Patent Publication Number: US-2023149032-A1

Title: Offset guide

Description:
FIELD 
     The present disclosure relates to guides for tissue repair. More specifically it discloses a guide with a guide arm that engages a bone and places a tool through the bone at a preferred location along the bone. 
     BACKGROUND 
     Reconstructive surgery for joints such as arm and leg joints often involve surgical attachments that are subject to substantial force due to the pivotal movement these joints provide and weight of the limbs themselves. Reconstructive surgery involving functional, structural fixation to bones of a joint may involve drilling into at least one of these bones. This may form a passage within the bone for fixation constructs including flexible connecting members and anchors to extend through and/or anchor within. In the case of an acromioclavicular joint repair, the surgery may employ a tunnel guide with a drilling locator to facilitate compression/reduction of a joint to place the two bones (clavicle and coracoid) in a target arrangement relative to each other while drilling. The drill locator aligns the drill along and through the axis of reduction for repair of the acromioclavicular (AC) and/or coracoclavicular (CC) joint. A drill may extend along the axis of reduction until it meets a distal hard stop feature of the guide at an inferior aspect of the coracoid. 
     The coracoid however is a fragile arch shaped process of bone, with a variable cross section, that crisscrosses under the clavicle. The arch shape has an apex portion that defines a stable location for a guide arm to hold the coracoid and position the coracoid and clavicle in the target arrangement (reduced configuration) and thereby the apex portion may define one end of the reduction axis. Guides known in the art that hold a clavicle and coracoid in a reduced configuration guide a drill along an axis that is coincident with the guide arm location and therefore through the apex portion of the coracoid. This portion however tends to be thinner in cross section than other portions of the coracoid, and therefore less preferable a location to drill a hole therethrough. Moving the guide arm distal end along the coracoid towards these more preferably locations for drilling, however, may frustrate a stable hold on the coracoid, as a result of the arch shape of the coracoid. There is therefore a need for a guide that holds the coracoid and clavicle in a reduced configuration, accommodating for the coracoid anatomy relative to the clavicle. There is also a need for a guide that guides a drill through the coracoid, along a trajectory that defines a subsequent fixation location through a portion of the coracoid with sufficient cross section, to reduce a risk of fracture. 
     There may also be risk of coracoid fracture, should the drill form a passage offset from a center of the coracoid cross section. The coracoid is a relatively thin process of bone. Guides known in the art may guide a drill along an axis coincident with the guide arm location but depending on the shape of the guide arm and shape of the coracoid cross section, the trajectory may be offset or angled away from a center of the coracoid cross section and risk fracture thereof. Fracture may occur during drilling or later one, via uneven stresses from the fixation construct. There is therefore a need for a guide that holds the coracoid and clavicle in an anatomically reconstructed arrangement, centering the drill trajectory through the coracoid cross section. 
     SUMMARY 
     Disclosed herein is a drill guide that locates a drill at a location offset from an axis of reduction. The guide may engage a bone outer surface at a location that is stable for gripping and holding the bone for stable joint reduction, while placing a drill hole through the same bone in an offset location therefrom. The offset location may be along a portion of the bone that has a larger cross section and therefore is less likely to fracture while drilling a hole therethrough. The hole is drilled to aid in coupling a repair construct to the bone, and the larger cross section may be better able to withstand the clinical loading requirements transmitted via the repair construct. This offset location may also provide improved visualization of the drill and/or repair construct implants, as they exit the bone at the offset location spaced away from the reduction axis. This offset may also provide space for an implant to deploy outside the bone without encountering the guide. Deploying may include expanding laterally and towards the reduction axis. This offset is also sufficient to avoid metal to metal contact between the drill and the guide, reducing the generation metal debris inside the body. 
     Disclosed herein is a drill guide that centers a drill through the coracoid for a range of coracoid cross sections. The guide may wrap around three side surfaces of the bone outer surface at a location that is stable for gripping the bone for joint reduction. The guide may define a V-shaped opening that engages two discrete surface portions of the bone, on opposite sides of the bone. The V-shaped opening may center the bone within the V-shaped opening. The drill may then form a passage through a center of the bone. This passage may be offset from the V-shaped opening. The offset location may be along a portion of the bone that has a larger cross section and therefore is less likely to fracture while drilling a hole therethrough. The hole is drilled to aid in coupling a repair construct to the bone, and the larger cross section may be better able to withstand the clinical loading requirements transmitted via the repair construct. This offset location may also provide improved visualization of the drill and/or repair construct implants, as they exit the bone at the offset location spaced away from the reduction axis. This offset may also provide space for an implant to deploy outside the bone without encountering the guide. Deploying may include expanding laterally and towards the reduction axis. This offset is also sufficient to avoid metal to metal contact between the drill and the guide, reducing the generation metal debris inside the body. 
     Disclosed herein is an offset guide for holding a surgical joint in a reduced configuration. The offset guide is configured to place a fixation construct in an offset location relative to the axis of reduction. The offset guide may include a proximal end, a distal end and a curved arm extending therebetween, the curves arm extending around the joint. The distal end engages a bone of the surgical joint at a first location along the bone to as to apply a load to the bone to hold the bone in the reduced configuration. The proximal end includes a guiding means that aims placement of a surgical tool through the bone towards an offset location along the bone, the offset location spaced away from the first location. The offset location is axially spaced from the first location. The offset location is a portion of the bone that has a larger cross section than a corresponding cross section of the first location. 
     In some offset guide embodiment, the offset location may be through a portion of the bone that frustrates engagement with the guide distal end, and more specifically the offset location frustrates applying a load at that location that effectively reduces the surgical joint. The surgical tool may include a drill tool and then an implant insertion tool, the implant a part of a fixation construct. The distal end may be offset by at least 5 mm from the offset location. The guide distal end may engage an apex of a coracoid bone and the offset location may be a segment of the coracoid bone proximally or medially disposed relative to the apex. The guide distal end may be formed in a hook that wraps around three sides of the bone and self-centers the distal end relative to the bone such that the surgical tool is placed through a center of the bone at the offset location. 
     Another example guide is disclosed, that guides formation of a passage through a first and second bone at a target location. The example guide includes a proximal end, a distal end and a curved arm extending therebetween. The guide proximal end includes a channel having a longitudinal axis that defines a passage trajectory through a bone thickness of both a first and a second bone. The distal end is formed in a hook sized and shaped to wrap around three sides of the first bone to self-center the guide distal end relative to the first bone, such that the passage trajectory extends through the target location which includes through a center of the first bone. 
     Some distal end hooks may include two opposing surfaces, facing each other and wherein the two opposing surfaces are configured to engage, one each, a first and a second side surface of the first bone three sides, the first and second sides defining opposing sides of the first bone. The guide distal end may wrap around three sides of an apex of a coracoid and the passage trajectory may place a surgical tool through a location through the coracoid posteriorly offset from the apex. Some example guides define a passage trajectory that extends through the center of the first bone at an offset location along an axis of the first bone, from the guide distal end. The channel may sequentially receive a drill tool and an implant insertion tool therethrough. The passage trajectory through the bone thickness of the first and the second bone may place the passage at an offset location through the first bone, the offset location a location that frustrates engagement and joint reduction with the guide distal end. The offset location may be at least 5 mm from the hook along the first bone. The guide distal end may engage an apex of a coracoid bone and the offset location may be a portion of the coracoid bone medially disposed relative to the apex. 
     An example method for locating an insertion site for a repair of a surgical joint is also disclosed herein. The method may include engaging an outer surface of a first bone of the surgical joint with a distal end of an offset guide, defining a first engagement location and engaging an outer surface of a second bone of the surgical joint with a proximal end of the offset guide defining a second engagement location, and thereby defining a reduction axis that extends through the first and second engagement locations. While engaging the outer surfaces of the first and second bones the method may include inserting a surgical tool through a guide sleeve of the offset guide proximal end, and then through the outer surfaces of the first bone at an offset location, spaced away from the first engagement location. 
     Engaging the outer surfaces may hold the first and second bones in a reduced arrangement. The surgical tool may be an implant delivery device and inserting may also include placing an implant through the first and second bone and placing the implant at the offset location, while the offset guide remains engaged with the outer surfaces. The outer surface of the first bone may be an inferior surface of a coracoid, and the outer surface of the second bone may be a superior surface of a clavicle. The first location may be an apex of an arched portion along a coracoid and the offset location may be disposed along the coracoid and towards a base of the coracoid. The method may also include observing the surgical tool as it extends through the first bone outer surface, the offset guide second end spaced away from the offset location to provide a clear view thereof. 
     These and other features and advantages will be apparent from a reading of the following detailed description and a review of the associated drawings. It is to be understood that both the foregoing general description and the following detailed description are explanatory only and are not restrictive of aspects as claimed. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The disclosure will be more fully understood by reference to the detailed description, in conjunction with the following figures, wherein: 
         FIG.  1 A  illustrates the anatomy of the shoulder for reference purposes; 
         FIG.  1 B  illustrates a superior surface of the coracoid for reference purposes; 
         FIG.  2 A  illustrates the guide and drill components of the offset guide system, in accordance with this disclosure; 
         FIG.  2 B  illustrates the guide with the drill inserted along the guide sleeve, in accordance with this disclosure; 
         FIG.  2 C  illustrates an end view of the guide with the drill sleeve inserted along the guide sleeve, in accordance with this disclosure; 
         FIG.  3 A  illustrates the offset guide engaged on a coracoid with the drill sleeve inserted through the coracoid at a location offset from the guide distal end, in accordance with this disclosure; 
         FIG.  3 B  illustrates a close-up of the offset guide components through the coracoid, in accordance with this disclosure; 
         FIG.  3 C  illustrates a close-up of the offset guide engaging the coracoid apex, and observing an anchoring implant through the offset tunnel, in accordance with this disclosure; 
         FIG.  4 A  illustrates a bone cross section with a passage extending through the center, for illustrations purposes; 
         FIG.  4 B  illustrates a bone cross section with a passage extending through off-center, for illustrations purposes; 
         FIG.  5 A  illustrates a hook end of a drill guide, known in the art relative to a bone cross section; 
         FIG.  5 B  illustrates a hook end of a drill guide, known in the art relative to another bone cross section; 
         FIG.  6 A  illustrates a V-shapes drill guide distal aspect engaging two opposing sides of a bone, in accordance with this disclosure; 
         FIG.  6 B  illustrates a V-shaped drill guide distal aspect, in accordance with this disclosure; 
         FIG.  7 A  illustrates a drill guide and drill with a V-shaped drill guide distal aspect, in accordance with this disclosure; 
         FIG.  7 B  illustrates the V-shaped drill guide distal aspect, in accordance with this disclosure; and 
         FIG.  7 C  illustrates a V-shaped drill guide distal aspect that is offset from the drill trajectory, in accordance with this disclosure. 
     
    
    
     DETAILED DESCRIPTION 
     In the description that follows, like components have been given the same reference numerals, regardless of whether they are shown in different examples. To illustrate example(s) in a clear and concise manner, the drawings may not necessarily be to scale and certain features may be shown in somewhat schematic form. Features that are described and/or illustrated with respect to one example may be used in the same way or in a similar way in one or more other examples and/or in combination with or instead of the features of the other examples. 
     As used in the specification and claims, for the purposes of describing and defining the invention, the terms “about” and “substantially” are used to represent the inherent degree of uncertainty that may be attributed to any quantitative comparison, value, measurement, or other representation. The terms “about” and “substantially” are also used herein to represent the degree by which a quantitative representation may vary from a stated reference without resulting in a change in the basic function of the subject matter at issue. “Comprise,” “include,” and/or plural forms of each are open ended and include the listed parts and can include additional parts that are not listed. “And/or” is open-ended and includes one or more of the listed parts and combinations of the listed parts. Use of the terms “upper,” “lower,” “upwards,” and the like is intended only to help in the clear description of the present disclosure and are not intended to limit the structure, positioning and/or operation of the disclosure in any manner. 
       FIG.  1 A  illustrates the anatomy of the shoulder joint  10 , for reference purposes.  FIG.  1 A  illustrates the AC ligament  12 , trapezoid ligament  14  and conoid ligament  16 , all of which may be damaged or torn. During an AC joint repair, the clavicle  18  may be reattached to the coracoid process  22  of the scapula  20  (hereinafter “coracoid”). During the repair, the clavicle  18  may be relocated relative to the coracoid  22 . This is oftentimes referred to as reducing the joint or placing the joint in a reduced configuration. During the repair, a repair construct may be coupled to both the clavicle  18  and coracoid  22  to hold them in the reduced configuration. This may involve drilling holes through the clavicle  18  and coracoid  22  to receive portions of the repair construct therethrough. An example repair of an AC joint is illustrated in U.S. Pat. No. 10,123,813, commonly owned and herein incorporated by reference in its entirety. 
     The coracoid  22  is an arch shaped projection with segments including a tip  122 , an arched midportion including an apex  123  and a base  124 . The coracoid  22  is relatively small and fragile, and drilling holes has been known to compromise the coracoid  22 . The base  124  is posterior and medial to the tip  122  and apex  123 . The coracoid  22  crisscrosses under the clavicle  18  and therefore in an anatomical reconstruction, the clavicle  18  and coracoid  22  may vertically align with each other for only a short segment of each bone. This may be approximately along the apex  123  of the coracoid  22  and may be adjacent attachment points of trapezoidal ligament  14 . The coracoid base  124  gradually broadens as it extends posteriorly and is attached by a broad base to the upper part of the neck of the scapula. The apex  123  is generally located along a segment of the coracoid  22  that is smaller in cross section than the base  124 .  FIG.  18    illustrates a top-down view of the coracoid  22 , with the clavicle  18  removed. Illustrated is the cross-sectional width CS 1  at the apex  123  relative to the cross-sectional width CS 2  closer to the base  124 . 
     Advantageously, the offset guide  100  disclosed herein allows the user to grip the anatomy, in this case the inferior surface of the coracoid  22 , in a “low energy” portion of the coracoid  22 . This may be the apex  123  of the arched midportion of the coracoid  22 . The apex  123  may stably nest a guide distal end. The offset guide  100  however inserts a drill along a trajectory that extends through the coracoid  22  at a more optimal location along the coracoid  22 , for forming passages therethrough, and therefore spaced away from the apex  123 . This offset location is preferably proximal and posterior to the apex  123 . This offset location is closer to the base portion  124  of the coracoid  22 . The proximal posterior base portion  124  is larger in width, and therefore preferable for placing a hole or tunnel therethrough, as explained herein. 
     The offset guide  100  allows the user to observe the drill tip and/or implantable device of the repair construct as it exits the inferior surface of the coracoid  22 . Stated another way, the guide distal end preferably does not obscure or obstruct visualization of the drill and implant/anchor as it exits the bone tunnel. The offset guide  100  allows space for an implantable device to deploy outside the bone without encountering the guide. Deployment oftentimes involves changing the implantable device to a laterally expanded configuration or flipping the implant to a larger footprint to engage the outer cortical surface of the bone. The offset is preferably sufficient to avoid interference between the deployed implantable device and guide distal end. This allows the offset guide  100  to remain engaged with the coracoid  22 , maintaining the joint in the reduced configuration, while fixing the joint with the repair construct, including deploying the implant/anchor. Offsets may be between  5-10  mm between the guide arm that engages the coracoid inferior surface to hold the coracoid  22 , and the drill location through the coracoid inferior surface. 
     Offset guide  100  disassociates the drill stop mechanism from the distal aspect of the guide. This is advantageous as the drill avoids the distal aspect of the guide at the coracoid inferior surface, and therefore avoids metal to metal contact between the spinning drill point and the guide, which can generate metal debris inside the body. 
       FIG.  2 A  illustrates an embodiment of a system including an offset guide  100  and drill  150 . The offset guide  100  includes a guide distal aspect or distal end  110  and proximal end  120 . A curved arm  130  may extend therebetween, to wrap around the target joint anatomy. Distal end  110  defines a finger  111  defining a proximal facing surface  111   a  configured to wrap around and engage an inferior surface of coracoid  22 , the point or area of engagement defining one end of the reduction axis R-R. Proximal end  120  may include a housing  126  with a distal surface  166  for engaging the shoulder of the patient. Housing  126  also defines an elongate opening  170  for receiving bullet  115 . Bullet  115  may be axially slideable along elongate opening  170  and controlled with ratchets or pawls  116 . Distal end  118  of bullet  115  may be axially advanced, to engage a superior surface of clavicle  18 . This defines a second end of the reduction axis R-R, and bullet distal end  118  and finger  111  are configured to hold the two bones (coracoid and clavicle) in a target reduced configuration while attached a fixation construct. 
     Seen in  FIG.  2 B , elongate opening  170  and bullet  115  both extend along an axis (D-D) that is angularly offset from reduction axis R-R, to define the offset location through the coracoid  22 . Bullet  115  may be cannulated, to receive surgical tools therethrough. For example, a wire, or drill  150  may be inserted therethrough. Drill  150  may be a sleeved drill to extend over wire. Bullet  115  therefore defines the trajectory of drill tip  152  through the clavicle  18  and coracoid  22 , along axis D-D. Bullet  115  therefore also defines an axis that places the drill through the coracoid  22  at an offset location relative to the guide finger  111 . Offset “0” may be seen in  FIG.  2 B  and  FIG.  2 C . Drill  150  may include a drill stop  155  configured to limit the insertion depth of drill tip  152  through the coracoid  22 . Drill stop surface  128  on guide  100  is sized to interact with drill stop  155  and limit the depth of insertion.  FIG.  2 C  illustrates a bottom view of guide  100  with drill stop  152  inserted.  FIG.  2 A- 2 C  illustrate a right sided guide system, for the right AC joint of a patient. A mirror image guide may also be provided where the arrangement of the bullet and guide arm are a mirror image for the patient&#39;s left side. 
       FIGS.  3 A- 3 B  shows the guide and drill (right sided) assembled to the AC joint. Guide housing  126  may be positioned on top of the patient shoulder  300 . Guide arm  130  may be positioned through at least one patient portal and finger  111  may be wrapped around and under the coracoid  22 . More specifically, guide finger  111  engages apex  123  of coracoid, best seen in  FIG.  3 B . Bullet  115  is inserted through elongate opening  170  of housing and through another patient portal to engage a superior surface of clavicle  18 . The two bones are held in position relative to each other via bullet end  118  and finger superior surface  111   a . Drill tip  152  is shown inserted through cannulated bullet  115  and forms a passage through both the clavicle  18  and coracoid  22 , the passage through coracoid  22  at an offset location relative to finger  111  and thereby offset from apex  123  of the coracoid  22 . Offset location is posterior and towards the coracoid base  124 . Drill tip  152  may be inserted until drill stop  155  abuts drills top surface  128 . Drill may include a sleeved drill. A guide wire may first form a passage through the bones and a sleeve drill may enlarge the passage diameter.  FIG.  3 B  illustrates a close-up of finger  111  engaged with apex  123 . Drill tip  152  has formed a passage through coracoid  22  closer to the base  124  of coracoid  122 . Resulting passage has a diameter configured to cooperate with a repair construct and preferably has as small a diameter possible to save coracoid bone tissue. Passage diameter is preferable smaller than a deployed footprint size of an implant/anchor of fixation construct. Illustrated in  FIG.  3 C , the drill may be removed and an anchor  310  may be inserted through passages (clavicle and/coracoid) and deployed to anchor repair construct to the coracoid  22 , while the guide arm  130  and finger  111  are still engaged with the joint. This helps to keep the joint in the reduced configuration while the repair construct is being assembled. 
     In some embodiments, a drill stop may be avoided, as the surgical tools are readily observed as they exit the coracoid  22 . In some embodiments the proximal end may include several elongate passages similar to  170 , at a variety of locations or angles for different offset locations. In some embodiments the elongate passage may be articulable, to adjust the offset location. 
     In some embodiments, the distal aspect of the AC joint guide may be configured to center the drill trajectory relative to the target bone. Referring to previous figures, finger  111  may be shaped to center the drill trajectory.  FIGS.  4 A and  4 B  schematically show two example cross sections of a coracoid  22  with example passages that may be formed therethrough.  FIG.  4 A  illustrates a centered passage P 1  therethrough.  FIG.  4 B  illustrates an example off-centered passage P 2  therethrough. Coracoid cross section is represented in these figures as approximately circular. It may be more oblong, or egg shaped, and  FIGS.  4 A- 4 B  are illustrative, for discussion purposes only. Coracoid  22  may have a cross section width between 12-18 mm. Consider now that a passage formed therethrough during an AC joint repair may be 2-5 mm is diameter. This not only is a substantial portion of the coracoid cross section, which is considered a fragile bone to begin with, but should the passage be offset ( FIG.  4 B ) from the center “C”, one side  422   a  may be considerable smaller still. This may risk coracoid fracture either while drilling or under load. In addition, when placed off center, the anchor may be positioned at a location that risks repair failure. For example, the anchor may gain insufficient footprint purchase with the coracoid  22  causing higher stress loading on the target bone. Furthermore, the resulting force vector between the coracoid  22  and clavicle  18  with an anchor offset from the bone center may draw the two bones out of the anatomical reconstruction arrangement. 
       FIGS.  5 A and  5 B  illustrate a guide distal aspect, known in the art. Guide may be coracoid guide disclosed in commonly owned US patent application number 2021/0015504, titled “Coracoid Drill Guide Assembly and Methods Of Use Thereof” and may include a guide arm with a hooked tip. The guide arm may engage a side surface of the coracoid  22 , while the hooked tip may engage an inferior surface of the coracoid  22 , as shown. The hook tip is laterally offset from the guide arm by a fixed offset distance. By engaging the hooked tip and arm, the drill trajectory may be guided through the coracoid  22 , as illustrated. However, this distal aspect shown does not reliably center the drill trajectory, as illustrated. Centering depends on the actual curved outer surfaces of the coracoid cross section and the offset of the hook tip. For example, in  FIG.  5 A  the hook offset is too great for the size and shape of the coracoid and places the drill trajectory off center. Another example is shown in  FIG.  5 B , where coracoid is more oblong in cross section, the oblong interacting with the example guide arm to place the drill trajectory off center. In practice the operator then needs to interpret and manually adjust the example guide that is known in the art to compensate for this off centering, taking both time, expertise and carrying with it some risk. 
       FIG.  6 A  illustrates a guide arm distal aspect  650  that has a fixed (non-adjustable) geometry, configured to center a passage trajectory through the coracoid  22 , in accordance with this disclosure. The passage trajectory preferably extends from a first external surface to an opposing surface of the coracoid  22 , defining a thickness or diameter of the bone. The term “diameter” is a straight-line distance through a bone anchor from one side of the bone to the other side of the bone that passes through a cross-sectional center of the bone. A “diameter” as used herein is not limited to an object with a circular cross-section. The passage trajectory is preferably from a superior surface to an inferior surface of the coracoid  22 . The guide arm distal aspect  650  accommodates a range of curved outer surfaces of a coracoid, of varying diameters. The distal aspect  650  self-centers a drill passage trajectory despite engaging a rounded but not necessarily circular bone surface. The distal aspect  650  may be in the form a hook, shaped and configured as a rounded V-block. As such, the distal aspect  650  wraps around three sides of the coracoid  22  and engages it on two opposing sides (approximate anterior and posterior surfaces) of the coracoid  22 . The distal aspect  650  wraps around the inferior/underside of the coracoid  22  but may remain spaced away from the inferior facing side, relying on the two opposing sides of contact to self-center the guide distal aspect  650  and therein the drill trajectory. Illustrated in  FIG.  6 A  is an oblong coracoid cross section  622  engaged on two opposing sides by guide distal aspect  650  and may be spaced away from the inferior side. More specifically arm  655  extends from proximal aspect of guide and around a first side surface (anterior or posterior) of the coracoid  22 . Arm distal aspect  650  engages coracoid on the first side surface  622   a . Opposite the arm  655  is a free leg  660 , terminating in a tip  662 . Free leg  660  engages a second, opposing side surface  622   b  of the coracoid  22 . Tip  662  may engage coracoid, depending on coracoid shape and curves. 
     At the distal aspect, arm  655  and free leg  660  define boundaries of a “V” or U″ shaped opening  670 , configured to receive the coracoid inferior surface therein. Opening  670  may define a maximum width “Y” configured to receive the coracoid  22  therethrough. Width “Y” may approximate a maximum cross section width or diameter of the target coracoid. Width “Y” may be between 12-18 mm. Free leg  660  may extend in a retrograde direction and towards a guide proximal end defining an opening depth “X”. Depth “X” is configured to receive the coracoid  22  inferior aspect therein sufficient to center the coracoid  22 . Depth “X” may approximate half of the coracoid height or diameter when measured along a vertical plane (superior-inferior) of the target coracoid. Depth “X” may be between 6-9 mm. Free leg  660  is limited in length for easy insertion through a small incision through the patient skin and around the inferior side of coracoid  22 . The longer the free leg  660  the more rotation and/or translation may be required to place tip  662  around the inferior side of coracoid. This may require extra dissection around the coracoid  22 , or a larger port size. “V” or U″ shaped opening  670  may be symmetrical, extending at equal and opposite angles θ1, θ2 to each other. “V” or U″ shaped opening  670  may define an angular opening that may be up to 120 degrees)(°) in total. In some preferred embodiments, the opening  670  may define a 60-degree opening. Having a wider opening (closer to 120 degrees) may more easily slide under the coracoid. However, a wider opening may frustrate centering for small coracoid cross sections, as the inferior surface of coracoid  22  may preferably engage the distal aspect  650 . As a reminder, guide distal aspect  650  preferably engages the inferior portion of coracoid  22  at two opposing sides of the coracoid  22  while remaining spaced away from the inferior side surface between these two opposing sides. This ensures that the two points of contact on the opposing sides center the guide distal aspect  650  around the coracoid  22 . In some embodiments the distal aspect  650  may include gripping features such as teeth. 
       FIG.  7 A  illustrates a guide system  600  similar to system  100 , with the exception of the guide distal aspect  650 .  FIG.  7 B  illustrates the guide system  600  with the drill  150  inserted through bullet, the trajectory of drill  150  offset from the distal aspect in a first direction and centered relative to the distal aspect  650  in a second, perpendicular direction. 
     A method of AC joint repair may include placing a distal aspect  650  of guide  600  around an inferior surface of the coracoid  22 , the distal aspect  650  configured to center a coracoid cross section with respect to a drill trajectory. More specifically the distal aspect  650  may define a V-block opening and placing the distal aspect  650  places an inferior portion of the coracoid  22  within the V-block opening. Placing the distal aspect  650  may engage two opposing sides of the V-block opening with two opposing external surfaces of the coracoid  22 , the two opposing sides approximately facing each other. Placing the distal aspect  650  may preferably avoid engagement of the inferior most surface of the coracoid. A bullet may then axially advance and engage a superior surface of clavicle  18 . Guide may then be adjusted to hold the coracoid  22  and clavicle  18  in an anatomical reconstruction arrangement. 
     Bullet may be oriented to aim a drill trajectory through the clavicle  18  and coracoid  22 . Drill  150  may be inserted through bullet to form a passage through the clavicle  18  and then through the coracoid  22 , the passages axially aligned. The guide and bullet define a passage trajectory through both bones and disposes an inferior exit to the coracoid  22  at a posteriorly offset location along the coracoid  22  from the guide distal aspect  650 . The guide and bullet define a passage trajectory through both bones and disposes a passage trajectory through the coracoid  22  through the center of the coracoid  22 . Drill  150  may then be removed, while the guide  600  and bullet remain engaged with the two bones. While the guide remains engaged, a repair construct may be operatively coupled to the two bones. The repair construct may include a coracoid anchor, placed at the inferior passage exit while guide remains engaged with the two bones. 
     One skilled in the art will realize the disclosure may be embodied in other specific forms without departing from the spirit or essential characteristics thereof. The foregoing examples are therefore to be considered in all respects illustrative rather than limiting of the disclosure described herein. Scope of the disclosure is thus indicated by the appended claims, rather than by the foregoing description, and all changes that come within the meaning and range of equivalency of the claims are therefore intended to be embraced therein.