Patent Publication Number: US-2016228263-A1

Title: Precise hip component positioning for hip replacement surgery

Description:
CROSS-REFERENCES TO RELATED APPLICATIONS 
     This patent application is a continuation-in-part application of U.S. patent application Ser. No. 13/431,944, filed Mar. 27, 2012, entitled “Precision Hip Replacement Method,” which claims the benefit of U.S. Provisional Application No. 61/528,744, filed Aug. 29, 2011, and U.S. Provisional Patent Application No. 61/567,869, filed Dec. 7, 2011. All applications are incorporated herein by this reference thereto. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     This invention relates to the field of minimally invasive surgical techniques for a joint replacement, and more particularly, methods for accurately positioning components for hip or knee joint replacement procedures. 
     2. Description of the Related Art 
     During the course of total hip arthroplasty, acetabular and femoral prostheses are placed. In order for the implants to function up to their capacity, generally meaning greater than twenty (20) years of clinical reliability, each component must be placed in a specific position in relation to the patient&#39;s native anatomy. Specifically, proper positioning of the acetabular component in a hip replacement procedure appears to be crucial to the long-term success of the surgery. What exactly constitutes proper positioning of the acetabular component is the subject of much debate. A commonly used range, established by Lewinnek et al., involves a cup position in which the abduction angle is within the range of 30° to 50° and in which the anteversion angle is within the range of 5° to 25°. Generally, surgeons use radiographic techniques to achieve these angles. 
     Studies have shown, however, that a substantially large percentage of surgeries result in cups that are not within this range. This is especially true with respect to minimally invasive surgical procedures. Callanan et al. surveyed 1952 hip replacements, observing several prediction factors, and found that only 48.7% resulted in acetabular cups within this range. Indeed, of the 93 hip replacements in Callanan&#39;s survey that used minimally invasive techniques, only 19.4% resulted in acetabular cups within this range. 
     This supports the proposition that traditional techniques have been considered by many to be unreliable for determining proper positioning of the acetabular cup or femoral component. 
     A variety of tools are available, however, to assist the surgeon in achieving correct component alignment. The so-called traditional guides, or line-of-sight, have been in use for over 40 years and are very helpful, but not as reliable as one would hope. 
     In the last 8-9 years, in an effort to improve reliability, there have been attempts at using so-called navigation or computer guidance systems relying on pre-operative CT scans to pre-load information pertaining to the patient&#39;s anatomy, intraoperative registration (a cumbersome and potentially tedious method to match the patient&#39;s anatomy to the preloaded image), the placement of multiple skeletal pins for orientation, and elaborate line-of-site transmitters relying on complex computer algorithms to guide component placement. Unfortunately, in spite of the promise of improved results, the reluctance of patients to be exposed to a significant amount of radiation during a CT scan, the significant cost of such a test against a simple intraoperative x-ray treatment, the total cost of the computer guidance system (many hundreds of thousands of dollars plus the ongoing cost of support annually as the machine is maintained and updated), the incalculable cost to the healthcare system, and the patient of an unpredictable workflow as system breakdown occurs frequently, add operation time and potential risk to the patient, as well as considerable cost. Consequently, this method has not been widely adopted. 
     Furthermore, in spite of the existence of such tools, the current success rate for acetabular component positioning is only sixty percent (60%). Therefore, there is still a need to improve the reliability and efficiency of instrumentation in achieving these specific recognized optimal component positions. 
     SUMMARY OF THE INVENTION 
     One embodiment of the present invention comprises methods for accurately positioning the acetabular cup in a minimally invasive, or conventional, total hip arthroplasty (THA), comprising the use of an elongated handle to place the cup in roughly the correct position with respect to the acetabulum of the patient, taking a first abduction reading and a first anteversion reading using a gyroscopic positioning unit aligned with the handle, taking an image of at least a portion of the cup using a radiography unit, using the image to determine the actual orientation of the cup and thereby the amount of movement in the abduction plane and in the anteversion plane to properly orient the acetabular component, incrementally altering the position of the cup by using a striking tool and an elongated instrument to tap a contact surface at one or more preformed impact receiving points, wherein the contact surface is in mechanical communication with the cup, taking new abduction and anteversion readings using the gyroscopic unit to determine the relative movement of the cup caused by the tapping, and repeating this striking step and this reading step until the cup has proper abduction and anteversion readings. 
     In another embodiment of the present invention, the surgeon may take additional intra-operative radiographic images during this process as needed. Other embodiments may also involve taking readings from a second gyroscopic unit aligned with a point on the pelvis so that any movement of the pelvis in any direction during surgery may be detected, quantified, and corrected. Such quantified movements are then used to adjust the target abduction and anteversion angles of the acetabular cup. 
     In some embodiments, a sterile surgical bag may be used to enclose the gyroscopic unit(s) to allow them to be situated within the operative field. 
     In further embodiments, employing the use of a portal incision remote from the main incision to permit precise acetabular bone preparation and cup implantation while employing a minimally invasive surgical approach, the proper placement of the portal incision is determined using an inside-out technique by using the geometry of the acetabulum to direct a path along a trajectory extending out from the plane formed by the face of the acetabulum to a point on the skin that provides perpendicular access to the acetabulum. 
     To assist with proper femoral bone preparation and implantation, other embodiments may involve using a laser pointer or other positioning device to more accurately verify that the femoral broach is properly aligned with the femur while the surgeon is preparing the femur to receive the femoral prosthetic. The laser pointer may create a visible line or spot projecting generally parallel to the line of attack of the femoral broach. This permits more precise targeting of accepted anatomical landmarks such as the center of the popliteal space. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Some elements in the drawings have been drawn not to scale so that different features can be shown with better clarity. 
         FIG. 1  is a front view of an X-ray image of the pelvis showing acetabular components on both sides of a patient in a prescribed range of abduction angles as discussed above for long-term wear and joint stability in keeping with one embodiment of the present invention. 
         FIG. 2A  is a perspective view of a tubular member in keeping with one embodiment of the present invention utilizing a directional device which is directed toward the center of the acetabulum, trial cup, or attachment end of an acetabular component placement tool, as discussed below, so that the directional device may reliably point the tubular member away from the acetabulum along a path that is generally perpendicular to the plane defined by the face of the acetabulum. The cutting member may thereby be directed through the tubular member and outward to the patient&#39;s skin where the portal incision will be made effectively at the optimal location, thereby creating access to the acetabulum along this path through the newly created portal incision. 
         FIG. 2B  is a diagram of a tubular member in keeping with another embodiment in keeping with the present invention in which the turn radius is minimized to reduce the size of the cross-section necessary for the tubular member. 
         FIG. 2C  is a perspective view of another embodiment of a tubular member that does not require a flexible tool. 
         FIG. 3  is a diagram of an embodiment showing the tubular member placed through a main incision in which the directional device assists the surgeon by pointing to the middle of the acetabulum (or trial cup, as discussed below, not shown). The cutting member thereby optimally takes a path generally perpendicular to the plane defined by the face of the acetabulum while allowing the surgeon to avoid critical blood. Note, the tissue such as nerves, tendons, ligaments, muscles, fat, and the like have been removed for clarity. 
         FIG. 4  is a diagram of another embodiment showing a tubular member in the vicinity of the pelvis bone and the acetabulum. 
         FIG. 5  is a diagram of a trough in keeping with one embodiment in which a trough is used instead of or in conjunction with a cannula. 
         FIG. 6  is a drawing showing an acetabular component placement tool in keeping with one embodiment of the present invention inserted into the main incision with a cannula (to permit placement of, for example, an in-line impaction tool) resident in the portal incision. The side hole in the handle of the acetabular component tool is shown as round, but could readily be keyed or any other shape to ensure the proper orientation of the gyroscope holder that holds the gyroscopic unit. 
         FIG. 7  is a perspective view of another acetabular component placement tool with a gyroscopic unit attached to the gyroscope holder in keeping with one embodiment of the present invention. 
         FIG. 8  is a depiction of an acetabular component placement tool in use. 
         FIG. 9  is a drawing of the surgeon observing an image from a radiography unit in keeping with one embodiment of the present invention showing one preferred viewpoint of the radiography unit for use in combination with the gyroscopic unit in precisely positioning the acetabular component about two axes, the abduction angle and the anteversion angle. 
         FIG. 10A  is a drawing of a strike plate in keeping with one embodiment of the present invention. 
         FIG. 10B  is a drawing of a strike plate placed within a cavity of an acetabular component in keeping with one embodiment of the present invention. 
         FIG. 11  is a drawing of another embodiment of the strike plate showing a number of impact points to allow the selection of the appropriate locations on the strike plate for the surgeon to tap with a tapping instrument in order to achieve the desired movement of the acetabular component in situ as it engages the bone. 
         FIGS. 12A and 12B  are diagrams of the relatively harder and relatively softer bone regions that the acetabular component encounters and that greatly add to the difficulty of precise placement and positioning of the acetabular component. These relatively hard and soft bone regions often cause the acetabular component to move in a complex path in reaction to the tapping described herein as part of one embodiment of the present invention. As a result, these hard and soft bone regions are one reason a strike plate having multiple impact points is particularly critical to achieving proper orientation of the acetabular component. 
         FIG. 13  is a perspective view of an embodiment of a disengagement tool to remove an impaction tool. 
         FIG. 14A  is a drawing of a smartphone being used as the gyroscopic unit. It may have an open source or proprietary gyroscope application. The unit may then be placed in a sterile bag as shown for use during the surgical procedure. 
         FIG. 14B  is a drawing of a smartphone gyroscopic unit in the sterile bag of  FIG. 10  wherein the bag is stretched tightly and any excess is folded back and away from the screen so that the screen of the smartphone (or iPod or the like) remains readily visible to the surgeon and the touch-sensitive functionality of the screen remains accessible through the bag membrane. 
         FIG. 15  is a perspective view of a second gyroscopic unit fixed to a point on the patient&#39;s pelvis. 
         FIG. 16  is an image that may be produced by the combination of the positional data from the first and second gyroscopic units reflecting the position of the cup relative to the acetabulum and the plane defined by the face of the acetabulum during a hip replacement procedure in keeping with one embodiment of the present invention. 
         FIG. 17  is a perspective view of a femoral broach handle showing an adjustable mount for a pointer alignment device extending laterally from the handle that can allow adjustments for anteversion rotation of the broach and broach handle as it is inserted and to maintain a pointer directed precisely along the true posterior or true anterior surface of the femur. In keeping with one embodiment of the present invention, this alignment indicator—capable of indicating either or both of the broach longitudinal direction and anteversion orientation—reduces the risk of malposition of the femoral implant which can result in incorrect sizing or femur fracture. 
         FIG. 18  is another perspective view of the femoral broach handle of  FIG. 17  in combination with a broach in place in keeping with one embodiment of the present invention. 
         FIG. 19  is a side view of the femoral broach handle with a laser pointer device attached in keeping with one embodiment of the present invention. 
         FIG. 20  is a perspective view of the femoral broach tool in use with a laser indicator light pointing toward the vicinity of the popliteal space and a gyroscopic unit to read the anteversion of the femoral broach in keeping with one embodiment of the present invention. 
     
    
    
     DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     The detailed description set forth below in connection with the appended drawings is intended as a description of presently-preferred embodiments of the invention and is not intended to represent the only forms in which the present invention may be constructed and/or utilized. The description sets forth the functions and the sequence of steps for constructing and operating the invention in connection with the illustrated embodiments. However, it is to be understood that the same or equivalent functions and sequences may be accomplished by different embodiments that are also intended to be encompassed within the spirit and scope of the invention. 
     In general, minimally invasive techniques for total hip arthroplasty require making a main incision in the hip area of the patient to access the acetabulum of the pelvis, making a portal incision (described by this author in prior disclosures) to facilitate the proper positioning of an acetabular component, properly positioning the acetabular component in the acetabulum by making adjustments of the acetabular component through the main incision and the portal incision, utilizing the main incision to facilitate preparation of the femur to receive a femoral implant, and preparing the femur with a femoral broach to receive the ball that will be coupled with the acetabular component. One major goal is to achieve the proper abduction angle and anteversion angle as shown in  FIG. 1 . 
     One embodiment of the present invention involves an intraoperative system and method of locating the optimal position for the portal incision for a minimally invasive THA, properly positioning the acetabular cup, and properly preparing the femur. The portal incision in such an embodiment, the portal incision is located by making a main incision to access an acetabulum of a patient, using either a blunt or cutting member to forge a path through the patient&#39;s tissues along a trajectory generally perpendicular to the plane defined by the face of the acetabulum, thereby identifying an appropriate portal incision location on the patient&#39;s skin while allowing the surgeon to avoid numerous blood vessels, muscles, tendons, and nerves in the process, making a portal incision at this identified point on the patient&#39;s skin. Then, the surgeon may use the direct, frontal access to the acetabulum created by this portal incision and path to prepare the acetabulum to receive an acetabular cup. This access may be further secured and maintained by using a cannula, trough or spatula device. In such instances, the surgeon may introduce the device to maintain the channel and thereby protect the contiguous tissues from additional injury by placing the device around the tip of the blunt or cutting member and then guide the trough-like device through the portal incision in into the forged path. 
     In some embodiments, the acetabular component or cup may then be properly positioned to greatly improve the likelihood of success and longevity of the component, including attaching the acetabular cup to the end of an acetabular component placement tool and using the acetabular component placement tool to place the cup in roughly the correct position with respect to the pelvis of the patient. Knowing the approximate position of the patient&#39;s pelvis by virtue of the use of at least a semi-secure positioning device, the surgeon may then take a first abduction and a first anteversion reading using a gyroscopic positioning unit aligned with the acetabular component placement tool. The surgeon may then use a radiography unit to take an image of the pelvis containing the newly placed cup and use this image to more accurately determine the position of the cup. 
     In light of this true initial position, the surgeon may then alter the position of the cup incrementally by using a striking tool to tap a contact surface at one or more preformed impact receiving points, wherein the contact surface is in mechanical communication with the cup. The surgeon may taking new abduction and anteversion readings to determine the how far the cup moved relative to the initial position due to the tapping, and then repeat the tapping and reading steps until the cup has reached a proper abduction angle and anteversion angle as indicated by the gyroscopic device display. The proper position for an acetabular cup is defined as a position in which the abduction and anteversion angles are within the predetermined acceptable ranges, as discussed above and widely researched in the literature. 
     This method indeed, among other benefits, allows the surgeon to properly position the cup without having to place any positioning pins in or on the patient, thereby avoiding the pain, risk of infection, and risk of pin movement that may accompany the use of positioning pin. This technique also eliminates the use of line of sight transmitters, e.g., RF type, which can be disrupted during the typical movements of personnel in and around the operative field, or by blood contacting the transmitters, or the computer crashing. 
     In some embodiments of the present invention, the femur may be prepared by a femoral broach mounted to a broach handle that involves a striking post and a straight-line pointer means. The means could be a light or laser pointer on an adjustable mount that is mounted on the handle to allow moving the pointer around, toward or away from, and/or along the handle or striking post. It can be locked into place once properly positioned to point along an optimal line, such as along the back of the patient&#39;s thigh generally toward or medial to the popliteal space of the knee. The surgeon then observes that the pointer continues to point at the chosen target in the direction of this chosen line while he or she repeatedly strikes the broach handle or striking post, thereby ensuring that the femoral broach itself is properly oriented and aligned with the femur. 
     I. Positioning the Portal Incision 
     In one embodiment of the present invention, the surgeon locates the optimal position for the portal incision  244  by cutting from the inside out, or from within the main incision, along a trajectory away from the acetabulum  202  perpendicular to the plane defined by the face of the acetabulum. This technique allows the surgeon to locate a safe internal starting point and a safe path directed out to the under surface of the patient&#39;s skin better avoiding certain critical structures (veins, arteries, tendons, muscle, sciatic nerve, other nerves), forging a safe path or course around these structures while “sighting” or directing from inside or from within the main incision  242 . Then, once the starting location is identified adjacent to these critical structures as observed by the surgeon through the main incision  242 , a rigid, sharp or blunt or generally tubular body  100  is inserted adjacent to and without damaging these structures. The body  100  may be either curved as shown in  FIGS. 2A and 2C , or angled as shown in  FIG. 2B . In some embodiments, the body  100  is generally tubular and a flexible tool  108  is passed through the hollow of the body and used to cut a path in the direction of the skin  240  distal to the main incision  242  to create an acetabular portal incision  244  from the inside out. In other embodiments, the body  100  itself has a sharp or blunt front end that may be used to cut or forge a path in the direction of the skin  240  distal to the main incision  242  to create an acetabular portal incision  244  from the inside out. In both scenarios, the path may be forged adjacent to and without damaging these critical structures in a manner best achieved in this inside-out method. 
     That is, by contrast, existing methods generally establish a location for the acetabular portal incision from visual cues or measurement made exclusively outside of the patient&#39;s body. With such outside-in methods, however, a trajectory is created and forged in which the surgeon cannot readily observe and avoid these critical structures in order to alter the path to accommodate variations in anatomy. These methods, therefore, typically cause the surgeon to risk encountering critical blood vessels, muscles, tendons, and nerves. Severing any of these can cause serious complications and unnecessary bleeding. Indeed, most outside-in methods lend to misjudging the proper location of the portal incision due to the inaccuracies in the rotational orientation of most common external visual guides. This error in rotation can even lead to perforating the femur anteriorly or piercing the sciatic nerve posteriorly. All of this may be avoided by the several inside-out methods described herein in keeping with the present invention. 
     In one embodiment of the present invention, therefore, a tubular body  100  is equipped on one end with a linear sighting or directional mechanism  104  to maintain a trajectory generally perpendicular to the plane P of the face of the acetabulum  202 . As shown in  FIG. 2A , in a preferred embodiment, the tubular body  100  is a hollow rod having a first portion  101  with a first opening  103 , a second portion  102  adjacent to the first portion  103 , the second portion  102  having a second opening  107  in communication with the first opening  103 , and a bend  109  connecting the first and second portions  101 ,  102 . In other words, the first portion  101  bends into the second portion  102 . 
     The first portion  101  of the tubular body  100  is generally cylindrical and straight defining a first axis A and may serve as a handle. The first opening  103  may be positioned at or near the top or terminal end of the first portion  101  opposite the second portion  102 . In some embodiments, the first opening  103  may be on the side surface of the first portion  101 . In some embodiments, the first opening  103  of the tubular body  100  may be on an auxiliary shaft  111  protruding outwardly from the first portion  101  at an acute angle. In some embodiments, the first portion may comprise multiple openings for the surgeon to choose from. 
     The second portion  102  allows the tubular body  100  to be properly positioned adjacent to the acetabulum in order to identify and create a path towards the location of the portal incision  244 . The second portion  102  comprises a lead  115  and a directional tool  104  coaxially aligned with the lead, the lead and the directional tool defining a second axis B. In some embodiments, the lead  115  comprises a second opening  107  perpendicular to the second axis B. Due to the bend  109 , the first axis A and the second axis B are non-parallel to each other. In some embodiments, the first axis A and the second axis B may form an acute angle with each other. In some embodiments, the angle between axis A and axis B is between 25° and 75°, in a preferred embodiment this angle is within the range of 35° and 65°. In some embodiments, the angle between axis A and axis B may be greater than 90° but less than 180° as shown in  FIG. 2C . This directs any tool traveling parallel to or along the second axis to move towards the surface of the skin  240  when the tubular body is properly placed in the main incision  242 . 
     In some embodiments, the bend  109  creates a tubular body  100  having an overall “J”-shape or hook-shape appearance as shown in  FIGS. 2A and 2B . Due to the small amount of space afforded by the main incision in such surgeries, in some embodiments, the bend  109  may have a tighter curvature giving the external appearance of the tubular body more of a “T”-, “L”-, or “V”-shape as shown in  FIG. 2C . 
     That is, preferably, the main incision should be made as small as possible. Therefore, utilizing a tubular body  100  with a “tight” bend  109 , such as in the “V”-shaped embodiment in  FIG. 2C , would minimize the overall lateral dimensions, or width, of the tubular body  110 ; thereby, allowing for a smaller main incision. With a “tight” bend, however, a flexible tool  118  may need to be particularly flexible to make the turn as easily as in a hook shaped bend. Therefore, the back wall of the bend  119  may instead have a rounded or curved shape, gradually turning away from the directional tool  114  and up toward the second opening  117  to guide the flexible tool  118  to make the turn at the bend  119  and proceed towards the second opening  117 . 
     The tubular body  100  may further comprise a directional tool  104  attached to the second portion  102  in a way that it defines a line of sight or a trajectory that is parallel to the second axis B. In other words, the lead  115  and the directional tool  104  are coaxially aligned. In some embodiments, the trajectory is along the second axis B as shown in  FIGS. 2A and 2B . In another embodiment, the middle of the trial cup or the middle or the backside of the attachment portion of the acetabular component placement tool may comprise a feedback mechanism to facilitate this sighting by the directional tool  104  of the tubular body  100  and ensure that the tubular body  100  was in the correct position. 
     Alternatively, the directional tool  104  could be a laser pointing device, emitting a visible laser light  106  or the like. In some embodiments, the directional tool  104  may emit laser light  106  bidirectionally. For example, the directional tool  104  may be a cylindrical device emitting laser light  106  from both ends in opposite directions but along the same path. One end of the directional tool  104  could then emit a laser light  106  pointing to the middle of the acetabulum  202 , the middle of the trial cup that the surgeon may use for such positioning purposes, or the backside of the attachment portion of the surgical tool  300  that attaches to the trial cup and holds it in place for such positioning purposes. 
     In such an embodiment, the opposite end of the directional device  104  would then emit a laser light  106  along the trajectory to illuminate a safe path to the portal incision  244  location. Alternatively, the safe path may be illuminated by a lighting device that is fed through the hollow of the tubular body  100 , such as an optical fiber or the like, and an imaging device may similarly be fed through the tubular body  100 . 
     In some embodiments, the directional tool  104  is configured to be removable from the tubular body  100 . 
     Due to the hollowness of the tubular body  100 , the tubular body  100  can receive a flexible tool  108  via the first opening  103  that can be fed through the first portion  101 , to the second portion  102 , and out the second opening  107 . Therefore, a diameter of the flexible tool  108  is smaller than a diameter of the first and second openings  103 ,  107 . As the flexible tool  108  exits the second opening  107  it follows the path of the trajectory established by the directional tool  104  parallel to or along the second axis B. The flexible tool  108  may comprise a cutting instrument  150  at one end to cut through non-critical tissues or move aside the critical tissues to create a path towards the skin  240  where the portal incision  244  is to be made. In some embodiments, the flexible tool  108  may have a blunt end. 
     In addition, the flexible tool  108  may be a guide wire that traverses the path established by the trajectory towards the portal incision  244  while bypassing the critical tissue. A cannula, scoopula, sleeve, spatula, or similar guide tool  120  can be passed over or along the guide wire to maintain the path access to the acetabulum and/or to put the guide tool  120  in the proper position and orientation relative to the acetabulum for performing other techniques in the surgery without damaging critical tissue. In this embodiment, a cannulated, blunt, or sharp trocar, preferably approximately 8-10 mm in diameter, or other suitable tissue-protecting sleeve can be passed over this guide wire. 
     The flexible tool  108  can feed through the tubular body  100  and cut through the subcutaneous tissue and simply tent the skin  240 , thereby identifying the portal location  244 . While the skin  240  is tented, an apex is created and a 1-1.5 cm incision is made at this apex. Alternatively, still in keeping with the present invention, the surgeon may prefer to select a feed-through cutting member that is sharp enough and rigid enough such that the cutting member itself could actually cut through the skin at this optimal incision point  244 . 
     The cutting member  150  may then be fed through the skin a short distance. This tubular body can be proportioned so that a 4-12 inch cannula  121 , or a trough  120  as shown in  FIGS. 3-5 , can then be placed over its tip at a distance of about 1 cm (or enough to hold it in place) and the cannula  121  can then be led through the same safe soft tissue path thus avoiding veins, which in the common outside-in approach are typically severed and cause unnecessary bleeding. In such embodiments, the tip  124  or cutting member  150  of the flexible tool  108  may have a diameter that is slightly smaller than the diameter of the remainder or main body of the flexible tool  108  so that the junction where the main body transitions into the tip  124  defines a rim or ledge  122  extending radially outward from the outer surface of the tip  124 , as illustrated in  FIG. 3 . 
     The flange or ledge  122  may be slight, approximately 0.5 mm, for example, and may be located about 1 inch or more or less from the free end of the tip  124 . The cannula  121  can be placed over the pointed tip  124  as it penetrates the skin  240  or otherwise passes through the portal incision until the cannula or spatula reaches the ledge  122 . The sharp edges of the thin metal or plastic spatula or cannula  121  will thereby be covered as it is drawn through the soft tissue pathway defined by the flexible tool  108 . 
     In another embodiment, the working cannula can also simply be fed over a smooth trocar that is directed along the safe trajectory towards the skin. The skin is then tented, and an incision is made to permit the trocar to be accessible for mounting of and guidance of the cannula, spatula, or trough. In yet another embodiment, the flexible tool  108  may be a thin-walled cannula or tissue-protecting sleeve, such as having a wall thickness of approximately 1-3 mm, an outer diameter of approximately 8-12 mm, and a length of roughly 10-40 cm. In this way, the cannula or trough member that maintains the just created path for use in preparing the acetabulum may be introduced from the inside out. 
     In some embodiments, the tubular member  100  is indeed not hollow but solid instead, as illustrated in  FIG. 2C , having its own pointed or blunt tip  126  projecting from the lead  115  that may be used to forge the path along the generally perpendicular trajectory. The second end  102  of the member  100  may then have a ledge  128  between the lead  115  and the tip  126  that may then receive the end of the cannula or spatula member  120  and thereby act as a cannula introducer in a similar manner as discussed above. In some embodiments, the ledge  128  of the second end  102  may taper towards the tip  126 . In such an embodiment, the main body of the second end  102  may have a diameter that is slightly larger than a cannula, scoopula, spatula, sleeve, or similar type of guide tool  120  and the tip  126  may have a diameter that is smaller than any guide tool  120 . This allows any guide tool  120  to slip over the end  126  and stop where the opening of the guide tool  120  is substantially the same size as the diameter of the second end  102  (i.e., at the ledge  128 ). In this sense, a single second end  102  can be used for different guide tools  120  having different sizes. 
     As mentioned above, the fixed trajectory created by the outside-in technique does not afford the surgeon with the opportunity to observe critical tissues and critical variations in anatomy or a misjudged anteversion orientation of an externally fixed sighting guide, all of which is avoided by the inside-out technique disclosed herein with reference to one embodiment of the present invention. 
     That is, this novel inside-out approach in this embodiment of the present invention allows the surgeon to actually see these vital structures from within and direct the potentially damaging hook or trocar through less vital tissues, such as fatty tissues, and particularly away from and around the vital structures and tissues. This visualization of the soft tissue environment can be additionally facilitated by optical fiber illumination and/or digital imaging of the environment to determine the alternative paths through the soft tissue along the trajectory generally perpendicular to the plane defined by the face of the acetabulum. In one embodiment, the illumination and imaging fibers can be passed through the cannulated hook. The fiberoptic light may also illuminate the skin from the inside out to indicate where to make the portal incision. The incision can be made on the brightest portion of the skin. 
     In some embodiments, the second portion  102  or  130  of the tubular body  100  or  110  may further comprise a joint or a hinge  112  or  125  to connect the first portion  101  to the second portion  102 . The hinge  112  or  125  allows the directional device  104  or  114  and the lead  115  or  127  (together defining axis B) to tilt in such a way so as to change the angle between axis A and axis B. The tilt of axis B relative to axis A may be controlled by a control mechanism  113  or  129  to adjust the second portion  102  relative to the first portion  101 . Preferably, the control mechanism  113  or  129  is a dial located at the top of first portion  101  or  132  of the tubular body  100  or  110  opposite the second portion  102  or  130 . The control mechanism  113  or  129  may also have a locking mechanism (not shown) to lock the directional device  104  or  114  in place once the proper angle has been established. The locking mechanism may restrict or prohibit the movement of the control mechanism  113  or  129 . 
     In other embodiments, the surgeon may tilt the first portion  101  or  132  of the tubular member during the procedure to manipulate the blunt or cutting end through the soft tissue and create the optimal path. In such embodiments, the surgeon may be able to continuously or periodically adjust the directional device  104  or  114  using the control mechanism to insure that the blunt or cutting end  150  continues to travel along the trajectory generally perpendicular to the face of the acetabulum. 
     The control mechanism  113  or  129  may utilize a connecting device (not shown), such as a flexible cable, rigid cable, rod, and the like, to operatively connect to the directional device  104  or  114 , the lead  115  or  127 , and/or the hinge  112  or  125 . Movement of the control mechanism  113  or  129  can increase or decrease the length of the connecting device so as to cause the directional device  104  or  114  and the lead  115  or  127  to tilt. Use of the control mechanism  113  or  129  allows the surgeon to make very precise adjustments to the directional device  104  or  114  so as to point the directional device  104  or  114  to the center of the acetabulum  202  with minimal movement of the tubular body  100  or  110 . 
     II. Positioning the Acetabular Component 
     As discussed above, proper positioning of the acetabular component  400  is critical for the prosthesis to function up to its capacity, but current methods are inaccurate, risky, and time-consuming. An acetabular component  400  may be any device designed to fit inside the acetabulum of a patient. By way of example only, an acetabular component  400  may comprise a cup, a trial cup, a reamer, a strike plate, and the like. 
     In one example, an acetabular component placement tool  300 , such as the standard cup holder/alignment guide shown in  FIGS. 6 and 7 , is commonly used in the medical profession to place and/or align the acetabular component  400  in the typical “best guess” position. Historically, because of the time consuming and technically challenging nature of obtaining an intraoperative x-ray, the true position of the component was not known until a recovery room, or office, x-ray was taken. The generally achieved success rate (achieving accurate positioning) is sixty percent (60%) (Rubash, et al.). Unless a very severe error was identified, nothing was done, and the patient carried the risk of early failure of the hip arthroplasty. If the cup position was too steep, then the plastic bearing surface could see excessive load and wear out prematurely, requiring corrective operation. If the angle was too shallow, then impingement of the femoral neck on the anterior rim of the acetabulum could result in dislocation. 
     Using the very recent advances in imaging technology, i.e., the availability of computer and or digital radiography, now makes it possible to obtain an accurate intraoperative image within a few seconds, such as approximately ten (10) seconds, to approximately one hundred twenty (120) seconds. This image (film or fluoroscopic image, or possibly even CT or MRI) demonstrates the result of the “first try” or “best guess” position. Thus, in one embodiment, this image of the patient&#39;s anatomy is used in conjunction with a gyroscopically enabled guide. 
     Having this intraoperative measurement, the surgeon now has an opportunity to make an immediate correction. At present, the sighting techniques with the traditional “best guess” instruments required one or more additional x-rays to confirm the correction. In addition, the traditional instruments were not constructed to permit careful, precise, known degrees of adjustment. 
     The present invention offers a new method and tool incorporating application for gyroscopic technology that provides a significant improvement when compared with the current sighting approach, i.e., sight, guess again, repeat the x-ray, and even possibly requiring that these steps be repeated again. 
     The present invention also eliminates significant cost, a critical factor in today&#39;s health care system. There is no pre-operative CT scan, avoiding potentially damaging radiation exposure, especially in younger patients and particularly women of childbearing age. There is no upfront cost to the hospital in the form of capital investments of up to a million dollars or more, there is virtually no disruption of the desired workflow as the required intraoperative image can be obtained in under two minutes, interpreted in less than thirty seconds, and can be acted upon immediately thereafter. 
     In the preferred embodiment, a gyroscopic unit  402  may be placed in a sterile holder/container and affixed to a surgical tool  302 , such as a straight or carefully angled cup holder/alignment guide, as illustrated in  FIG. 7 . This upgrades the traditional directional device to a metered tool providing improved estimates during initial positioning of a prosthesis. An intra-operative radiographic image of the then-present position is achieved during initial estimated placement. The radiographic measurement is then used as part of the method for achieving successful positioning or the basis for making an intra-operative adjustment. Now, upon obtaining measurements from the gyrometer and an image from the intra-operative radiographic unit, the “best guess” positioning of the acetabular component  400  relative to the acetabulum  202  can be improved, the desired positioning can be determined and quantitated as to the correction required for proper placement of the acetabular component within the acetabulum. 
     In order to improve the accuracy, reduce the risk, and work efficiently, besides the proper positioning of the portal incision  244 , some embodiments of the present invention utilize gyroscopes removably mounted on surgical tools  302  involved in acetabular component placement, referred to as an acetabular component placement tool  300 , to provide a metered approach for adjusting the acetabular component in the acetabulum. Examples of surgical tools  302  that can be used in the present invention include, but are not limited to, a trial cup holder, a cup holder/alignment guide, an impaction tool, a reamer unit, and the like. 
     In general, an acetabular component placement tool  300  comprises a surgical tool  302  used in positioning the acetabular component  400 , and a gyrometer or gyroscopic unit  402 . The surgical tool  302  has a proximal end  304  connected to a distal end  306 . The proximal end  304  is the end directly attached to or directly associated with the acetabular component  400 . The distal end  306  is the end that the surgeon can grasp to move the tool  302  in order to adjust the acetabular component  400 . The distal or upper end  306  may comprise a handle  308  to facilitate movement of the surgical tool  302 . 
     In the preferred embodiment, a gyroscope  402  may be attached to the distal end  306 . In some embodiments, the gyroscope  402  may be attached to the handle  308 . It is anticipated, based on the cost of gyroscopic technology, that only a nominal cost is required to add such a metering system, i.e., the “gyrometer,” to many existing surgical instruments with only minor modifications. Indeed, in some embodiments, a single gyroscope  402  may sense and display the angular orientation of the acetabular component  400  in two or all three of the traditional three (X, Y, and Z) planes. In other embodiments, two or three separate gyroscopes  402  may be employed to sense and indicate the angular orientation of the acetabular component  400  in each of the two or three orthogonal metered planes, separately. In this way, the surgeon can feel further assured that each sensor will most accurately detect the orientation or relative orientation within the chosen metered plane (e.g., the Y plane), exclusive of any movement in either of the two other planes (i.e., the X and Z planes). 
     In some embodiments, the gyroscope  402  may be integrally formed with the surgical tool  302 . In other embodiments, the gyroscope  402  may be removably mounted to the surgical tool  302  using a gyroscope holder  404 . The gyroscope holder  404  may be an elongated rod having a first end  408  that attaches to the surgical tool  302  and a second end  410  opposite the first end  408  that attaches to the gyroscope  402 . The surgical tool  302  may comprise a plurality of holes  406  at different levels. The holes  406  can be of any shape so long as the gyroscope holder  404  has a cross-sectional configuration keyed to fit into the holes  406  securely. For example, the holes  406  may be triangular, rectangular, hexagonal, star-shaped, circular with a notch, and the like. One end  408  of the gyroscope holder  404  would then have a cross-sectional shape corresponding to the shape of the hole  406  so as to fit tightly and securely into one of the holes  406  without being able to rotate. This allows the surgeon to attach a gyroscope  402  to the surgical tool  302  in such a way as to view the gyroscope readings. Adjustment of the holder, and thus the gyroscope, could also be carried out in order to facilitate a “zeroing effect,” creating a true read-out rather than a relative number. 
     In some embodiments, the gyroscope  402  may be incorporated in a conventional mobile electronic device  1000  containing a gyroscope  402 , such as a smart phone, iPod touch, iPhone, personal digital assistant, and the like as shown in  FIGS. 14A and 14B . These common mobile electronic devices can be installed with an application for converting the yaw, pitch, and tilt or roll of the gyroscope  402  into the abduction and anteversion of the acetabular component  400 , and the tile of the patient&#39;s pelvis. 
     The gyroscopic unit  402  may be a gyrometer, inclinometer, accelerometer, magnetometer or compass, inertial sensor, GPS (Global Positioning System) unit, or an optical, infrared, or RF sensor. A gyroscope or gyrometer may be preferred in some embodiments in that such units often measure relative movement in two or three dimensions and in that many commercial devices have gyrometer units that can provide high-resolution measurements. 
     The gyroscope  402  can measure its relative position in three-dimensional space. Thus, any movement in the X, Y, and Z direction can be read by the gyroscope  402 . When the gyroscope  402  is attached to a tool or a patient&#39;s hip or thigh, one or more reference angular readings of the tool or patient in three-dimensional space may be communicated to the surgeon by the gyroscope  402  to monitor any movement of the patient&#39;s pelvis. When associated with a smart phone or other computing device, the gyroscope  402  can display, announce, or otherwise indicate its relative position. The surgeon can set the initial position as the origin and calculate the amount of deviation from the origin necessary for correct positioning and move the surgical tool attached to the gyrometer  402  until the proper readings are reached. Alternatively, the correct positioning may be established as the origin and the gyrometer  402  may indicate the amount of deviation from the origin. Therefore, the gyrometer  402  can be moved until its readings reflect that it has reached the origin. 
     As mentioned above, in some embodiments, a gyroscopic unit  402  may be superior to a standard inclinometer or magnetometer. A standard inclinometer allows angular readings and correction relative to only the vertical axis. This single reading by itself cannot correctly position the acetabular component  400  to minimize wear and reduce risk of dislocation. Similarly, a magnetometer typically allows angular readings only relative to a near-linear magnetic field, such as the Earth&#39;s magnetic field. The dual-axial or tri-axial reading from the gyroscopic unit  402 , by contrast, can inform the surgeon as to the relative movement of both the abduction angle (in a first plane) and the anteversion angle (in a second plane perpendicular to the first plane), as well as the tilt of the pelvis (in the third and remaining orthogonal plane). 
     Additional precision can be achieved if the pelvic tilt is controlled. The holder may also have a hinge  702  and set screw  704  so that the surgeon may “zero” the anteversion angle reading simply be adjusting the hinge  702  and then tightening down using the set screw  704  when the anteversion reading is just as the surgeon prefers. Examples of such hinge  702  and set screw  704  are illustrated in  FIG. 7 . 
     In the preferred embodiment, the gyroscopic unit  402  may be enclosed in a container  1002  to reduce and/or eliminate cross-contamination between the gyroscopic unit  402  and the patient. For example, the gyroscopic unit  402  may be wrapped inside a sterile bag. This also makes cleaning and reusing the gyroscopic unit  402  easy. 
     In yet another example that is still in keeping with some embodiments of the present invention, two or more gyroscopes  402 ,  403  may be used for additional reference points to compensate for movement of the patient&#39;s body, or the pelvis, rather than the movement of the acetabular component  400 . For example, a second gyrometer  403  may be used as a second reference point. The second gyrometer  403  may be mounted to a point on the patient&#39;s anatomy, such as a point on the patient&#39;s pelvis  200 , with a rod (not shown) or some other type of holder that would facilitate proper positioning of the acetabular component  400 . In some embodiments, the second gyrometer  403  may be attached directly to the patient&#39;s anatomy without a rod, for example, with an adhesive that would still permit the surgeon to read the second gyrometer  403 . The direct attachment may be removable so as to remove the second gyrometer  403  when the surgery is complete. The surgeon may then be able to verify to what degree the patient&#39;s pelvis  200  has moved since the initial readings were taken from both the first and second gyrometers  402 ,  403 . The surgeon may then use this degree of movement of the pelvis  200  to recalibrate the first gyrometer  402  or otherwise take such adjustments into account when calculating his or her target readings on the first gyrometer  402 , which, in combination with the readings from the second gyrometer  403 , is reflective of the position of the acetabular component  400  in relation to the acetabulum  202  of the patient&#39;s pelvis  200 . In some embodiments, first and second gyrometers  402 ,  403  may be in communication with each other so that the first gyrometer  402  receives the readings from the second gyrometer  403  and the first gyrometer  402  displays its readings regarding the positioning of the acetabular component  400  after compensating or adjusting for the movement of the pelvis as determined by the second gyrometer  403 . 
     In some embodiments, the two gyrometers  402 ,  403  may communicate with each other or with a local computer  800  so that the changes in target readings of the first gyrometer  402  (i.e., the target position of the prosthetic cup) may be tracked, communicated, and even displayed on a monitor  802  to indicate to the surgeon how the patient&#39;s pelvis may shift during the procedure. As shown in  FIG. 16 , computer software can transform the readings and radiographic image of the actual, relative orientation of the acetabulum  202  and acetabular component  400  into a two- or three-dimensional image representation of the cup  300 ′; acetabulum  202 ′; and plane  203 ′ defined by the face of the acetabulum combination and display it on a screen  802  either on one of the gyrometer units  402 ,  403  or on the local computer  800  in real time so that the surgeon may get a good sense of how the acetabular component  400  is located and moving relative to the acetabulum  202  during the procedure as the surgeon moves the acetabular component  400  in at least two dimensions relative to the acetabulum  202  (i.e., in the abduction and in the anteversion directions) and as the patient&#39;s acetabulum  202  itself may move in any direction during the procedure. 
     In some embodiments, instead of, or in addition to, displaying the readings of the gyrometer  402 , the gyrometer  402  may announce the readings orally, or use a tone or some other aural indicator, so that the surgeon does not have to take his eyes of the patient to read the gyrometer  402 . The gyrometer  402  can announce either the current location so the surgeon knows where he needs to move the acetabular component  400 , or the gyrometer  402  can announce the type of movements the surgeon needs to make the properly position the acetabular component  400 . 
     Minor adjustments may be made with an impaction tool  600 , such as a strike plate as shown in  FIGS. 10A, 10B, and 11 . An impaction tool  600  is configured to protect the acetabular component  400  as the acetabular component is being struck for proper positioning. In some embodiments, the impaction tool  600  may comprise multiple striking ports  700 , such as corrugations, dimples, depressions, divots, recesses, and the like impaction surface on the inside  602 . The outside surface (not shown) of the impaction tool  600  contacts the inside of the acetabular component  400  and creates a high-friction contact. Due to the high friction, movement of the impaction tool  600  causes movement of the acetabular component  400 . Therefore, small increments of precise adjustment of the acetabular component  400  can be made by tapping on the impaction tool  600  without damaging the acetabular component  400 . Such precise and incremental movements are critical, particularly because of the combination of hard and soft bone surfaces that the acetabular component  400  must engage with and seat into. The impaction tool  400  also, in some embodiments, may have regions through which the surgeon may see through to the bone to confirm that the cup is fully seated. 
     In some embodiments, the impaction tool  600  may be a total contact shell mating with the inner concavity of the acetabular component  400  and secured via a central screw. The exposed surface of this shell presents multiple striking ports  700  on the inner face  602  to assist with fine adjustments of abduction or anteversion as the acetabular component  400  is seated. The surgeon may alternately strike the off center ports  700  and then the central port, depending upon the changing position of the prosthesis as it is seated. It is important to appreciate that the bone density typically varies around the rim, along the walls and at the dome of the prepared acetabulum as shown in  FIGS. 12A and 12B . For example, the acetabulum may have hard areas  900  and soft areas  902 . Because of this variability, the prosthesis, if not monitored and controlled as it is seating, will follow the course of least resistance. Following that course creates a high risk of component malposition. Traditional positioners provide only for a central striking surface and a handle to generate a rotational force at a point removed from the implant itself and therefore not as precise as needed. The latter, central striking only technique, typically requires disengagement and re-engagement as the cup approaches final seating. This allows for the possibility of losing some pressfit as the bone is compressed with the first seating and then can lose some “stiction friction” or press fit upon reseating into the newly compressed bone. 
     In some embodiments, the impaction tool  600  may further comprise a flange  608  at the opening of the impaction tool  600 . The flange  608  can be one continuous ring around the open edge of the impaction tool  600  parallel to and in the plane of the strike plate opening. Alternatively, the flange  608  may be short segmented flanges intermittently spaced apart around the edge of the opening. These flanges  608  can further serve as striking points to permit greater angular momentum for moving the actual acetabular component  400 . In some embodiments, the flanges  608  may comprise striking ports  700 , such as dimples, recesses, divots, depressions, corrugations, or other modifications to facilitate striking of the impaction tool  600 . The striking elements in all cases are situated and construed in a manner that protects the surfaces of the acetabular prosthesis. 
     In some embodiments, the surgeon may tap the flange  608  with the impaction tool  600  while the elongated handle remains attached to the acetabular component. In other embodiments, the surgeon may remove the elongated handle so that the surgeon may have numerous other striking ports  700  to select to tap with a striking tool (not shown). In such an embodiment, the strike plate or acetabular component  400  can have a keying surface, such as one or more component keying features  605 , so that the surgeon may quickly and easily re-seat the elongated handle within the acetabular component  202  from time to time to take new abduction and anteversion readings from the gyroscope  402 . 
     For example, the component  202  may also be keyed, such as with one or more matching keying members  405 , to mate with the keying surface of the impaction tool  600  in order to re-seat the proximal end  304  of the tool  300  in an identical orientation. The gyrometer holder may also be keyed in order to re-seat it in an identical orientation. 
     In some embodiments, a disengagement tool  1300  is provided for the surgeon in case the acetabular component is so firmly impacted that simply striking off center will not result in the desired repositioning and may get stuck in the hard and soft bone material  900 ,  902 . That is, surgeons may find the cup or other component may get stuck or frozen within the acetabulum making it difficult or nearly impossible to adjust the component any further. The surgeon may then use the disengagement tool  1300  shown in  FIG. 13  to carefully and minimally, in a controlled manner, pry the component, such as the impaction tool  600 , loose so that he or she may then re-institute the routine described above in a further attempt to properly position the component using the radiographic unit and/or the gyroscopes. 
     The disengagement tool  1300  may comprises a handle  1302  and an arm  1304  attached to the handle  1302 . At the end opposite the handle  1302 , the arm  1304  may branch or fork into multiple prongs. The impaction tool  600  may comprise a plurality of fenestrations  604 . A first prong  1306  may be configured to engage a first fenestration. A second prong  1308  may be bent at an angle relative to the arm  1304  and/or the first prong  1306  so as to engage a second fenestration. In some embodiments, the first and second prongs  1306 ,  1308  may be configured so that the first prong  1306  can engage the first fenestration while at the same time the second prong  1308  is able to engage a second fenestration. This can improve the leverage of the disengagement tool  1300  to more easily remove the impaction tool  600 . To further improve the leverage, additional prongs may be added, one or more of the prongs may be adjustable or extendable to accommodate a number of feature configurations on the accessible surface of the impaction tool  600 . In some embodiments, the disengagement tool  1300  may be configured to engage the striking ports  700  to remove the impaction tool  600 . 
     The handle  1302  may be any shape. In some embodiments, the handle  1302  may be planar. A planar surface could provide a striking surface to controllably move or remove the impaction tool  600 . In some embodiments, the handle  1302  may comprise contours so as to be ergonomically shaped to facilitate grasping of the handle  1302 . 
     Example 1 
     Generally, when using an acetabular component placement tool  300 , start with the “Best Guess” approach (using the traditional “Sighting” Guide approach, plus the Cup Holder/Alignment Guide), obtain a radiographic or fluoroscopic image, and then use one embodiment of the present invention to make precise adjustments. 
     For example, once all of the proper incisions have been made and the acetabular components  400  is initially put in place with an acetabular component placement tool  300 , the present settings of abduction and anteversion are read from the gyroscopic device  402 . An imaging device  804 , such as those used in radiographic or fluoroscopic imaging, can be used to create a radiographic or fluoroscopic image. For example, the imaging device  804  may be an x-ray machine emitting x-rays  806 . From the radiographic imaging, the degree of abduction and anteversion needed for proper placement of the acetabular component  400  can be determined. Then, as the acetabular component placement tool  300  is shifted in the desired direction(s), the gyroscopic device  400  displays the real time changes in degrees so that the surgeon knows how much movement has been made, and how much more movement in a particular direction is still required. This reading, in reference to the starting position, gives the surgeon precise affirmation that the ideal position for stability and durability has been achieved. 
     The application of the gyroscopic indicator offers a reading, a numerical equivalent, that records the position in space that corresponds to the instant positioning confirmed on x-ray. The correction can then be made. Precise adjustments in the two critical planes (abduction and anteversion) can now be guided by observing the gyroscopic readout. For example, the readout can be calibrated to the amount of correction desired in each plane and noted to be correct when reading zero for abduction and anteversion. Another embodiment would be to set the gyroscope at the measured abduction and anteversion and simply correct or change the component position to the desired reading which would then indicate the desired position has been achieved. 
     Example 2 
     In yet another embodiment, the best guess position can be made more precise by applying the present invention to the standard cup holder/alignment guide and, rather than relying on line of sight, i.e., identifying a neutral or zeroing orientation that at present is simply “sighted” in relation to operating room structures (a corner of the room, a vertical line of tiles on the wall, or any nearby straight vertical object) or imprecise anatomical landmarks (patient&#39;s trunk, shoulder, opposite kidney). That is to say, that the gyroscopic indicator is capable of indicating true vertical for the upright part of the guide and true zero or neutral for anteversion. After cup placement in the orientation directed by the combined references of the present invention connected (physically or remotely) to the recently redesigned alignment guide, the guide is then removed. Screws or a trial liner may then be placed. A femoral trial may also be placed in the best guess position either before or after placing the acetabular component. An x-ray or fluoroscopic image is then obtained. 
     Those “corrected numerical” readings are used when placing the actual acetabular component. The instrumented portion of the reamer handle can then be transferred to the standard alignment guide. 
     Example 3 
     This example is similar to Example 1 above, but including an attached “gyrometer.” The reamer basket (not shown) itself can act as a surrogate for the acetabular component  400 . The gyrometer  402  settings can then be noted, an x-ray taken, and any corrections identified by measuring angles on the x-ray. This could be considered a way of calibrating the gyrometer  402 . When returned to the same position (as indicated by the subsequent gyrometer  402  readout), correct acetabular component  400  positioning is then achieved by placing the acetabular component  400  in position, which results in corrected gyrometer readings. 
     By using a digital gyroscopic unit, the surgeon can quantify the orientation in space of the acetabular component greatly improving on the “best guess” orientation in which the surgeon might otherwise eyeball the positioning. Clinical research to date (including, Rubash, et al.) confirms a 40% error rate with current “best guess” in which the surgeon does not use such digital sighting or directional instruments. 
     The combination may create an advantage, including by avoiding the need for the unreliable “line of sight” relative referencing or the booting and rebooting of a computer, both of which take substantial time and have been cumbersome and unreliable. Indeed, these cumbersome and unreliable techniques have been abandoned at many centers. As stated, forty percent (40%) of the time, the position will be outside of the desired range and a correction will be desirable. The data indicates that the success rate using the intraoperative imaging and adjustment methods of the present invention can be improved from sixty percent (60%) to almost ninety-nine percent (99%)—and this significant success rate may be produced using minimally invasive surgery procedures. 
     Some embodiments of the present invention also may eliminate the need for reference pins in the pelvis as such pins can loosen, change position, and diminish precision. The pin sites can become infected and require treatment with costly and risky antibiotics. A persistent pin site infection could result in migration of bacteria to the new prosthesis with disastrous results. While placing pins there is risk to nearby nerves and blood vessels. Numbness, weakness, or unnecessary blood loss could occur. There is also a price to pay in terms of time and materials. Clearly, avoiding reference pins offers a significant advantage. 
     III. Positioning the Femoral Broach 
     In some embodiments of the present invention, the femur  220  is prepared by a femoral broach tool comprising a femoral broach  1401 . The femoral broach  1401  may be mounted to a broach handle  1400 , which comprises an elongated connecting member  1402 . A striking post  1403  then may be connected either to the connecting member  1402  or directly to a portion of the femoral broach  1401  to allow the surgeon to strike the striking post repeatedly until he or she has displaced the appropriate amount of bone material from the femur to leave room for the prosthesis and any associated mounting structures and cementing material. 
     The lengthwise orientation of the femoral broach  1401  during this process is critical to the successful preparation of the femur  220  and ultimate positioning of the prosthesis. In previous methods, the surgeon lined up either the connecting member  1402 , the striking post  1403 , or the hammer itself with line of sight methods previously disclosed by Applicant in considerable detail. In short, this often entails envisioning the femoral broach  1401  to be in line with the striking post  1403  and attempting to keep the striking post  1403  therefore in line or parallel to some straight line along the patient&#39;s leg or other straight line in the operating room that serves as a proxy to the centerline of the patient&#39;s femur  220 . 
     As shown in  FIGS. 17 through 20 , another aspect of the present invention is the femoral broach handle  1400  being equipped with a more precise alignment means to visibly align the femoral broach  1401  during the bone displacement. The femoral broach handle  1400  comprises an elongated connecting member  1402  defining a central axis C (which defines the line of attack), attached to a striking surface, platform, or post  1403 , to hold and drive the femoral broach  1401  into the femur, and an adjustable mount  1404 . The adjustable mount  1404  is connected to the connecting member  1402  in such a way as to allow the adjustable mount  1404  to rotate about the connecting member  1402  as well as slide up and down the connecting member  1402 . 
     The adjustable mount  1404  comprises a post  1406  and a lock  1408  to receive and secure a pointing device  1500 , such as a laser pointer. The post  1406  may also be telescopic to adjust the distance of the pointing device  1500  relative to the connecting member  1402 . Due to the adjustable mount  1404 , the laser pointer  1500  may be offset from the central axis C of the femoral broach  1401  and connecting member  1402 , and it is oriented to emit a light or laser generally parallel to this central axis C. In some embodiments, the surgeon then can adjust the positioning of the pointer  1500  so that the light emitted from it runs along the back of the thigh approximately toward the popliteal space  602 , strikes the back of the thigh near the region of the popliteal space  602 , strikes the back of the calf just past the region of the popliteal space  602 , or strikes any other desired precise reference point that guides broach and the prosthesis orientation. 
     The mount  1404  for the pointer  1500  may be adjustable in a number of ways relative to the connecting member  1402  to accommodate the surgical procedure. In one such embodiment, for example, the mount  1404  may be a collar rotatably mounted to the connecting member  1402 , such that it can be rotated about the central axis C of the connecting member  1402 . The surgeon may simply rotate the offset mounting arm about the central axis C of the connecting member  1402  and then fix the pointer at an appropriate angle using the lock  1408 , such as a set screw or the like, to indicate the anteversion angle as the broach seeks the desired neutral position in the femoral canal. The mount  1404  may also be slidable along the connecting member  1402  so as to adjust the distance from the broach  1401 . The mount  1404  may also have a tilting capability to allow the laser pointer  1500  to be adjusted so as to be parallel to the connecting member  1402 . 
     In this way, the pointer  1500  may be adjusted to visibly maintain the central axis C in any preferred anteversion angle, regardless of the anteversion angle of the handle  1400  so that the surgeon can project the laser light  1600  directly over the posterior or anterior femur while orienting the broach  1401  in the same or any other desired anteversion angle. The surgeon then observes that the pointer  1500  continues to point at the chosen target in the direction of this central axis C of the connecting member  1402  as he or she repeatedly strikes the striking post  1403  or surface of the broach handle, thereby being certain that the central axis C of broach  1401  itself is properly oriented and aligned with the central axis of the femur. 
     In one preferred embodiment, therefore, the anteversion angle of the femoral broach may be monitored, and in fact a gyroscopic unit  402  may be mounted to the broach handle  1400  in a similar fashion as discussed above with respect to the handle  1400  for the acetabular component  200 . As illustrated in  FIG. 20 , there may be a mounting arm  1407  having a lock  1411  as well as a pivot means  702  and locking means  704  so that the anteversion of the broach may be zeroed intraoperatively. Furthermore, a second gyroscopic unit  403  may be temporarily mounted to the patient&#39;s body, such as the thigh or knee region, as a reference reading to assist with a precise anteversion reading for the broach  1401  even if the patient&#39;s leg happens to move or shift during the procedure. 
     This is especially important when placing a cemented implant that is not guided by the prepared bone envelope. That is, the handle and alignment means may hold the femoral component in the proper longitudinal alignment while the cement sets so that any forces on the femoral component as the cement begins to set may be overcome by the surgeon. The surgeon may additionally wish to maintain a given anteversion angle for the femoral component using the same handle and alignment means. 
     Whether employed in the setting of the femoral prosthesis or not, the anteversion readings for the femoral broach and/or prosthesis itself can be used to calculate or modify the target anteversion range for the acetabular component  200  unique for the given patient. That is, the anteversion angle for the femoral component can fall within a wide range, ordinarily between 0° and 70°, and typically is dictated by the contours of the patient&#39;s femur. This may be due to a number of factors unique to each patient. As a general rule, therefore, the anteversion angle of the acetabular component normally is more easily varied than the anteversion angle of the femoral component. 
     The actual angle of anteversion of the femoral component for most patients can affect what is the appropriate target range for the anteversion angle of the acetabular component for a hip replacement to have a successful longevity. Typically, the larger the anteversion angle of the femoral component, the larger the anteversion angle needs to be for the acetabular component, leading to increasing the target acetabular anteversion angle to within a range of 20 to 25, where the patient&#39;s femoral anteversion angle is on the higher end of the above-mentioned range. 
     While the present invention has been described with regards to particular embodiments, it is recognized that additional variations of the present invention may be devised without departing from the inventive concept.