Patent Publication Number: US-2022233225-A1

Title: Rotary Impactor for Orthopedic Surgery

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     The present application is a non-provisional application and claims priority under 35 U.S.C. § 119 on pending U.S. Provisional Patent Application Ser. No. 63/141,786, filed on Jan. 26, 2021, on pending U.S. Provisional Patent Application Ser. No. 63/188,542, filed on May 14, 2021, and on pending U.S. Provisional Patent Application Ser. No. 63/277,754, filed on Nov. 21, 2021 the disclosures of which are incorporated by reference. 
    
    
     FIELD OF THE DISCLOSURE 
     The present disclosure relates to a rotary impact reamer for use by surgeons and or surgical robots, and more particularly, to a rotary impact reamer in which negligible reactionary force is imparted to the surgeon and/or robot. 
     BACKGROUND OF THE DISCLOSURE 
     The current direction of surgery is towards using robot assistance in the surgery process. In this regard, an end effector of the robot may be used by a robot, for example, to perform a surgical procedure. The end effector is, in an embodiment, a device, tool, or manipulator at an end of the robot that is capable of engaging and interacting with a surgical site. The end effector is directed by the robot to perform surgical actions. In the field of robotic surgery, the end effector may comprise a surgical tool. 
     To date, robotic automation in surgery has worked well in laproscopic procedures and surgeries with low energy requirements, however, in the orthopedic environment where large forces and energies are routine, the adoption of the robot has been hindered. In such an environment and in the field of orthopedic surgery, larger energy requirements have necessitated a different approach (such as machining) due to the inability of surgical robots to handle the magnitude of reactionary forces that result from typical large bone surgical tools (such as saws, drills or reamers). 
     An exemplary robot that is used in large bone surgeries is Stryker Corporation&#39;s MAKO product. The MAKO has three purposes: enhanced planning, dynamic joint balancing, and robotic-arm assisted bone preparation. 
     As part of its operation, the robot must have the bone geometry of the surgical site identified in order to accurately navigate, guide, and manipulate its end effector through the surgical site. Such identification of bone geometry is referred to as registration. Existing surgical power tools produce a significant amount of reactionary torque (such as in the case of a surgical reamer) or shock (such as in the case of a surgical impacting tool) when used in orthopedic surgery. This torque and or shock can not only cause the robot to lose its registration but it can also damage the robot&#39;s highly intricate machinery and components. 
     Rotary reamers are used in hip and hip replacement surgery such as when preparing the cavity for the acetabular cup of a prosthetic hip. These rotary tools have a significant reactionary torque associated with the surgical procedure. This can result in the tool being wrenched from the grip of the surgeon performing the operation and in severe cases damage to the surgeons wrist or forearm. Clearly, such reactionary torque can cause navigational or guidance errors which in the case of use by a robot will often result in loss of registration and shut down of the robot. Testing has shown this to be the case and is one of the most common complaints about using robots for large bone orthopedic surgery. 
     The navigation capability is arguably the most important feature of orthopedic robotics. For a successful surgery, the robot must hold the tool (or instrument) in the correct orientation and alignment with respect to the bone. If the surgical instrument is allowed to move off the stereotactic boundary then the surgery can suffer from any of a number of drawbacks, including injury to soft tissue if the instrument is still powered. Currently-available rotary tools can generate large destabilizing forces (reactionary torque caused by the reamer encountering and/or snagging on a hard section of bone.). These forces interfere with a robots programmed navigation and can result in the robot shutting down. 
     Furthermore, there are at least two problems with simply placing a surgical power tool designed for a surgeon onto a robot. One, the reactionary force/torque imparted by the tool can move the robot off of its guided path. Secondly in large bone surgery, the robot often cannot supply sufficient linear force to enable progression of the reamer into the acetabulum. The surgeon often has to exert linear force on the tool in order to achieve the desired outcome. 
     Accordingly, a need exists for an impacting tool (also referred to herein as an impactor) that allows for easier operation by the surgeon as well as creating a pathway to robotic and eventually full autonomous surgery. As such, the present disclosure provides for a rotary and or rotary/linear surgical tool which through the use of impacting significantly reduces the reflected torque while achieving a similar outcome as current rotary surgical reamers. Furthermore in the case that linear impaction is used to augment the rotary impaction, both the linear and rotary force requirements are significantly reduced as compared to conventional surgical reamers and drills. For example, current art requires the surgeon to apply all the required linear force to advance the surgical reamer into the surgical site. This linear force can be in excess of 25 pounds, which is far more than a surgical robot is capable of providing. It has been discovered that linear impaction by the disclosed tool reduces the required linear supporting force from the surgeon by ˜50%. 
     SUMMARY OF THE DISCLOSURE 
     In view of the foregoing disadvantages inherent in the prior art, the purpose of the present disclosure is to provide a solution to the high reactionary forces that occur from the use of orthopedic surgical tools. These solutions work to reduce the reactionary forces upon a surgical robot and/or the surgeon to allow better control of the surgical instrument (for example, positioning thereof) during surgery. In addition to reducing the reactionary forces, it is also the purpose of this disclosure to mechanically provide all or a significant portion of the required forces to complete the surgery such that the surgeon and/or robot should only have to guide the tool with minimal force. 
     In an embodiment, the present disclosure provides for a rotary impacting tool for orthopedic surgery that is configured to minimize reactionary forces during large bone orthopedic surgery. The tool preferably comprises a mechanism (such as an absorbing means) that decreases the peak reactionary forces from the tool end that act on a gripping surface of the tool. Such gripping surface may include, but is not necessarily limited to, a hand grip or the like in the case of a tool that is designed for manual operation by a surgeon, or a cylindrical body or other mounting means in the case of a tool that is coupled to and operated by a surgical robot. It is to be understood that “surgical tool” and “impactor” refer to the invention disclosed herein, while “surgical implement” refers to attachments to the surgical tool&#39;s output. For example, surgical tool would refer to the rotary impact handpiece while surgical implement could refer to a semi-hemispherical reamer that attaches to the surgical tool output. 
     In an embodiment, the reactionary force is further reduced by using a dampening mechanism, which allows the reactionary force to be spread across a larger time period, thus reducing the reactionary force seen or felt at the gripping surface. In said embodiment, the dampening mechanism comprises a viscoelastic or non-Newtonian fluid disposed between the motor mount and the housing of the tool such that the reactionary torque is isolated from the tool housing and therefore from the surgeon/robot as well. It is obvious that this dampening mechanism can also be used to isolate the motor drive from the hammering mechanism and hence the location of this dampening mechanism can vary although its preferable location is between the gripping surface and the tool housing and/or the motor mount and the tool housing. In yet another embodiment, the tool may also comprise a counter movement element to absorb and spread reactionary forces across a longer time period. 
     In an embodiment, the tool comprises a torque sensing means, which torque sensing means, when a threshold torque value is reached or exceeded, may initiate a rotational impacting mechanism that transmits rotary impact force to the surgical implement. Said threshold torque value is preferably a torque lower than the torque which could damage the operating robot or surgeon&#39;s wrist. It has been discovered that the transition should occur around 30 to 50 inch pounds. The tool may then initiate a rotary impacting force on the impact hammer that is to be transmitted and/or translated to the surgical implement. 
     In yet another embodiment, the present disclosure provides for a rotary and linear impacting tool for orthopedic surgery that is configured to minimize reactionary forces during large bone orthopedic surgery. The tool may comprise a mechanism (such as an absorbing means) that decreases the peak reactionary forces from the tool end that act on a gripping surface of the tool. Such gripping surface may include, but is not necessarily limited to, a hand grip or the like in the case of a tool that is designed for manual operation by a surgeon, or a cylindrical body or other mounting means in the case of a tool that is coupled to and operated by a surgical robot. It is to be understood that “surgical tool” refers to the invention disclosed herein, while “surgical implement” refers to attachments to the surgical tool&#39;s output. For example, surgical tool may refer to the rotary/linear impact handpiece while surgical implement may refer to a semi-hemispherical reamer that attaches to the surgical tool output. 
     In an embodiment, an impactor or impacting tool comprises a hammer. an output anvil, and an energy storage means (which means may comprise, in an embodiment, a spring). The hammer and anvil are operatively coupled to and are capable of being rotated by a lead screw element (an example of such being a Torqspline®). It is understood that the term “torqspline” is used in this disclosure as an exemplary embodiment of a lead screw element and as such the term “torqspline” should not be considered limiting. Upon rotation, when a sufficient load on the output anvil is reached, the output anvil and hammer may temporarily cease being rotated by the torqspline element, the hammer may translate up the torqspline, away from the object that is the target of impacting to energize the energy storage means until the hammer and output anvil are so aligned to allow the now-energized energy storage means to act on the hammer to allow the hammer to translate down the torqspline (while also rotating) to impact the output anvil with minimal reactionary torque. 
     The minimal reactionary torque is a result of two things: first, substantially decoupling the hammer from the output anvil. This restricts the reactionary torque to a certain threshold value dependent only on the energy storage means (a spring for example) and the pitch of the torqspline. Second, the sharp impact on the output anvil from the hammer allows the impact reamer to overcome a high load area (such as sclerotic bone/bone spurs in the acetabulum), with minimal reactionary torque to the surgeon. The high impact forces generated as a result of the impact of the hammer on the anvil breaks through the high load area, with minimal reactionary torque. 
     It is conceivable to those familiar in the art, that the translation and rotation of the hammer in the above-mentioned mechanism could be partitioned in such a way as to impart impacts in the both the rotary and linear direction simultaneously. It has been discovered that adding a linear impaction element to the reaming process increases the overall speed of the reaming stage while also reducing surgeon fatigue (the surgeon does not need to apply the linear push force that they do with a normal reamer. This push force can be in excess of 25 pounds). In an embodiment, impacting of the hammer in a linear direction is accomplished by an impact element that is disposed on the hammer and/or the output anvil, which element imparts or receives a linear impact when the hammer comes into contact with the output anvil as more specifically described elsewhere herein. 
     In an embodiment, the tool comprises a torque sensing means, which torque sensing means may cause rotational motion of the output anvil and/or hammer to cease. 
     In another embodiment, the surgical impacting tool comprises a hammer. an output anvil, and an energy storage means (which means may comprise, in an embodiment, a wave spring). The hammer and anvil are operatively coupled to and are capable of being rotated by a leadscrew (such as a torqspline screw) element. The tool further comprises a cam (such as a barrel) cam and cam follower and an impact rod. Rotation of the hammer may spin the anvil to have the anvil output a torque on the impact rod. The impact rod may turn the barrel cam, causing the wave spring to compress. After the cam follower clears the barrel cam, the wave spring can expand to force the cam and impact rod forward to generate a linear impact on the anvil. 
     In another embodiment, a rotary linear impactor or impacting tool comprises a hammer. an output anvil, and an energy storage means (which means may comprise, in an embodiment, at least one wave spring, and, in a further embodiment, a linear actuator spring and a rotary spring). The hammer and anvil are operatively coupled to and are capable of being rotated by a lead screw element (such as a torqspline). When the user pushes the output anvil into a bone surface, the anvil will also compress a linear actuator spring to provide for only rotary impaction or both rotary and linear impaction, depending on the amount of force with which the user pushes the output anvil into the bone surface. 
    
    
     
       DESCRIPTION OF THE DRAWINGS 
       The advantages and features of the present disclosure will become better understood with reference to the following detailed description and claims taken in conjunction with the accompanying drawings, wherein like elements are identified with like symbols, in which: 
         FIG. 1  shows a rotating hammer which is used to impart rotational movement of a surgical implement, in accordance with an exemplary embodiment of the present disclosure. 
         FIG. 2  shows a dampening mechanism which reduces the reflected impulse to the surgeon and or surgical robot, in accordance with an exemplary embodiment of the present disclosure. 
         FIG. 3  shows a sample calculation of reactionary force reduction by expanding the time period over which that force is applied in accordance with an exemplary embodiment of the present disclosure. 
         FIG. 4  shows a dampening mechanism which reduces the reflected impulse to the surgeon and or surgical robot from both the rotating and linear impaction, in accordance with an exemplary embodiment of the present disclosure. 
         FIG. 5  shows a cutaway view of an orthopedic impacting tool, in accordance with an exemplary embodiment of the present disclosure. 
         FIG. 6  shows an exemplary hammer and an exemplary output anvil of an orthopedic impacting tool, in accordance with an exemplary embodiment of the present disclosure. 
         FIG. 7  shows a linear and rotary impactor comprising a cam in accordance with an exemplary embodiment of the present disclosure. 
         FIG. 8  shows another view of a linear and rotary impactor comprising a cam and impact bar in accordance with an exemplary embodiment of the present disclosure. 
         FIG. 9  shows a linear and rotary impactor comprising at least one bumper in accordance with an exemplary embodiment of the present disclosure. 
         FIG. 10  shows a linear and rotary impactor comprising at least one bumper in accordance in position to impart an impact on the output in accordance with an exemplary embodiment of the present disclosure. 
         FIG. 11  shows a linear and rotary impactor comprising at least one bumper in accordance with another exemplary embodiment of the present disclosure. 
         FIG. 12  shows a linear and rotary impactor comprising at least one bumper in accordance with another exemplary embodiment of the present disclosure. 
         FIG. 13  shows a comparison of the force applied to the back of a typical surgical reamer and the linear force imparted by an exemplary embodiment of a linear and rotary impactor. 
     
    
    
     DETAILED DESCRIPTION OF THE DISCLOSURE 
     The exemplary embodiments described herein detail for illustrative purposes are subject to many variations in structure and design. It should be emphasized, however, that the present disclosure is not limited to a particular surgical tool, robot, robotic end effector, or any intermediaries as shown and described. That is, it is understood that various omissions and substitutions of equivalents are contemplated as circumstances may suggest or render expedient, but these are intended to cover the application or implementation without departing from the spirit or scope of the claims of the present disclosure. The terms “first,” “second,” and the like, herein do not denote any order, quantity, or importance, but rather are used to distinguish one element from another, and the terms “a” and “an” herein do not denote a limitation of quantity, but rather denote the presence of at least one of the referenced item. 
     The present disclosure provides for rotary linear impacting tools for orthopedic surgery and more specifically to those tools designed to minimize reactionary forces during large bone orthopedic surgery. As used herein, the tool may also be referred to as a rotary impactor or a combined rotary and linear impactor. A rotary impacting tool in this context may be understood to be a tool which effects constant rotary motion to a surgical implement and can further provide rotary impacts under certain conditions (i.e. if the reactionary torque reaches and/or exceeds a threshold value). The tool further may include a mechanism for generating a combined rotary and linear impact. 
     The tool as disclosed herein includes a mechanism (such as an absorbing means) which decreases the peak reactionary forces from the tool end that act on a gripping surface of the tool. Such gripping surface may include, but is not necessarily limited to, a hand grip or the like in the case of a tool that designed for manual operation by a surgeon, or a cylindrical body or other mounting means in the case of a tool that is coupled to and operated by a surgical robot. As used herein, “reactionary force” may include linear or rotary shock and/or force or torque reflected back to the robot and or surgeon mounting or gripping surface 
     In an embodiment, and as shown in  FIG. 1 , the rotational action to the surgical implement  50  is communicated via an impact mechanism  20  such as a rotary hammer. In an embodiment, the tool  100  comprises a motor drive  10  that is operatively coupled to an impact bar (such as a rotary hammer  20 ). The motor  10  provides for rotational motion of the rotary hammer. The rotary hammer  20  is operatively coupled to a camming surface  30  through steel roller balls. The rotary hammer selectively engages an output anvil which output anvil can be coupled to an interface of the tool. Said interface is capable of receiving and rotating a surgical implement. The tool may also comprise at least one bearing  42  to maintain the output anvil  40  in a working position while it is acted on by the rotary hammer. The rotary hammer  20  rotates the output anvil until a threshold torque is reached on the output anvil. After said threshold torque is reached the roller balls pull the rotary hammer back against spring  22  until the rotary hammer is no longer in contact with the output anvil. At this point the rotary hammer is accelerated to a higher velocity and a spring  22  pushes the rotary hammer forward to allow the hammer to reengage and rotationally impact the output anvil. 
     It was discovered that by putting a reduction means between the rotary impacting mechanism and the output improves the safety profile of the existing rotary impact mechanisms without sacrificing output impact energy. This discovery allows for torque multiplication while leaving the maximum rpm of the output at a reasonable speed and avoiding the possibility of excessive rotational speed at the output (which can otherwise cause body fluids to be splattered in the operating room, cause uncontrolled reaming and soft tissue damage). 
     In an embodiment, the output anvil  30  has the ability to move linearly along the impact axis. The spring  22  can impart a linear impact by moving the rotary hammer  20  so that a face of the rotary hammer  23  contacts a face of the output anvil  24  and transfers energy from spring  22  in a linear direction whilst the hammer is also causing a rotary impact. In this embodiment, said spring can be allowed to translate through the output anvil such that a linear impact is also effected on the surgical implement. The advantage of linear impaction during the reaming process is illustrated in  FIG. 13 . Curve  501  shows the typical constant force that is imparted on the back of a reamer handpiece by a surgeon during the reaming process (typically in excess of 25 pounds). Curve  502  shows the sharp linear impacts imparted on the surgical site by the linear impaction mechanism as disclosed herein. The benefit of high frequency linear impacts is that the surgeon and/or robot does not have to provide the same external push force on the back of the tool in order to perform a successful surgical operation. 
     In an embodiment as shown in  FIG. 2 , a viscoelastic mechanism or a dampening mechanism  70  is used to reduce the reflected force and or torque during operation of the surgical impacting tool. The mechanism  70  may be disposed on, around, or in proximity to the motor  10  of the tool  10  such that some rotational freedom of movement is permitted, however, the mechanism  70  will also have a rotational spring constant to allow for predictable compensation and dampening as well as recovery between impacts by the impact hammer  20 . It will be apparent that this mechanism  70  may also be incorporated in the rotational impacting tool described further below herein. Referring to  FIG. 4 , a dampening mechanism  80  and  90  may be provided to reduce the reflected rotary and/or linear force of the impacting tool. 
     In a still further embodiment, the tool comprises one or more sensors  39  which establish spatial location with respect to the patient. In a still further embodiment, the measurements that determine spatial location are coordinated with the impacts such that the tool has recovered to at least 90% of its pre-impact position prior to communicating the tool position to either the robot or other device. It is apparent that this sensor-measurement integration system is advantageous because it makes efficient use of computing power by only taking measurements when needed and because it gathers and communicates only the most accurate and useful location data. 
     In an embodiment, the tool is designed in such a fashion as to isolate the tool function from the recoil or reactionary force by using a “free flight impacting member”. The free flight (or thrown) member, as used herein, is a moving member of and within the tool, a portion of which movement is in free flight with respect to the tool. The impact of the thrown member onto a receiving member imparts a consistent force onto the surgical implement of the tool (for example, the output  40 ) but equally important is the fact the launching of the thrown member is a predictable impulse which can be compensated for by a sleeve, slide cage or the like. In an embodiment, the reactionary force that is seen at the gripping surface is reduced by extending the time period (as shown in  FIG. 3 ) over which the thrown member impacts a surface. This is accomplished through conservation of momentum (m 1 v 1 =m 2 v 2 ), which can also be written in terms of impulse as F 1 Δt 1 =F 2 Δt 2  (where F is force and Δt is the time period over which that force occurs). Although the equation is for linear momentum, this concept applies to rotational momentum as well. 
     Referring now to  FIG. 3 , a sample calculation of reactionary force reduction by expanding the time period over which that force is applied is shown, as in accordance with an exemplary embodiment of the present disclosure. In an embodiment, the reactionary force that is generated by the impact hammer may be reduced by extending the time period (as shown in  FIG. 4 ) over which the force is imparted on to the motor mount or gripping surface, for example. This occurs due to the law of conservation of momentum as discussed above. The time period (Δt) can be extended by using a viscoelastic mechanism or dampening mechanism  70  between the motor mount and the tool housing or between the gripping surface and the tool housing, for example. 
     In another embodiment as shown in  FIG. 4 , the rotational action of the tool  100  can be combined with a linear action. Linear impacts as contemplated by this disclosure comprise a throw that is less than 1 mm per impact, which impacts are performed in the early stages of reaming the acetabulum. It was unexpectedly discovered that adding a small linear impact in combination with the rotary impact reduced the linear force needed by the surgeon by over 50% in the initial reaming of the acetabulum. In an embodiment, the motor  10  causes both linear and rotational motion of the hammer  20 . In such an embodiment the camming surface(s)  30  may comprise a linear ramp for permitting the force of linear (or axial) motion of the impact bar  20  to be translated to the output  40  (and surgical implement  50 ) and a rotary ramp for permitting the force of rotary motion of the hammer  20  to be translated to the output  40  (and surgical implement  50 ). In an embodiment, the tool further comprises a spring, which spring may be compressed when the camming surface for linear impacting causes the hammer to translate away from the output. The spring may be compressed by the translation of the hammer. After the hammer disengages from the linear ramp of the camming surface, the spring acts on the hammer to move the hammer in a linear direction to impact the output. The tool  100  may further comprise bearings  42  for facilitating rotational and linear motion of the output  40 . In an embodiment, the tool  100  may permit selection (by way of a switch  36 , for example) of translation of both linear and rotational force by the hammer  20  to the output  40 , and of translation of only rotational force to the output  40 . In an embodiment, the linear impact is limited to less than 0.5 mm per revolution of the arbor of the tool. 
     In an embodiment, the tool has the capability to determine the stiffness of the impact site (i.e. surgical site) by measuring the force of an impact as it relates to the change in either linear and/or rotary displacement. For example, the tool might count 10 impacts from the rotary hammer and determine (such as through a sensor) that the reamer has only moved by 0.1 degree rotationally and 0.001″ linearly over that period of impacts. The tool may thereupon indicate to the surgeon/robot (through a status light, sound or a pause or slowing of the tool&#39;s operation) that the reamer is no longer advancing and a decision could be made by either the surgeon or the robot to continue or cease impacting. 
     In a further embodiment and as shown in  FIG. 2 , the gripping or mounting surface can be lined with a force-absorbing sleeve or sleeves  80 , which may be made from a material (such as Sorbothane). This can be used to absorb and spread the reactionary forces over a long time period thus reducing the reactionary force of the tool on the surgeon and or robot 
     In an embodiment, the tool comprises an internal absorption means, which internal absorption means comprises a shock absorbing material such as urethane (including but not necessarily limited to Sorbothane and viscose), for example. In a further embodiment the internal absorption means comprises a dampening material and or mechanism and a spring restoration mechanism. In a still further embodiment, such a mechanism may be combined in a single material such as a shock absorbing urethane, rubber, foam, plastic or the like. Such a single material is not limited to a nonmetal. 
     In another embodiment, the internal absorption means includes a fluidic dampening system. 
     In an embodiment, the rotary impacting tool comprises an overload clutch as to limit the reactionary torque seen by the body of the tool. 
     In yet another embodiment, and as shown in  FIGS. 5 and 6 , a rotary linear impacting tool  200  that features rotational and linear movement is shown, which movement allows a hammer  220  to strike an output anvil  230 , which output anvil  230  then may deliver an impact to a surgical area, for example. In an embodiment, the tool  200  comprises a motor and gearbox  210  that is operatively coupled to a leadscrew such as a torqspline  215 . The motor provides for rotational motion of the torqspline. The torqspline  215  includes a lead nut  216 , which lead nut  216  rotates when the torqspline  215  rotates and the delivered torque to the anvil is below the threshold torque for impacting. The hammer  220  is operatively coupled to the lead nut  216  such that the hammer rotates along with the lead nut  216 . As the hammer  220  rotates, it may selectively engage and rotate the output anvil  230 . 
     In an embodiment, the hammer  220  comprises at least one tooth or other protrusion  221  that extends longitudinally away from the face  222  of the hammer  220 . In an embodiment, the output anvil  230  comprises at least one tooth or other protrusion  231  that extends away laterally from the body  232  of the anvil. In an embodiment, the at least one tooth (or protrusion)  221  of the hammer may engage the at least one tooth (or protrusion)  231  of the output anvil  230  such that while the hammer  220  rotates, such engagement causes the output anvil  230  to rotate. The rotation may continue until a sufficiently high load is imparted on the output anvil  230 , such that the output anvil  230  ceases rotating. This causes the hammer  220  to also stop rotating due to the still-engaged protrusions  231  and  221 , respectively of the output anvil  230  and hammer  220 . 
     In an embodiment, the impact tool  200  further comprises an energy storage means  240  (such as a die spring, for example) and a lead screw element (an exemplary example of which is a torqspline  215 ). In an embodiment, the die spring  240  is disposed between the lead nut  216  and the motor  210  of the tool  200 . It will be apparent that the coil of the spring facilitates placement of the spring  240  around the torqspline  215 . In an embodiment, the torqspline is constantly rotating. In such an embodiment, and when the hammer  220  ceases rotation, the lead nut  216  and hammer  220  to which it is attached will translate backwards (away from the output anvil  230 ). Such backward translation of the lead nut  216  and hammer  220  causes the die spring  240  to compress. The translation and compression continue until the hammer  220  has moved a sufficient backward distance such that the at least one protrusion  221  of the hammer  220  has disengaged from the at least one protrusion  231  of the output anvil  230 . 
     Once the hammer  220  has moved a sufficient distance backward such that its at least one protrusion  221  has disengaged from the at least one protrusion  231  of the output anvil  231 , the hammer teeth slide along the anvil teeth until they clear the anvil teeth and the spring  240  decompresses to force a high-speed rotational movement of the hammer  220  down the torqspline  215  toward the output anvil  230 . This high-speed rotational movement of the hammer  220  will cause a sharp rotational impact upon the anvil which sharp force is sufficient for the impact tool  200  to overcome the bone structure or malformity that has impeded the reaming action. In an embodiment, the motor  210  can be programmed to increase its speed when the hammer  220  is pulling back (which indicates that the threshold torque has been reached and a rotary impact is set to occur). This has the advantage of maintaining a constant output RPM whether in the rotary impacting stage or the constant rotation stage. 
     Such an impact mechanism allows much higher rotational torque to be achieved in reaming as compared to conventional orthopedic reaming tools. This improvement is at least 200% and the reduction of reactionary torque is over 2× that which can be achieved with conventional orthopedic reaming tools. In an unexpected discovery, the tool was discovered to switch from impact mode (which has an auditory signal resulting from the impacts) to a non-impact mode (minimal auditory signal) at or near the completion of the surgical reaming. 
     When the hammer  220  is forced down the torqspline  215  due to the decompression of the spring  240 , there is linear energy as well as rotary energy available from the hammer  220 . In an embodiment, a compression element  250  is provided to facilitate transmission of a linear impact and force from the hammer  220  to the output anvil  230 . The compression element  250  is preferably disposed between the face  222  of the hammer and the output anvil  230 . In an embodiment, the face  222  of the hammer  220  impacts the body  232  of the output anvil  230  as the hammer  220  translates down the torqspline  215  as a result of decompression of the spring  240 . In an embodiment, the compression element  250  comprises an elastomeric material friction disk. In such an embodiment, element  250  absorbs a portion of the rotational energy of the hammer  220  and translates that energy into a linear force that acts on the output anvil  230 . 
     In a still further embodiment, the tool  200  comprises one or more sensors (not shown) which establish spatial location with respect to the patient. In a still further embodiment, the measurements which determine spatial location are coordinated with the impacts such that the tool  200  has recovered to at least 90% of its pre-impact position prior to communicating the tool position to either the robot or other device. It is apparent that this sensor-measurement integration system is advantageous because it makes efficient use of computing power by only taking measurements when needed and because it communicates only the most accurate location data. 
     In an embodiment, the tool  200  has the capability to determine the stiffness of the impact site (i.e. surgical site) by measuring the force of an impact as it relates to the change in either linear and/or rotary displacement. For example, the tool  200  might count ten (10) impacts from the output anvil  230  and determine that the reamer has only moved by 0.1 degree rotationally and 0.001″ linearly over that period of impacts. The tool  200  could indicate to the surgeon/robot that the reamer is no longer advancing and a decision could be made by either the surgeon or the robot. In an embodiment, the tool  200  comprises an internal absorption means (not shown) which may be internal to the housing of the tool or at the gripping or mounting surface of the tool and may comprise a shock absorbing elastomer material such as urethane Sorbothane or viscose. 
     In another embodiment, and as shown in  FIGS. 7 and 8 , a rotary linear impacting tool  300  comprises a motor  310 , a hammer  320 , an output anvil  330 , and a linear energy storage means  340  (which means may comprise, in an embodiment, a wave spring) and a rotary energy storage means  342 . The hammer and anvil are operatively coupled to and are capable of being rotated by a leadscrew such as a torqspline  315  The tool further comprises a cam  350  (such as a barrel cam) and at least one cam follower  352  and an impact rod  360 . The impact rod  360  is at least partially contained within the cam  350  and is capable of imparting a rotational force on the cam to cause the cam to rotate or cycle. The tool  300  further comprises at least one bumper  380 . The anvil  330  comprises a slot  332  to accommodate and allow linear movement of the cam  350  and impact rod  360  with respect to the anvil  330 . 
     In this embodiment, rotary impaction by the tool  300  is accomplished similar to the rotary impaction performed by tool  200  disclosed elsewhere herein. In an embodiment, motor  310  provides for rotational motion of the torqspline  315 . The torqspline  315  includes a lead nut  316 , which lead nut  316  rotates when the torqspline  315  rotates. The hammer  320  is operatively coupled to the lead nut  316  such that the hammer rotates along with the lead nut  316 . As the hammer  320  rotates, it will selectively engage and rotate the output anvil  330  and may or may not impart impacting depending on the threshold torque. 
     For linear impaction by the tool  300 , impact rod  360  is disposed partially within the anvil  330  and is further operatively coupled to the cam  350 . Rotation of the anvil  330  (caused by rotation of hammer  320 ) outputs a torque on the impact bar  360 , which torque causes the barrel cam  350  to rotate. The cam follower  352  is operatively coupled to the barrel cam as well as to the wave spring  340 . When the barrel cam  350  rotates, the cam follower  352  follows the track of the barrel cam and compresses the wave spring  340  in the process to store potential energy in the spring. The slot in the anvil  330  allow the impact rod  360  and the barrel cam  350  to move linearly with respect to the anvil  330  during this operational phase. After the cam follower  352  clears the track of the barrel cam  350 , the wave spring releases the stored energy to force the cam  350  and impact rod  360  in the direction of the surgical site. The cam and rod impact the anvil  330  such as at the end of the anvil slot  332  that is proximate to the surgical site, thereby imparting a linear impact force to the output of the tool. A bumper  380  may be provided as shown in  FIG. 7  to limit the linear travel of the anvil  330  for reduced recoil and increased control of the tool. 
     In another embodiment and as shown in  FIGS. 9, 10, 11 and 12 , a rotary linear impacting tool  400  comprises a motor  410 , a hammer  420 , an output anvil  430 , and an energy storage means  440  which means may comprise, in an embodiment, at least one wave spring. The hammer  420  and anvil  430  are operatively coupled to and are capable of being rotated by a lead screw element (such as torqspline  415 ). The tool  400  may include at least one bumper such as a stop bumper  481  and an impact bumper  482 . The stop bumper is preferably disposed between anvil  430  and the housing. Impact bumper  482  may be disposed on the end of the anvil  430  that is contacted by the hammer  420  for example. When the surgeon or robot pushes the surgical implement  485  which is coupled to the anvil onto a bone surface, the anvil will compress at least one spring  440  (and, in an embodiment, linear actuator spring  441  and rotary spring  442 ), which will allow for linear impaction as well as rotary impaction. 
     In this embodiment, rotary impaction by the tool  400  is accomplished similar to the rotary impaction performed by tool  200  and tool  300  disclosed elsewhere herein. In an embodiment, motor  410  provides for rotational motion of the torqspline  415 . The torqspline  415  includes a lead nut  416 , which lead nut  416  rotates when the torqspline  415  rotates. The hammer  420  is operatively coupled to the lead nut  416  such that the hammer rotates along with the lead nut  416 . As the hammer  420  rotates, it will selectively engage and rotate the output anvil  430 . 
     In an embodiment, the hammer  420  comprises at least one tooth or other protrusion  421  that extends longitudinally away from the face  422  of the hammer  420 . In an embodiment, the output anvil  430  comprises at least one tooth or other protrusion  431  that extends away laterally from the body  432  of the anvil. In an embodiment, the at least one tooth (or protrusion)  421  of the hammer may engage the at least one tooth (or protrusion)  431  of the output anvil  430  such that while the hammer  420  rotates, such engagement causes the output anvil  430  to rotate. The rotation may continue until a sufficiently high load is imparted on the output anvil  430  (such as, in the course of surgical reaming, the tool encounters a bone spur), such that the output anvil  430  ceases rotating. This causes the hammer  420  to also stop rotating due to the still-engaged protrusions  431  and  421 , respectively of the output anvil  430  and hammer  420 . 
     In an embodiment, the spring  440  is disposed between the lead nut  416  and the motor  410  of the tool  400 . In an embodiment, spring  440  comprises a wave spring. It will be apparent that the coil of the spring  440  facilitates placement of the spring  440  around the torqspline  415 . In an embodiment, the torqspline is constantly rotating. In such an embodiment, and when the hammer  420  ceases rotation, the lead nut  416  and hammer  420  to which it is attached will translate backwards (away from the output anvil  430 ). Such backward translation of the lead nut  416  and hammer  420  causes the rotary  440  to compress. The translation and compression continue until the hammer  420  has moved a sufficient backward distance such that the at least one protrusion  421  of the hammer  420  has disengaged from the at least one protrusion  431  of the output anvil  430  as shown in  FIG. 16 . 
     Once the hammer  420  has moved a sufficient distance backward such that its at least one protrusion  421  has disengaged from the at least one protrusion  431  of the output anvil  431 , the hammer continues to rotate until its teeth slide past the anvil teeth and then rotary spring  442  decompresses to force a high-speed rotational movement of the hammer  420  down the torqspline  415  toward the output anvil  430  and impact bumper  482 . This high-speed rotational movement of the hammer  420  will cause a sharp rotational impact upon the at least one protrusion  431  of the output anvil  430 , which sharp force upon the output anvil  430  should be sufficient for the impact tool  400  to overcome the bone structure or malformity that has impeded the reaming action. In an embodiment, the motor  410  can be programmed to increase its speed when the hammer  420  is pulling back (which indicates that the threshold torque has been reached and a rotary impact is set to occur). This would be beneficial to maintain a constant output RPM whether in the rotary impacting stage or the constant rotation stage. 
     When the hammer  420  is forced down the torqspline  415  due to the decompression of the rotary spring  442 , there may be linear energy as well as rotary energy available for the anvil  430  for impacting a surgical site. That is, depending on the extent of compression of the linear actuator spring  441  prior to the hammer moving down the torqspline the tool may impart both a linear and rotational impact on the anvil  430 . In an embodiment, an impact bumper  482  facilitates transmission of a linear impact and force from the hammer  420  to the output anvil  430 . In an embodiment, the face  422  of the hammer  420  impacts the impact bumper  482  which transmits the linear impact to the anvil  430  as a result of decompression of the rotary spring  442 . 
     It will be apparent that the linear actuator spring  441  may be compressed by the user and/or by the mass of the tool  400  when the tool  400  is placed against the surgical site. The user may increase the compression of the spring  441  by applying additional pressure on the tool  400  as it is disposed against the surgical site. If the spring  441  is sufficiently compressed that it does not have time (dependent on the spring constant of this spring) to expand before the linear impact and force from the hammer  420  is transmitted to the output anvil  430 , the anvil  430  will receive and transmit the linear force to the surgical site. If the linear actuator spring  441  is insufficiently compressed before the hammer  420  transmits its rotational energy to the output anvil  430 , the energy is absorbed rotationally or through the stop bumper  481 . 
     The present disclosure offers the following advantages: reduction of reactionary forces from a surgical tool to the gripping and or mounting surface. Another advantage is that the tool will provide a significant amount of the forces required to complete a surgery without the need for external forces (for example, the external force from a surgeon that leans into the reamer handpiece to get the reamer to advance in the surgical site). This results in less wear and tear on a robotic platform in the case of robotic surgery and less surgeon fatigue for a surgeon operator. This also improves the accuracy and capability of the robot in the case of a robotic surgical tool and may drastically reduce instances of a loss of registration by a surgical robot. 
     The foregoing descriptions of specific embodiments of the present disclosure have been presented for purposes of illustration and description. They are not intended to be exhaustive or to limit the present disclosure to the precise forms disclosed, and obviously many modifications and variations are possible in light of the above teaching. The exemplary embodiment was chosen and described in order to best explain the principles of the present disclosure and its practical application, to thereby enable others skilled in the art to best utilize the disclosure and various embodiments with various modifications as are suited to the particular use contemplated.