Abstract:
A method for arthroscopically accessing a region of a joint, wherein the joint has a capsule disposed intermediate at least one layer of outer tissue and the joint, the method comprising:
       arthroscopically positioning visualization apparatus adjacent to an exterior surface of the capsule; and   while visualizing the exterior surface of the capsule, arthroscopically forming an opening through the capsule.

Description:
REFERENCE TO PENDING PRIOR PATENT APPLICATIONS 
       [0001]    This patent application: 
         [0002]    (i) is a continuation-in-part of pending prior U.S. patent application Ser. No. 12/631,514, filed Dec. 4, 2009 by James Flom et al. for METHOD AND APPARATUS FOR ACCESSING THE INTERIOR OF A HIP JOINT, INCLUDING THE PROVISION AND USE OF A NOVEL TELESCOPING ACCESS CANNULA AND A NOVEL TELESCOPING OBTURATOR (Attorney&#39;s Docket No. FIAN-3143); 
         [0003]    (ii) is a continuation-in-part of pending prior U.S. patent application Ser. No. 12/726,268, filed Mar. 17, 2010 by Julian Nikolchev et al. for METHOD AND APPARATUS FOR DISTRACTING A JOINT, INCLUDING THE PROVISION AND USE OF A NOVEL JOINT-SPACING BALLOON CATHETER AND A NOVEL INFLATABLE PERINEAL POST (Attorney&#39;s Docket No. FIAN-28424953); and 
         [0004]    (iii) claims benefit of pending prior U.S. Provisional Patent Application Ser. No. 61/301,005, filed Feb. 3, 2010 by Hal David Martin for ARTHROSCOPIC ACCESS TO THE INTERIOR OF THE HIP JOINT (Attorney&#39;s Docket No. PROV). 
         [0005]    The three (3) above-identified patent applications are hereby incorporated herein by reference. 
     
    
     FIELD OF THE INVENTION 
       [0006]    This invention relates to surgical methods and apparatus in general, and more particularly to surgical methods and apparatus for treating a hip joint. 
       BACKGROUND OF THE INVENTION 
       [0007]    Successful hip arthroscopy generally requires safe and effective access to the interior of the hip joint. 
         [0008]    The current technique for arthroscopically accessing the interior of a hip joint generally comprises the following steps. First, the patient&#39;s leg is typically placed under traction so as to dislocate the femoral head from the acetabular socket. This action creates a gap, or opening, between the femoral head and the acetabular socket, thereby allowing the interior surfaces of the joint to be accessed. Under fluoroscopic guidance, and looking now at  FIG. 1 , the surgeon then advances a hollow needle  5  (temporarily filled with a stylet  10 ) from the surface of the skin  15  down into this gap, so that that the tip of needle  5  resides in the interior of the joint. As the tip of needle  5  passes from the surface of the skin  15  down into the gap between the femoral head and the acetabular cup, the needle (with stylet) must pass through the intervening tissue, which includes the outer tissue  20  (skin, muscle, etc.) and the tough band of tissue (i.e., the capsule  25 ) which surrounds the joint. After needle  5  (with stylet  10 ) has been advanced into the interior of the joint, stylet  10  is removed from needle  5 , as seen in  FIG. 2 . Next, a guidewire  30  is advanced through needle  5  and into the interior of the joint ( FIG. 3 ). Needle  5  is then removed ( FIG. 4 ), leaving guidewire  30  extending from the surface of the skin  15  down into the interior of the joint. Next, a skin incision may or may not be made about guidewire  30 . Then an access cannula  35  is advanced over guidewire  30  and down into the interior of the joint ( FIG. 5 ). Guidewire  30  is then removed ( FIG. 6 ). 
         [0009]    The foregoing procedure is then typically repeated so as to deploy additional access cannulas  35  into the joint ( FIG. 7 .) 
         [0010]    Once the desired access cannulas  35  have been installed in the anatomy, an arthroscope  40  ( FIG. 8 ) is advanced through one of the access cannulas  35  so as to visualize the interior of the joint. Other arthroscopic instrumentation (e.g., a burr  45 , as shown in  FIG. 9 ) may then be advanced down other access cannulas so as to treat the interior of the joint. 
         [0011]    Unfortunately, it is not uncommon for needle  5  to cause iatrogenic damage to tissue structures as the needle is advanced into the interior of the joint. For example, needle  5  may accidentally penetrate and damage the labrum, which is a soft tissue structure located on the rim of the acetabulum. Or, the needle may scuff or gouge cartilage on the femoral head. Or the needle may damage cartilage on the inner surface of the acetabular cup. In many cases, this iatrogenic damage is caused by “needle plunge”, which often occurs as the needle is forced through the tough capsule which surrounds the joint. More particularly, the surgeon typically needs to apply substantial force to the proximal end of the needle in order to force the distal end of the needle through the tough capsule, but it can then be very difficult for the surgeon to stop the needle from plunging forward into underlying anatomical structures when the needle finally breaks through the tough capsule. When this occurs, the underlying anatomical structures (e.g., the labrum, the head of the femur, the acetabular cup, etc.) can be damaged by such a needle plunge. 
         [0012]    Thus there is the need for a safer approach for arthoscopically accessing the interior of a hip joint. 
       SUMMARY OF THE INVENTION 
       [0013]    The present invention provides a safer approach for arthroscopically accessing the interior of a hip joint. 
         [0014]    In one preferred form of the present invention, there is provided a method for arthroscopically accessing a region of a joint, wherein the joint has a capsule disposed intermediate at least one layer of outer tissue and the joint, the method comprising: 
         [0015]    arthroscopically positioning visualization apparatus adjacent to an exterior surface of the capsule; and 
         [0016]    while visualizing the exterior surface of the capsule, arthroscopically forming an opening through the capsule. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0017]    These and other objects and features of the present invention will be more fully disclosed or rendered obvious by the following detailed description of the preferred embodiments of the invention, which is to be considered together with the accompanying drawings wherein like numbers refer to like parts, and further wherein: 
           [0018]      FIGS. 1-9  are schematic views showing a conventional approach for achieving arthroscopic access to the interior of a hip joint; 
           [0019]      FIGS. 10-24  are schematic views showing a new approach for achieving arthroscopic access to the interior of a hip joint; and 
           [0020]      FIGS. 25-29  are schematic views showing another new approach for achieving arthroscopic access to the interior of a hip joint. 
       
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
       [0021]    The present invention provides a safer approach for arthroscopically accessing the interior of a hip joint. 
         [0022]    In one preferred form of the present invention, the new approach for arthroscopically accessing the interior of a hip joint comprises the following steps. First, the patient&#39;s leg is placed under traction so as to dislocate the femoral head from the acetabular socket. This action creates a gap, or opening, between the femoral head and the acetabular socket, thereby allowing the interior surfaces of the joint to be accessed. Under fluoroscopic guidance, and looking now at  FIG. 10 , the surgeon then advances needle  5  (with stylet  10 ) down to, but not through, the outer surface  50  of capsule  25  ( FIG. 10 ). The extent of needle advancement can be determined by fluoroscopy or “surgeon feel”, or both. Next, stylet  10  is removed from needle  5  ( FIG. 11 ). Then guidewire  30  is advanced through needle  5  so that the guidewire extends down to, but not through, the outer surface  50  of capsule  25  ( FIG. 12 ). Next needle  5  is removed, leaving guidewire  30  extending from the surface of the skin  15  down to, but not through, the capsule ( FIG. 13 ). Then a skin incision may or may not be made about guidewire  30 . Next, an access cannula  35  is advanced over guidewire  30  and down to, but not through, capsule  25  ( FIG. 14 ). Guidewire  30  is then removed ( FIG. 15 ). 
         [0023]    At this point at least one additional access cannula is introduced into the tissue using the same technique ( FIG. 16 ). Preferably at least two additional access cannulas are introduced into the tissue using the same technique, however, only one additional access cannula is shown in  FIGS. 16-29  for the sake of clarity. Again, during deployment of the additional access cannulas into the tissue, care is taken to prevent needle  5 , guidewire  30  and/or access cannulas  35  from penetrating the capsule. 
         [0024]    Next, an arthroscope  40  is advanced through one of the access cannulas  35  so that the outer surface of the capsule can be visualized ( FIG. 17 ). Then, while the outer surface of the capsule is being visualized by arthroscope  40 , a cutting instrument  55  (e.g., an arthroscopic scalpel) is advanced through the other access cannula  35  ( FIG. 18 ). While under such visualization, cutting instrument  55  is then used to make a cut, or opening,  60  through capsule  25  ( FIGS. 19 and 20 ). The surgeon is able to make this cut or opening  60  with precision, and without fear of unintentionally plunging into the underlying anatomical structure of the joint, due to (i) the nature of the cutting instrument (i.e., it is a cutting scalpel, not a needle), (ii) the controlled application of the cutting instrument to the tissue (i.e., it is applied directly against the capsule before any cutting occurs, and is not driven through numerous layers of intervening tissue before it encounters the capsule), and (iii) the direct visualization of the capsule penetration which is provided by the arthroscope (i.e., the cut is made into the capsule while under direct visualization, it is not made “blind” as is the case with the prior art). Cut  60  is preferably made in the region of the capsule that resides over the gap between the acetabular rim and femoral head. This cut provides full access into the interior of the hip joint. 
         [0025]    The same process is then repeated so as to create a cut in the capsule below each of the access cannulas positioned in the patient ( FIGS. 21-23 ). 
         [0026]    It should be appreciated that, when making cuts  60 , the surgeon may use anatomical landmarks to identify the location of a cut. In one embodiment, the anatomical landmark is the direct head or indirect head of the rectus femoris. In one embodiment, the cut is made between the lateral and medial arms of the iliofemoral ligament. 
         [0027]    Once these cuts (or openings) have been created in the capsule beneath each of the access cannulas, the access cannulas  35  are then advanced through the cuts made in the capsule and into the interior of the hip joint, whereby to provide a corridor from the surface of the skin down into the interior of the joint ( FIG. 24 ). 
         [0028]    Alternatively, if desired, once a first cut  60  has been made in the capsule ( FIG. 25 ), the arthroscope can be advanced through that cut ( FIG. 26 ) so as to visualize the underside of the capsule. While the underside of the capsule is so visualized, additional cuts are made in the capsule ( FIGS. 27 and 28 ). Once all of the cuts  60  have been made in the capsule, access cannulas  25  are then advanced through the cuts made in the capsule and into the interior of the joint ( FIG. 29 ). 
         [0029]    In one preferred form of the invention, the access cannulas  25  may comprise telescoping access cannulas of the sort taught in pending prior U.S. patent application Ser. No. 12/631,514, filed Dec. 4, 2009 by James Flom et al. for METHOD AND APPARATUS FOR ACCESSING THE INTERIOR OF A HIP JOINT, INCLUDING THE PROVISION AND USE OF A NOVEL TELESCOPING ACCESS CANNULA AND A NOVEL TELESCOPING OBTURATOR (Attorney&#39;s Docket No. FIAN-3143), which patent application is incorporated herein by reference. These telescoping access cannulas are designed to allow their overall length to be adjusted in situ, which can be highly advantageous when the distal tip of the access cannula is to be advanced from a position outside of the capsule to a position inside of the capsule. 
         [0030]    It should be appreciated that variations may be made to the approach described above without departing from the scope of the present invention. 
         [0031]    For example, the surgeon may not place an access cannula in the patient, but rather introduce an arthroscopic instrument through the anatomical tissue pathway created by the needle. 
         [0032]    Additionally, the capsule may not initially be cut at the gap between the acetabular rim and femoral head—in an alternative approach, the cut may be made in the region of the capsule that is over the femoral neck. Accessing the joint over the femoral neck may be safer then accessing the joint over the gap between the femoral head and the acetabular cup, as there may be less likelihood to damage cartilage or soft tissue structures during capsule penetration. In this alternative embodiment, the cut could subsequently be extended from the femoral neck to the gap between the acetabular rim and femoral head, thus gaining access to the hip interior. 
         [0033]    In yet another alternative embodiment, a balloon or other space-creating structure may be disposed between outer tissue  20  (skin, muscle, etc.) and capsule  25  prior to advancing needle  5  (with stylet  10 ) through outer tissue  20  and down to, but not through, the capsule. Such an approach can make it easier to appropriately position needle  5 , guidewire  30 , access cannulas  35 , arthroscope  40  and/or cutting instrument  55  in the gap between tissue  20  and capsule  25 . 
         [0034]    Furthermore, once passageways have been created through capsule  25  (e.g., the placement of access cannulas through capsule  25 ), one or more balloons can be placed within the central compartment (i.e., the gap between the head of the femur and the acetabular cup) so as to further distract and/or otherwise support the joint. Furthermore, one or more balloons may be placed in the peripheral compartment (i.e., the space between the capsule  25  and the neck of the femur) so as to lift the capsule away from the femur and/or provide a fulcrum structure for levering the femur relative to the acetabular cup. These and other balloon applications are disclosed in pending prior U.S. patent application Ser. No. 12/726,268, filed Mar. 17, 2010 by Julian Nikolchev et al. for METHOD AND APPARATUS FOR DISTRACTING A JOINT, INCLUDING THE PROVISION AND USE OF A NOVEL JOINT-SPACING BALLOON CATHETER AND A NOVEL INFLATABLE PERINEAL POST (Attorney&#39;s Docket No. FIAN-28424953), which patent application is incorporated herein by reference. 
         [0035]    It should also be appreciated that the cutting instrument could have various embodiments. It could be a mechanical blade, a radio-frequency device, an ultrasonic cutter, an oscillating blade, or any other instrument consistent with the present invention and capable of cutting tissue. The cutting instrument may be used over a guidewire or a switching stick. 
       USE OF THE PRESENT INVENTION FOR OTHER APPLICATIONS 
       [0036]    It should be appreciated that the present invention may be used for accessing joints other than the hip joint, e.g., it may be used to access the shoulder joint. 
       MODIFICATIONS OF THE PREFERRED EMBODIMENTS 
       [0037]    It should be understood that many additional changes in the details, materials, steps and arrangements of parts, which have been herein described and illustrated in order to explain the nature of the present invention, may be made by those skilled in the art while still remaining within the principles and scope of the invention.