has a straight first arm portion  22  that extends in a straight path to an end  22 A for holding a pinning member  30 . The end  22 A is transverse to the arm portion  22 . As shown, the shank of the pinning member  30  has marked gradations  33  that establish the distance to the tip or point  30 A. The pinning member  30  can be a pin, a drill bit or punch, by way of example. At the end  22 A, a shank tightening nut  34  or fixation device is shown that, when tightened, holds the pinning member  30  securely to the arm  22  thereby fixing the tip  30 A location. At the opposite end  22 B of the first or straight arm  22  is a second swing or arcuate arm  24 . The second arm  24  is shown in a partial section view showing a slot  23  that allows a movable guide  40  to slide in the slot  23  over a range of angles between at least 0 and 90 degrees relative to the tip of the pinning member  30 , most typically between 30 and 60 degrees. Preferably, the movable guide  40  has a cannulated shaft, sleeve or tube  42  with a tightening clamp  41  having a nut  43  that fixes the movable guide  40  onto the second arm  24  anywhere along the slotted opening or slot  23 . As shown, a drill bit, a punch or a trocar  50  can be slipped through the movable guide  40  tube  42  to create the second access portal or track  12 ,  14 . Preferably, when locating the desired location to form the second or additional access portals, the tube  42  is moved relative to the guide  21  to set the tube solidly against the tissue then the components are tightened to fix the angle and the sleeve length. Then the drill  50  can be inserted to create the second or more access tracks or portals  12 ,  14 . The shape of the guide component  21  allows the system  20  to be pinned at one location and flipped to an opposite side of the knee joint while still pinned if desired to make additional or even third or more access portals or tracks as shown in  FIG. 5 . This feature makes the procedure to create additional entry points remarkably easy. Once the two access portals  12 ,  14  are created, the use of a visualizing camera system  70  as the surgeon uses other devices and instruments to remove or repair the lesion  10  is available so real time observation of the surgical repair is available which vastly improves the likelihood of successful lesion tissue removal and treatment. Once the lesion  10  cavity is cleared, substances  62  can be added through the access portal. One such substance  62  is bone cement that can greatly improve screw or pin fixation. 
         [0063]    Essentially the next aspect of this is taking bone marrow lesions  10  with ocd and osteochondritis dissecans and when the surgeon is trying to fix these, generally the bone  7  behind it is poor so he is not getting very good fixation so the two additional elements are needed after one utilizes the technique, either after or during utilization of the technique the surgeon can actually put screws in place, they can be metal or they can be biocomposite. These fixation devices  90  actually go into the lesion  10  then he can put the substance  62  around it, the grout or a bone cement which may include different types of bone cement, different types of putty  62 , which might harden when set actually allow the screw to be better fixed, alternatively he can put the bone cement substance  62  in the lesion cavity first, then screw directly through it which can again both of these provide better fixation than without any of the bone substances  62 . The cement is either put around once the screws are placed or the screws  90  are placed through it. And these can be screws or these can be darts or any variety of fixation devices  90 . 
         [0064]      FIG. 8  is the picture showing what an OCD lesion would look like intra articular, you can see the cartilage wrap  5  coming off and the subchondral bone  7  behind it. Often you can&#39;t see the bone behind it. This one is a lesion  10  that is more advanced and fixation pins  90  are placed to stabilize the bone. 
         [0065]      FIG. 9  is a picture with  3  photos  9 A,  9 B and  9 C above it showing how a lesion  10  has completely come off and that is what the bone  7  looks behind it. There is more dead bone behind that we want to access so either you could have a cartilage cap that was intact on it or you have the exposed bone. That is why with the guide system  20  one can go through either cartilage  5  or intact bone  7  when it is exposed. That bone is called subchondral bone  7 . Again, the surgeon wants to get behind it and he can&#39;t see it, that&#39;s why he wants to pass the tip or end of the pinning member and that&#39;s the tip end that he wants to access blindly from a different portal  12 ,  14 . One can see on  FIG. 9  that&#39;s the x-ray which shows what a lesion  10  like this might look like, and one can try to pin that lesion or try to get behind it. 
         [0066]    The  FIG. 8  illustration of this is an actual photograph just shows how one currently can secure that lesion  10 , stabilize with screws or degradable pins  90 ,  92 . The present invention technique is more predicated upon actually a couple of different things. Number one addressing the tissue behind that bone and then more importantly, once that has been actually addressed that tissue, where bone marrow lesion has been removed can be filled with substances such as cement, etc. Now the surgeon can fix into those substances which is another extension of this system because one of the things now that can be done because one has created an appropriate bed behind that lesion you now have new techniques of fixation which can actually fix into that bone which currently cannot be done because there is no way of stressing that foundation absent this type of repair. 
         [0067]    The second or the first entry access itself or the track created can be enlarged. Its important to note that the second entry access although generally extra-articular, does not necessarily have to be so. More importantly, this access track can be away from the cartilage and subchondral bone so that it does not damage these structures. The current state of the art does not allow for addressing lesions of bone distant to the entry point of the localizing site. It is also important to restate that the present inventive technique allows for accessing or accessing as well as addressing the lesion. Specifically, although the surgeon can address bone lesions by removing damaged tissue, sometimes he can choose to address them by simply adding structural materials or stem cells or both without removing any tissue. 
         [0068]    An important feature of this technique is that fixation of the lesion utilizing stabilizing devices such as the initial localizing pin or additional ones which can now either be drilled or punched through the lesion and then be filled with the grout material, such as concrete being poured on rebar, or filling with the grout material before and then the fixation device is placed through it, such as placing screws through concrete once it has set. This introduces an entirely new methodology of addressing these lesions which previously has not been effectively or precisely performed. 
         [0069]    With reference to  FIGS. 10-12 , a normal joint with a lesion  10  is shown where the lesion has been prepared forming a cavity in the region  10  and  10 A. In this cavity, bone anchors, screws, or anchors or pins  90  can be positioned as illustrated in  FIG. 10 . These pins and screws  90  enter into the cavity location as shown in  FIG. 10 . With reference to  FIG. 11 , when a syringe  60  is positioned into the entry access  12 , the syringe filled with bone cement  62  can be used to deliver bone cement or other adhesive or bonding material into the cavity  10  or  10 A of the lesion  10 . When this occurs, the bone cement  62  encapsulates and surrounds the anchors  90  that have previously been positioned as illustrated in  FIG. 10 . As the cement fills the cavity, the syringe  62  can be backed out and as illustrated in  FIG. 10 , the entire entry access portal  12  can be filled. This provides a secure structurally enhanced repair of the area where the lesion  10  or abnormality had existed, as illustrated in  FIG. 12 . Alternatively, a bone repair mixture  62  can be inserted into the cavity via the entry access portal  12  and then the screws or pins  90  can be positioned drilling into the cement  62 . If the cement  62  is soft, it will simply go into the cavity and will surround the screws or pins  90  with the cement  62  which will harden later or alternatively if provided with sufficient cutting flutes, can be threaded into the prepared area with the cement  62  already hardened. Any of these methodologies are possible with the benefit that the damaged knee will be strengthened substantially by the introduction of the bone hardening cement  62  into the cavity  10 ,  10 A via the entry access  12 . 
         [0070]    With reference to  FIGS. 13-18 , a second embodiment of the invention is shown. The second embodiment uses a guide component  21  similar to the guide component  21  of the first embodiment. However, in this embodiment, the localizing pinning member  30  is short, shown truncated, having a point or tip  30 A that can rest onto the cartilage  5  above the subchondral bone  7 . In this location  11 A, the tip  30 A can be pinned onto the cartilage  5  so that it is held there by the surgeon and the entry access portal  12  can be created using the movable guide  40 . The movable guide  40  can then have a drill, punch or trocar  50  directed into the bone towards the lesion  10  to create an entry access portal  12 . As illustrated in  FIG. 14 , the entry access portal  12  is shown approaching the region of the lesion  10  and is delivered to a desired target location within the lesion. What is unique about the second embodiment method is, as shown in  FIG. 14 , there is no hole or first entry access tunnel  11  created by the localizing pinning member  30  instead a virtual pathway  11 V is created by the guide component  21 . As shown in  FIG. 15 , the guide component  21  has the arcuate arm  24  with the movable guide  40  that can be positioned anywhere along the angular approach of the arcuate arm portion  24 . The straight arm portion  22  holds the localized pinning member  30 . The localized pinning member  30  may have gradations  33  as previously discussed along the shank of the pinning member  30 . However, the pinning member  30  has an end  30 A that rests on top of the cartilage  5  and subchondral bone  7  such that a virtual pathway  11 V along line L 1  is created pointing into the lesion  10 . If desired, when the movable guide  40  is positioned along the arcuate arm portion  24 , a second line L 2  is created. The intersection of lines L 1  and L 2  creates the desired target location or point l PT  as illustrated. The benefit of this component is that no cartilage or subchondral bone needs to be cut or drilled into using this device. As shown in  FIG. 16 , the entry access portal  14  is already created using the virtual pathway  11 V that was further described with reference to  FIG. 13 . In  FIG. 16 , however, the device can be then pivoted in such a fashion that an additional access portal  14  can be created on an opposite side of the joint as illustrated. Again, when pivoting the guide  21 , the subchondral bone and cartilage are never penetrated through, however, all access portals will be directed along the virtual pathway  11 V of the localized pinning member  30 . With reference to  FIG. 17 , multiple entry access portals  12  and  14  are illustrated. With reference to  FIG. 18 , a device  80 ,  81  is shown on one side with the device  70  with a camera viewing the area of the lesion  10  through the additional access portal  14 . In this fashion, the device  80  can be used to probe into the cavity where the surgeon observes what is happening using the camera  70 . 
         [0071]    With reference to  FIG. 19 , the guide component  21  can be repositioned such that the localized pinning member  30  is positioned in the entry access  12 . When this occurs, the surgeon can locate an additional location for an entry access or an additional entry access  14  by simply pivoting the guide component  21  about the localized pinning member  30  positioned in the access portal  12  in such a fashion that the movable guide  40  can then be positioned and directed such that an additional entry access portal  14  can be drilled on the opposite side of the bone. In the embodiment of  FIG. 19 , a pin  90  is shown positioned in the area of the lesion  10 . This method of moving the localized pinning member  30  to an entry access portal for making additional entry access portals can be used with either the first embodiment of the invention or the second embodiment of the invention. 
         [0072]    Variations in the present invention are possible in light of the description of it provided herein. While certain representative embodiments and details have been shown for the purpose of illustrating the subject invention, it will be apparent to those skilled in this art that various changes and modifications can be made therein without departing from the scope of the subject invention. It is, therefore, to be understood that changes can be made in the particular embodiments described which will be within the full intended scope of the invention as defined by the following appended claims.