Patent Publication Number: US-11033306-B2

Title: Articulating tool and methods of using

Description:
CROSS-REFERENCES TO PRIORITY APPLICATIONS 
     This application is a continuation of U.S. patent application Ser. No. 14/065,259, filed Oct. 28, 2013, now U.S. Pat. No. 9,924,986. The &#39;259 application, in turn, is a continuation of U.S. patent application Ser. No. 12/886,474, filed Sep. 20, 2010, now U.S. Pat. No. 8,568,417, which is based upon and claims the benefit under 35 U.S.C. § 119(e) of U.S. Provisional Patent Application Ser. No. 61/288,198, filed Dec. 18, 2009. 
     Each of these priority applications is incorporated herein by reference in its entirety for all purposes. 
    
    
     STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT 
     The U.S. Government has a paid-up license in this invention and the right in limited circumstances to require the patent owner to license others on reasonable terms as provided for by the terms of contract No. FAR 52.227-11 awarded by Dept. of Defense U.S. Army Medical Research and Material Command. 
    
    
     FIELD OF THE INVENTION 
     The disclosure relates to exemplary embodiments regarding articulating tools to enable drilling or placement of fasteners. More specifically, exemplary embodiments relate to articulating tools for use in endoscopic surgery to place fasteners into bone. 
     BACKGROUND OF THE INVENTION 
     Rib fractures are common in trauma patients; about 4-10% of trauma patients have rib fractures, of which 10-15% exhibit paradoxical motion. This condition is painful at best, but also reduces respiratory efficacy; and in extreme cases the fracture endangers the integrity of the lungs or heart due to chest wall instability. Chest wall instability may be treated by sedation of the patient or through artificial respiration, though internal fixation (placement of an osteosynthetic device) is often required. 
     Despite the benefits of internal fixation, existing procedures are quite invasive. Due to the invasive nature of the surgery many surgeons opt to treat indications with ventilation and analgesia alone. Titanium osteosynthetic plates are perhaps the most prevalent fixation method in the literature. These plates are screwed to the anterior surface of the rib at each fracture site. 
     SUMMARY OF THE INVENTION 
     In one aspect, embodiments of an articulating tool may include a housing having a proximal housing end and a distal housing end, an articulating head pivotably connected to the distal housing end by an articulating joint, a controller connected to the proximal housing end, a rotatable drive shaft within the housing having a proximal shaft portion, a medial shaft portion, and a distal shaft portion wherein at least the medial shaft portion is non-rigid, the proximal shaft portion extending through the proximal housing end and the medial shaft portion extending through the articulating joint, and an operable tip connected to the distal shaft portion. The articulating tool may be constructed and arranged to move between at least a first position and a second position by manipulation of the controller, in the first position the articulating head is at a first angle with respect to the longitudinal axis of the housing, and in the second position the longitudinal position of the housing is altered with respect to the rotatable drive shaft wherein the articulating head is at a second angle with respect to the longitudinal axis of the housing. The operable tip may be, but is not limited to, a driver bit or a drill bit. 
     In other embodiments the articulating tool may include one or more of the following features. The articulating tool may include a fastener retainer connected to the driver tip. The fastener retainer may include a sleeve and a compliant element for retaining a fastener, wherein the compliant element has an inner diameter smaller than an outer diameter of a fastener head. The articulating tool may include an antagonistic spring connected to the articulating joint. The antagonistic spring may be made of a superelastic nickel titanium alloy. The articulating tool may include a motor operably connected to the proximal shaft portion. The articulating tool may include a controller connected to the proximal housing end of the housing, wherein the controller is configured to change between the first position and the second position of the articulating tool. The articulating tool may include a motor operably connected to the controller. The articulating tool may articulate between an angle of less than or equal to about 60°. The articulating head and the housing may have an outer diameter of less than or equal to about 12 millimeters. The articulating tool may be made of bio-inert and autoclavable materials. 
     In another aspect, embodiments of a method of using an articulating tool may include installing an operable tip at the distal end of the articulating tool, inserting the articulating tool into a body orifice in a mammal, manipulating the controller to adjust the articulating head of the articulating tool, and applying torque to the drive shaft of the articulating tool to engage the operable tip. In one embodiment, the operable tip may be a driver bit with a fastener. In another embodiment, the operable tip may be a drill bit. In one embodiment, the body orifice may be a natural orifice. In another embodiment, the body orifice may be an incision. In another embodiment, the orifice may be a small incision in the thorax. In one embodiment, engaging the operable tip may drive a fastener into body tissue. In another embodiment, engaging the operable tip may drive a fastener into a rib to secure an osteosynthetic implant. In another embodiment, engaging the operable tip may remove material such as in drilling a hole. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The invention is illustrated in the figures of the accompanying drawings which are meant to be exemplary and not limiting, in which like references are intended to refer to like or corresponding parts, and in which: 
         FIG. 1  illustrates an embodiment of an articulating tool; 
         FIG. 2  illustrates the same embodiment of an articulating tool in an articulated position; 
         FIG. 3  illustrates a cross-sectional view from one side of the same embodiment of the articulating tool in the straight position; 
         FIG. 4  illustrates a cross-sectional view from one side of the same embodiment of the articulating tool in the articulated position; 
         FIG. 5  illustrates an exploded view of the same embodiment of the end of the articulating tool in the straight position; 
         FIG. 6  illustrates an exploded view of an embodiment for attaching bits to the end of the articulating tool; 
         FIG. 7  illustrates a view of the same embodiment for attaching bits to the end of the articulating tool; 
         FIG. 8  illustrates an exploded view of a first embodiment of a fastener retainer at the end of the articulating tool; 
         FIG. 9  illustrates a cross-sectional view from one side of the first embodiment of a fastener retainer at the end of the articulating tool, wherein the fastener is in a fixed position; 
         FIG. 10  illustrates a cross-sectional view from one side of the first embodiment of a fastener retainer at the end of the articulating tool, wherein the fastener is in a free position; 
         FIG. 11  illustrates an exploded view of a second embodiment of a fastener retainer at the end of the articulating tool; 
         FIG. 12  illustrates a cross-sectional view from one side of the second embodiment of a fastener retainer at the end of the articulating tool, wherein the fastener is in a fixed position; 
         FIG. 13  illustrates a cross-sectional view from one side of the second embodiment of a fastener retainer at the end of the articulating tool, wherein the fastener is in a free position; and 
         FIG. 14  illustrates an embodiment of a method of using an articulating tool. 
     
    
    
     DETAILED DESCRIPTION 
     Described herein are embodiments of articulating tools and methods for conducting thoracoscopic rib fixation. In some embodiments the articulating tool may enter the thoracic cavity through an incision in the thorax of a patient and drill or drive a fastener into the proximal surface of a rib to secure an osteosynthetic implant, for example, but not limited to, an osteosynthetic plate. 
     Embodiments of the articulating tool may be used to secure osteosynthetic implants to bone during thoracoscopic surgery. More specifically, embodiments of the articulating tool may be used to secure osteosynthetic implants to the posterior cortex of an anterior rib segment, and/or to the anterior cortex of a posterior rib segment, and/or to the medial surface of a lateral rib segment, through a single incision, for minimally invasive internal fixation of rib fractures. The embodiments of the articulating tool may be small enough to be used with a 12 mm trocar sleeve and transmit sufficient torque to fully secure fasteners into bone. An articulating joint at the end of the articulating tool may provide for correct screw alignment at obtuse angles, up to 90° from the articulating tool axis. In some embodiments the articulating tool may facilitate obtuse angles up to 60° from the articulating tool axis. To facilitate obtuse angles up to 60° from the articulating tool axis, a drive shaft having at least a non-rigid intermediate shaft portion may be used to both transmit torque and actuate the articulating joint. The articulating joint may be actuated by changing the longitudinal position of the drive shaft with respect to the rigid housing, or by changing the longitudinal position of the rigid housing with respect to the drive shaft. 
     The articulating tool may be used for endoscopic placement of fasteners. The articulating tool may be used for endoscopic placement of fasteners, and may provide for minimally invasive internal fixation of rib fractures that may utilize video-assisted thoracic surgery (VATS). Performing internal rib fixation thoracoscopically with the embodiments of the articulating tool may provide a number of advantages. The use of embodiments of the articulating tool may reduce the need for large incisions and separation of musculature required for existing morbid techniques. The use of embodiments of the articulating tool may allow a fracture constrained on the medial surface to be placed in compression during normal respiratory stresses, offering greater mechanical stability and eliminating stress shielding. The use of embodiments of the articulating tool may allow the neurovascular bundle along the inferior edge of each rib to be visible during video-assisted thoracic surgery (VATS) placement, such that the surgeon may avoid nerve contact and associated post-operative patient pain. 
     Detailed embodiments of the present invention and methods of use are disclosed herein, however, it is to be understood that the disclosed embodiments are merely exemplary of the invention, which may be embodied in various forms. Therefore, specific functional details disclosed herein are not to be interpreted as limiting, but merely as a basis for the claims and as a representative basis for teaching one skilled in the art to variously employ the present invention. 
     In one aspect, an embodiment of an articulating tool may include a rigid housing, an articulating head, a drive shaft, and a driver tip. The housing and articulating head may be any shape, length and have any diameter appropriate for performing surgery. In one embodiment the rigid housing and articulating head may have an outer diameter at the widest point sufficient to allow for the housing and articulating head to fit through a trocar sleeve. For example, the housing and articulating head may have an outer diameter at the widest point of about 5-25 mm, 10-20 mm, or 10-15 mm. The housing and articulating head may have a cross-section of any geometric shape, such as but not limited to circular, elliptical, oval, square, triangular, rectangular, octagonal, polygonal, etc. The housing and articulating head may be straight, curved, etc. along the longitudinal axis. The housing and articulating head may be made of any material, such as but not limited to, metals, plastics, polymers, pliable materials, rigid materials, etc., or any combination of the foregoing. In one embodiment the housing and articulating head may be made of a material that may be bio-inert and/or resists high temperatures during autoclave sterilization, such as but not limited to stainless steel, titanium, bio-alloys, and etc. In another embodiment the housing and articulating head may be made of a material that is bio-inert and/or disposable. 
     The articulating head may be connected to the housing by an articulating joint. The articulating joint may be any type of joint that may allow the articulating head to articulate to a desired angle, such as but not limited to a pivot joint, a sliding joint, a ball and socket joint, a hinge joint, a linkage, a compliant joint, etc. Further, the articulating joint may include more than one joint, such as a series of joints. In one embodiment the articulating joint may be a dual pin hinge joint. More specifically, the hinge pins may be offset slightly from the axis of the actuating element to avoid a kinematic singularity at the straight position. The articulating joint may be made of any material, such as but not limited to, metals, plastics, polymers, pliable materials, rigid materials, etc., or any combination of the foregoing. In one embodiment the articulating joint may be made of a material that may be bio-inert and/or resists high temperatures during autoclave sterilization, such as but not limited to stainless steel, titanium, bio-alloys, etc. In another embodiment the articulating joint may be made of a material that is bio-inert and/or disposable. 
     The articulating head may articulate to any angle and maintain that angle. In one embodiment, the articulating head may articulate at angles from about 0° to 90°. In another embodiment the articulating head may articulate at angles from about 0° to 60°. It has been determined that based on rib geometry an angle of articulation from about 0° to 60° may allow full access to anterior fractures through a posterior incision. 
     The length of the articulating head may be directly related to the angle through which the articulating head must articulate. A shorter length of the articulating head may result in improved maneuverability. The length of the articulating head may be any length. The articulating head may be the same length as the housing, may be longer than the length of the housing, or may be shorter than the length of the housing. For endoscopic surgery the length of the articulating head may be about 3 cm to 20 cm. In one embodiment the length of the articulating head may be about 5 cm to 10 cm. In another embodiment the length of the articulating head may be about 6 cm. 
     The drive shaft may extend through the housing, the articulating joint, and the articulating head. The drive shaft may have a dual purpose to both transmit torque and to actuate the articulating joint. The drive shaft may control the angle of articulation by acting as a tensile element. In one embodiment the articulation of the articulating head may be controlled by altering the longitudinal position of the housing, the articulating head, and/or the articulating joint with respect to the drive shaft. As the longitudinal position of the drive shaft is altered with respect to the housing to increase the tension on the drive shaft the articulating head may be caused to articulate or increase the angle of articulation. For example, to increase the tension on the drive shaft the longitudinal position of the drive shaft may be altered to cause the drive shaft to move away from the articulating end of the articulating tool while keeping the longitudinal position of the housing stationary. As the longitudinal position of the drive shaft is altered with respect to the housing to decrease the tension on the drive shaft the articulating head may be caused to relax, or decrease the angle of articulation. For example, to decrease the tension on the drive shaft the longitudinal position of the drive shaft may be altered to cause the drive shaft to move in the direction of the articulating end of the articulating tool while keeping the longitudinal position of the housing stationary. Additionally, the drive shaft may be rotated simultaneously while the angle of articulation is adjusted. 
     The drive shaft may be made of any material in the art, such as but not limited to metals, plastics, polymers, pliable materials, rigid materials, flexible materials, etc., or any combination of the foregoing. In one embodiment the drive shaft may be made of a material that may be bio-inert and/or resists high temperatures during autoclave sterilization, such as but not limited to stainless steel, titanium, bio-alloys, etc. In another embodiment the drive shaft may be made of a material that is bio-inert and/or disposable. The drive shaft may be completely flexible, or a combination of flexible portions and rigid portions. The drive shaft may have a flexible portion which extends through the articulating joint to allow for the drive shaft to articulate with the articulating head. The flexible portion could be an element known as a flexible shaft. In another embodiment, the flexible portion of the drive shaft may be composed of an element known as a universal joint or a series of elements known as universal joints. In another embodiment, the flexible portion of the drive shaft may be composed of a gear set. 
     The articulating tool may further include a slot or aperture in the housing and/or the articulating head. The slot may allow for the drive shaft, when articulated, to move off center at high degrees of articulation. In one embodiment the portion of the drive shaft that articulates is flexible. When the drive shaft is articulated to a high degree of articulation the shaft may move or deflect a small distance from its neutral position or non-actuated position. The slot may allow for the deflecting portion of the drive shaft to move through the slot, thus allowing for full articulation. Additionally, the slot may be covered by a rigid or flexible mechanism to protect the drive shaft. 
     The articulating tool may further include an antagonistic element on the articulating joint to provide an antagonistic force to the articulating joint. One purpose of the antagonistic element may be to aid in the straightening of the angle of articulation to about 0°. Another purpose of the antagonistic element may be to provide for a more controllable angle of articulation. In one embodiment the antagonistic element may be a spring. The spring may be made of any elastic material capable of providing an antagonistic force and may be either in compression or tension. In one embodiment the antagonistic spring may be made of a super elastic material, such as but not limited to, a nickel titanium alloy. In another embodiment, the antagonistic element may be the flexible portion of the drive shaft. 
     The articulating tool may further include a controller connected to the proximal end of the housing or drive shaft to control the angle of articulation. In one embodiment the controller may control the longitudinal position of the housing with respect to the drive shaft, thus controlling the angle of articulation. In another embodiment the controller may control the longitudinal position of the drive shaft with respect to the housing, thus controlling the angle of articulation. The controller may be any device capable of altering the longitudinal position of either the housing or the drive shaft with respect to one another, such as but not limited to threaded screws, a gear set, a cam, etc. In one embodiment the controller may be a threaded device that, when turned, alters the longitudinal position of the housing with respect to the drive shaft, which may be held stationary with respect to the housing. In another example the controller may be a threaded device that when turned alters the longitudinal position of the drive shaft with respect to the housing, which may be held stationary with respect to the drive shaft. Further, the controller may be made of any material, such as but not limited to, metals, plastics, polymers, pliable materials, rigid materials, etc., or any combination of the foregoing. In one embodiment the controller may be made of a material that may be bio-inert and/or resists high temperatures during autoclave sterilization, such as but not limited to stainless steel, titanium, bio-alloys, etc. In another embodiment the controller may be made of a material that is bio-inert and/or disposable. 
     The articulating tool may further include at least one power device for supplying torque to the drive shaft and/or to the controller. Any means for supplying power may be used, such as but not limited to manual, electric, and pneumatic drives. In one embodiment power may be supplied by an electric device such as a DC motor, a DC gear motor, an AC motor, an AC gear motor, etc. The power device used to supply torque to the drive shaft may be capable of having a peak torque of about 1 N and be capable of operating at about 60 RPM with variable speed. The power device may be capable of operating at, for example, about 0-10,000 RPM, 0-1,000 RPM, 0-500 RPM, 0-100 RPM, or 0-60 RPM. In another embodiment, a means may be provided for manually turning the drive shaft, such as but not limited to a twist handle or a lever-screw drive. 
     The articulating tool may further include an operable tip attached to the drive shaft. The driver tip may be any operable device known in the art such as but not limited to a screwdriver tip, a drill bit, a blade, a socket, an allen tip, a file, etc. In one embodiment the driver tip may be compatible with screws that are about 2.0 mm or 2.3 mm in diameter. The operable device may be capable of easy replacement. The operable tip may be made of any material, such as but not limited to, metals, plastics, polymers, pliable materials, rigid materials, etc., or any combination of the foregoing. In one embodiment the operable tip may be made of a material that may be bio-inert and/or resists high temperatures during autoclave sterilization, such as but not limited to stainless steel, titanium, bio-alloys, etc. In another embodiment the driver tip may be made of a material that is bio-inert and/or disposable. 
     The articulating tool may further include a fastener retainer for retaining a fastener, screw, nail, staple, etc. on the driver tip prior to insertion into a bone or other material. This can allow the fastener to be placed on the tool prior to insertion into the patient. The fastener retainer may be made of any material, such as but not limited to, metals, plastics, polymers, pliable materials, rigid materials, etc., or any combination of the foregoing. In one embodiment the fastener retainer may be made of a material that may be bio-inert and/or resists high temperatures during autoclave sterilization, such as but not limited to stainless steel, titanium, bio-alloys, etc. In another embodiment the fastener retainer may be made of a material that is bio-inert and/or disposable. The fastener retainer may have a cross-section of any geometric shape, such as but not limited to circular, elliptical, oval, square, triangular, rectangular, octagonal, polygonal, etc. The fastener retainer may be straight, curved, etc. along its longitudinal axis. 
     The fastener retainer may incorporate any retainer for removably retaining a faster on the driver tip, such as but not limited to compliant rings, ball bearings, teeth, locking sleeves, retaining sleeves, magnetic retainers, etc. The retainer may be an active retainer, which requires the user to release the fastener from the retainer, or a passive means, which does not require the user to release the fastener from the retainer. In one embodiment the fastener retainer may include a compliant element, which may be a ring, having an inner diameter smaller than the outer diameter of the fastener to be retained. The compliant element may retain the fastener and as the fastener fully seats into bone or other material it pulls itself through the compliant ring to a released position. In this manner, the mechanism may be passive and does not require external actuation. The compliant ring may be capable of retaining the fastener even in the presence of reasonable radial forces, such as those on the order of about 10 N. Further, the compliant ring may be capable of retaining the fastener until an axial force of about 10-25 N is applied. In one embodiment, the compliant element may be a separate component of an assembled fastener retainer. In another embodiment, the compliant element may be a feature on a fastener retainer. In one embodiment the compliant ring may be made of a material that may be bio-inert and/or resists high temperatures during autoclave sterilization. In another embodiment the compliant ring may be made of a material that is bio-inert and/or disposable. 
     In another embodiment the articulating tool may include a handle on which the motor, housing, power supply, and/or controller may be mounted. The handle may be made of any material, such as but not limited to, metals, plastics, polymers, pliable materials, rigid materials, etc., or any combination of the foregoing. In one embodiment the handle may be made of a material that may be bio-inert and/or resists high temperatures during autoclave sterilization, such as but not limited to stainless steel, titanium, bio-alloys, etc. In another embodiment the handle may be made of a material that is bio-inert and/or disposable. Additionally, the handle may include a trigger for controlling the power distributed to the drive shaft and/or controller for controlling the torque applied to the drive shaft and/or the angle of articulation. In one embodiment, the handle may be detachable from the tool and may function as one piece of a modular surgical kit. In another embodiment, the handle may include a means for application of manual torque. 
     In another embodiment one or more portions of the articulating tool may be capable of being removed and/or disassembled. For example the housing, the articulating head, the controller, the driver tip, the drive shaft, the retention mechanism, etc. may be removed and/or disassembled from the articulating tool. The portions may then be disposed of or sterilized/autoclaved for multiple uses. 
     Turning to  FIG. 1 , in one embodiment the articulating tool may attach to a separate battery-powered handpiece  101 , may include a housing  102 , an articulating head  103 , and articulating joint  104 . In  FIG. 2 , the articulating joint  104  may be adjusted, by manipulating the controller  105 , to angles between about 0 and 60 degrees. The articulating tool may be made of a material that may be bio-inert and/or resists high temperatures during autoclave sterilization. The housing  102  and the articulating head  103  may have an outer diameter of sufficient size to allow the housing  102  and the articulating head  103  to fit through a 12 mm trocar sleeve. 
     Referencing  FIGS. 3, 4, and 5 , the rotatable drive shaft includes a rigid proximal shaft  106 , a non-rigid intermediate shaft  107 , and a rigid distal shaft  108 . In another embodiment, there may be a plurality of shaft sections, each of which may be rigid or non-rigid. In yet another embodiment, there may be as few as one or two shaft sections. The drive shaft assembly extends through the controller housing  109 , the tool housing  110 , the proximal hinge joint  111 , and the distal hinge joint  112 . The distal rigid shaft  108  is axially and longitudinally constrained in the distal hinge joint  112  by a bushing  113 . The proximal drive shaft  106  is axially constrained in the proximal hinge joint  111  by bushing  114 . The driver tip may be connected to the distal shaft  108  by means of a collet nut  115  or other appropriate coupler. The driver tip may be, for example, a screwdriver tip, a drill bit, a blade, a socket, an alien tip, a file, etc. 
     Referencing  FIGS. 3 and 4 , the articulating tool may be constructed and arranged to move between a first position and a second position. To change between the first and second positions the longitudinal position of the housing  110  may be altered with respect to the proximal drive shaft  106 . As the longitudinal position of the housing  110  is altered with respect to the proximal drive shaft  106  the proximal drive shaft  106  moves longitudinally through bushing  114  thereby altering the free length of flexible drive shaft  107 . As the free length of flexible drive shaft  107  decreases, the distal hinge joint moves away from the straight position to allow the flexible drive shaft to assume an arc of decreasing radius. Alternatively, as the free length of flexible drive shaft  107  increases, the distal hinge joint moves towards the straight position to allow the flexible drive shaft to assume an arc of increasing radius. Additionally, the drive shaft assembly, comprised of the proximal drive shaft  106 , the flexible drive shaft  107 , and the distal drive shaft  108 , may be rotated simultaneously while the angle of articulation is adjusted. In another embodiment, the movement between a first and second position may be activated by other means such as, but not limited to, a cable drive system, a set of gears, a linkage or set of linkages, a pushrod or set of pushrods. 
     Referencing  FIGS. 4 and 5 , in another embodiment the articulating tool may include an antagonistic spring  116 . The antagonistic spring  116  may be connected and extending through the proximal hinge joint  111  and the distal hinge joint  112 . As the free length of flexible drive shaft  107  increases, the antagonist spring  116  may assist the distal hinge joint  112  in moving towards the aligned straight position. 
     Referencing  FIGS. 5 and 6 , in another embodiment the articulating tool may include a slot or aperture in the proximal hinge joint  111  and the distal hinge joint  112 . When the flexible drive shaft  107  assumes an arc of small radius at a high degree of articulation, the flexible drive shaft  107  may move or deflect a small distance from its neutral position or non-actuated position. The slot may allow for a portion of the flexible drive shaft  107  to deflect through the slot, thus allowing for full articulation. 
     Referencing  FIGS. 3 and 4 , the articulating tool may include a controller comprised of a controller housing  109 , and controller handle  117 . The proximal drive shaft  106  may be rigidly attached to a controller drive shaft  118  that is axially and longitudinally constrained to the controller housing  109  by bearings  119 . The tool housing  110  may be constrained axially to the controller housing  109  by a sliding fit and longitudinally to the controller handle  109  by pins  120 , a snap ring, etc. Threads on the controller housing  109  and the controller handle  117  may allow the longitudinal position between the controller housing  109  and the controller handle  117  to be adjusted by rotation of the controller handle  117  with respect to the controller housing  109 . In this fashion, the relative longitudinal position of the proximal drive shaft  106  and the tool housing  110  may be adjusted due to their longitudinal constraint within the controller housing  109  and the controller handle  117 , respectively. The controller housing  109  and the controller drive shaft  118  may be fashioned to attach to a surgical drill  101 , manual driver handle, etc. 
     The controller may be capable of changing the articulating tool between a first and second position. In the first position, as shown in  FIGS. 1 and 3 , the distal hinge joint  112  and the distal drive shaft  108  are at a first angle, about 0°, with respect to the longitudinal axis of the housing  110 . In the second position, as shown in  FIGS. 2 and 4 , the distal hinge joint  112  and the distal drive shaft  108  are at a second angle, θ, to with respect to the longitudinal axis of the housing  110 . The angle θ may be anywhere from about 0° to about 60° and may allow full access a rib fracture site through a single thorax incision. Further, the articulating tool may be infinitely adjustable from about 0° to about 60° and may maintain that specific angle. In the first position, when the distal hinge joint  112  and the distal drive shaft  108  are at a first angle of about 0° with respect to the longitudinal axis of the housing  110 , the articulating tool may be capable of fitting through a 12 mm trocar sleeve. 
     Referencing  FIGS. 6 and 7 , the distal drive shaft  108  may be fitted with a means of interchanging tips  121 . The driver tip may be, for example, a screwdriver tip, a drill bit, a blade, a socket, an alien tip, a file, etc. In one embodiment, the articulating tool incorporates a collet  122  and collet nut  115  to allow attaching, detaching, interchanging, or replacing of a tip. 
     Referencing  FIGS. 8-10 , in another embodiment the articulating tool may accept a fastener retainer  123 . The fastener retainer  123  may hold a fastener  124  onto a driver tip  125  by attaching to the distal hinge joint  112 . The fastener retainer  123  may include a grooved feature at the distal end to accept the fastener head  124 , where the rim of the groove has an inner diameter smaller than the largest diameter of the fastener head  124 . The fastener retainer  123  may be designed with slots to decrease the stiffness of the grooved feature and allow the fastener  124  to be dislodged by elastic deformation of the fastener retainer. The fastener retainer  123  may have a proximal groove to allow the fastener retainer to clip onto a ridge feature on the distal hinge joint  112 , as shown in  FIG. 9 . The proximal groove in retainer  123  may be wide enough to allow the fastener retainer to slide longitudinally along the distal hinge joint between a first position shown in  FIG. 9  and a second position shown in  FIG. 10 . The first position may hold the fastener head  124  firmly on the driver bit  125  such that the fastener  124  can be safely delivered to point of installation. The second position is proximal relative to the first position and may release the fastener head  124  from the distal groove feature. As the fastener  124  fully seats in bone or other material, the fastener retainer  125  is forced from the first to the second position, thereby releasing the fastener  124  without external actuation. 
     Referencing  FIGS. 11-13 , in another embodiment the articulating tool may accept a fastener retainer  126 . The fastener retainer  126  may hold a fastener  124  onto a driver tip  125  by attaching to the distal hinge joint  112 . The fastener retainer  126  may include a groove to receive a soft compliant element  127 , at the distal end to accept the fastener head  124 , where the inner diameter of the compliant element  127  is smaller than the largest diameter of the fastener head  124 . This arrangement allows the fastener  124  to be dislodged from the elastic element  127  by applying a reasonable level of longitudinal force. The fastener retainer  126  may have a proximal groove to allow the fastener retainer to clip onto a ridge feature on the distal hinge joint  112 , as shown in  FIG. 9 . The proximal groove in retainer  126  may be wide enough to allow the fastener retainer to slide longitudinally along the distal hinge joint between a first position shown in  FIG. 12  and a second position shown in  FIG. 13 . The first position may hold the fastener head  124  firmly on the driver bit  125  such that the fastener  124  can be safely delivered to point of installation. The second position is proximal relative to the first position and may release the fastener head  124  from the distal groove feature. As the fastener  124  fully seats in bone or other material, the fastener retainer  126  and compliant element  127  are forced from the first to the second position, thereby releasing the fastener  124  without external actuation. 
     In another aspect a method of using an embodiment of the articulating tool for thoracoscopic surgery is described. In one embodiment of the method the articulating tool may be used for minimally invasive internal fixation of rib fractures using video-assisted thoracic surgery (VATS) to place fasteners in osteosynthetic implants. VATS is a well-established procedure for pulmonary resection, lung volume reduction, lung biopsy, and pericardial resection. By selectively ventilating one lung with a dual lumen endotracheal tube, much of the pleural cavity may become accessible. An embodiment of the articulating tool may be an appropriate device for fastener delivery using VATS fixation of rib fractures. Further, the embodiments of the articulating tool described herein may be articulated within the thoracic cavity to allow placement of fasteners normal to the local surface of a curved rib. 
     Referencing  FIG. 14 , an embodiment of a method of using the articulating tool to perform minimally invasive internal fixation of rib fractures is illustrated. While  FIG. 14  illustrates a number of steps, any step or steps may be added or removed, and the steps may be performed in any order. The method described is the preferred embodiment, however the method may be performed in alternative body cavities, may be performed with any operable tip known to the art, or may be performed to secure any device known to the art to body tissue. 
     The method of minimally invasive rib fixation using an embodiment of the articulating tool may include intubating the patient with a dual lumen endotracheal tube and selectively deflating one lung  128 . The method may include making a series of small incision in the thorax  129  such that trocar sleeves can be placed  130 , allowing the insertion of a camera  131 . Under the guidance of the camera, an osteosynthetic implant may be inserted and contoured to the rib  132  using tools known to the art. An embodiment of the articulating tool with a drill bit attached as the operable bit may be inserted through a trocar sleeve  133 . Under the guidance of the camera, the embodiment of the articulating tool may be adjusted to the appropriate angle for accessing a particular operating site  134 . 
     The method may include adjusting the placement of the osteosynthetic implant for use as a drilling template  135  using tools known to the art and drilling pilot holes  135  by applying torque to the articulating tool. After performing a task, the articulating tool may be straightened by manipulating its controller  136  and withdrawn from the thoracic cavity  137 . 
     The method may further include utilizing a driver bit as the operable tip with a fastener  138 . The fastener may be held in place with a fastener retainer  138 . The articulating tool may be inserted through a trocar sleeve  139 . Under the guidance of the camera, the embodiment of the articulating tool may be adjusted to the appropriate angle for accessing a particular operating site  140 . Torque may be applied to the articulating tool to drive the fastener into the rib  141 , at which time the fastener retainer may release the fastener. The fastener may secure an osteosynthetic implant to the rib. After performing a task, the articulating tool may be straightened by manipulating its controller  142  and withdrawn from the thoracic cavity  143 . Steps  138  through  143  may be repeated several times to deliver multiple fasteners. 
     While the invention has been described and illustrated in connection with preferred embodiments for use in surgery, many variations and modifications will be evident to those skilled in the art and may be made without departing from the spirit and scope of the invention. The invention is thus not to be limited to the precise details of methodology or construction set forth above as such variations and modification are intended to be included within the scope of the invention.