Patent Description:
A system according to the invention is defined in claim <NUM>. The methods disclosed herein are useful for understanding the system of the invention. In one aspect, an example method is disclosed. The method includes (a) accessing a medullary canal of a rib having a fracture, (b) advancing a guidewire into the medullary canal across the fracture, (c) advancing a delivery catheter containing a stent over the guidewire into the medullary canal and across the fracture; (d) retracting the delivery catheter relative to the stent; and (e) expanding the stent in the medullary canal.

In another aspect, an example method is disclosed. The method includes (a) creating a first access hole through a cortex of a rib on a first side of a fracture to a medullary canal of the rib, (b) creating a second access hole through the cortex of the rib on a second side of the fracture to the medullary canal, (c) accessing the medullary canal through the first access hole, via a first wire having a first reciprocal coupling at free end of the first wire, (d) accessing the medullary canal through the second access hole, via a second wire having second reciprocal coupling at a free end of the second wire, (e) advancing the free end of the first wire and the free end of the second wire through the medullary canal until the first reciprocal coupling and the second reciprocal coupling engage with each other thereby providing a through-and-through wire, (f) advancing a tension line through the first access hole into the medullary canal across the fracture and out the second access hole, wherein the tension line comprises a wire disposed through an alternating plurality of rods and beads arranged in series along at least a portion of the length of the tension line, and (g) placing the tension line under tension.

In another aspect, an example method is disclosed. The method includes (a) creating a first access hole through a cortex of a rib on a first side of a fracture to a medullary canal of the rib, (b) accessing the medullary canal through the first access hole, (c) advancing a catheter through the first access hole into the medullary canal across the fracture; and (d) injecting the medullary canal with a polymer.

In still another aspect, an example method is disclosed. The method includes (a) creating a first access hole through a cortex of a rib on a first side of a fracture to a medullary canal of the rib, (b) creating a second access hole through the cortex of the rib on a second side of the fracture to the medullary canal, (c) accessing the medullary canal through the first access hole, via a catheter, (d) advancing the catheter across the fracture, (e) advancing the free end of a tension line out of the catheter and into the medullary canal; where the tension line has a snare at the free end, (f) accessing the medullary canal through the second access hole, via an extractor, (g) engaging the snare of the tension line with a hook of the extractor and advancing the free end of the tension line out of the second access hole such that the tension line extends through the first access hole into the medullary canal across the fracture, where the tension line has threads, (h) removing the snare from the free end of the tension line, (i) advancing a first plug down the free end of the tension line and into the second access hole, wherein the first plug has a hole extending longitudinally therethrough that has reciprocal threads to mate with the threads of the tension line; and (j) placing the tension line under tension.

The system as recited in the appended claims includes (a) a tension line having a removable snare at a free end, where the tension line has threads, (b) a first plug configured to be advanced down the free end of the tension line and a second access hole of a rib, where the first plug has a hole extending longitudinally therethrough that has reciprocal threads to mate with the threads of the tension line, (c) a plurality of stents configured to be advanced over the tension line through a first access hole in a rib into the medullary canal of the rib until a length of the medullary canal between the first access hole and the second access hole is filled with the plurality of stents, where each of the plurality of stents has a concave face at a first end and a convex face at a second end such that, when the plurality of stents are arranged adjacent to each other along the tension line, the concave face of the first end of a first stent will mate with the convex face of the second end of an adjacent second stent, and (d) a second plug configured to be advanced down an end of the tension line and into the first access hole, where the second plug has a hole extending longitudinally therethrough that has reciprocal threads to mate with the threads of the tension line.

In yet another aspect, an example method is disclosed. The method includes (a) creating a first access hole through a cortex of a rib on a first side of a fracture to a medullary canal of the rib, (b) creating a second access hole through the cortex of the rib on a second side of the fracture to the medullary canal, (c) accessing the medullary canal through the first access hole, via a catheter, (d) advancing the catheter across the fracture, (e) advancing the free end of a tension line out of the catheter and into the medullary canal; wherein the tension line has a snare at the free end, (f) accessing the medullary canal through the second access hole, via an extractor, (g) engaging the snare of the tension line with a hook of the extractor and advancing the free end of the tension line out of the second access hole such that the tension line extends through the first access hole into the medullary canal across the fracture, where the tension line has threads, (h) removing the snare from the free end of the tension line, and (i) advancing a stent over the tension line through the first access hole and the medullary canal to the second access hole, where the stent has a hole extending longitudinally therethrough that has reciprocal threads to mate with the threads of the tension line.

In another aspect, an example method is disclosed. The method includes (a) creating a first access hole through a cortex of a rib on a first side of a fracture to a medullary canal of the rib, (b) accessing the medullary canal through the first access hole, (c) advancing a catheter through the first access hole into the medullary canal across the fracture to a distal end of the medullary canal, and (d) advancing a guidewire through the catheter distal to the fracture in the medullary canal and securing an anchor coupled to a distal end of the guidewire within the medullary canal, where the guidewire is configured as a tension line.

In still another aspect, an example method is disclosed. The method includes (a) creating a first access hole through a cortex of a rib on a first side of a fracture to a medullary canal of the rib, (b) advancing a first portion of a first drill bit through the first access hole into the medullary canal across the fracture to a position distal to the fracture in the medullary canal where the first drill bit has a plurality of notches configured to permit detachment from a drill, (c) applying a force to the first drill bit and thereby causing a fracture along one of the plurality of notches, and (d) detaching a second portion of the first drill bit from the first portion of the first drill bit in the medullary canal.

In another aspect, an example apparatus useful for understanding the invention is disclosed. The apparatus includes a drill bit having a first portion and a second portion, where the first portion of the drill bit has threads disposed along a length of the first portion, where the second portion of the drill bit has a plurality of notches along a length of the second portion, the plurality of notches configured to permit detachment from a drill upon application of a force to the drill bit such that a fracture is caused along one of the plurality of notches, where the first portion of the drill bit and one or more notches of the second portion of the drill bit are configured to remain in a medullary canal of a rib.

In yet another aspect, an example method is disclosed. The method is for placement of a rib plate having a first portion and a second portion each having a plurality of holes therethrough and a third portion arranged between the first portion and the second portion, the third portion of the rib plate having a hole configured to receive a protuberance coupled to a porous tube that has two open ends. The method includes (a) coupling the rib plate to the porous tube, (b) placing bone graft in a lumen of the porous tube, (c) implanting the tube in a gap between a first segment of a rib and a second segment of the rib, and (d) anchoring the first portion and the second portion of the rib plate to the first segment and the second segment of the rib such that the porous tube is aligned with the first segment and the second segment of the rib.

In another aspect, an example system useful for understanding the invention is disclosed. The system includes (a) a rib plate having a first portion and a second portion each having a plurality of holes therethrough and a third portion arranged between the first portion and the second portion, (b) a porous tube that has two open ends and a protuberance arranged between the two ends that extends from an exterior surface of the porous tube, wherein the third portion of the rib plate has a hole configured to receive the protuberance of the porous tube; and (c) bone graft disposed in a lumen of the porous tube.

Elements of an embodiment of the invention are represented in <FIG>, the remaining figures show examples useful for understanding the invention.

The drawings are for the purpose of illustrating examples, but it is understood that the invention is limited only by the claims.

Embodiments of the methods, systems, and apparatus described herein can be used minimally invasive solutions to treat rib fracture. The disclosed example methods, systems, and apparatus may advantageously re-align a fracture to substantially re-establish a rib to a pre-fracture position and/or to provide intra- and/or extra-medullary support. In addition, rib fractures occurring under the scapula may be accessed via an access hole in the rib located a distance away from the scapula without having to move the scapula. Alternatively, the access hole may be located a distance away from a vertebral fracture, not previously accessible under currently known techniques. This technique may be used to treat other fractures not easily accessible or manipulated by known techniques.

The disclosed methods, systems, and apparatus are contemplated to treat single linear fractures and may be effective for non-comminuted fractures involving multiple pieces in some circumstances. For example, situations may arise in which a rib is fractured in two locations such that there is a free-floating segment. In such a case, a stent, a tension line or a polymer, as described in detail below, may span multiple fractures in a rib that is not shattered or comminuted. Once the stent, tension line or polymer are delivered, these supports may act as an internal brace or cast providing structural support while bone heals around it. In certain embodiments, these supports may be left in the bone into perpetuity or may be bio-absorbable.

For example, when a rib is fractured, incisions are made through the skin and one or more access holes are made through stable bone on at least one side of the fractured rib. In an optional embodiment, through-access channels may be created via compression, flushing or reaming of the contents of the medullary canal to create a passageway through the stable bone of the rib to the fracture site and ultimately across the fracture site via one or more of the first and second access holes. Alternatively, the contents of the medullary canal may yield in response to placement of a stent or injection of a polymer. The first and second access holes may be created through a cortex of a rib to a medullary canal of the rib via drilling or using a tapered rod to puncture through the bone. A drill or tapered rod may likewise be used to compress, flush or ream one or more of the marrow or the bone.

In various embodiments described below, percutaneous instruments may be used that screw into a rib to manipulate the rib percutaneously to reduce the fracture site (e.g., where ribs are displaced or offset resulting in overlapping between the rib segments) by moving ribs back into place. For example, a rib may be screwed into or grasped at both ends via other access sites and then held or fixed in place during procedure. In one example, a feedback mechanism may be provided for a tension line to confirm a desired tension has been applied (e.g., a lock rod may be placed at one end and tension may be applied at the other end until there is no further movement of the rod). In addition, fluoroscopy guidance and palpating may also inform proper alignment. And if the access hole to the medullary canal is close enough to the fracture location, this may also help determine alignment.

As used herein, a "guidewire" is an elongated cable comprised of one or more biocompatible materials including metals and polymers. Guidewires may be used for selecting target lumens and guiding catheters to target deployment locations. Guidewires are typically defined as wires used independently of other devices that do not come as part of an assembly.

As used herein, a "stent" is a cylindrical frame or unstructured mesh and refers to any device or structure that adds rigidity, support and/or expansion force to a lumen. The stent can be made of any suitable material, including but not limited to biocompatible metals, implantable quality stainless steel wires, nitinol, cobalt, magnesium, nickel, titanium and alloys thereof, and biocompatible plastics. In addition, the stent structure may include coiled, mesh, zig zag, braided, knitted or woven wires. The stent structure could also include a laser cut sheet or a laser cut tube that may have various lengths, diameters or wall thickness. Alternatively, the stent may include injection molded metal. In another embodiment, the stent may include a bio-absorbable polysaccharide scaffold mesh that may be wrapped or coiled around itself to size the stent for a given medullary canal.

As used herein, an "injection catheter" includes a catheter having a plurality of openings at a first end configured to permit bone cement to exit the catheter. The plurality of openings may be arranged along a length of the injection catheter ranging from <NUM> to <NUM>. The injection catheter is configured for over-the-wire advancement in vivo.

As used herein, "medullary canal" refers to the central cavity of bone shafts where red bone marrow and/or yellow bone marrow (i.e., adipose tissue) is stored.

As used herein, "contents of the medullary canal" include, but are not limited to, marrow, bone fragments, blood and tissue.

As used herein, "a paravertebral fracture" refers to a fracture situated or occurring beside or adjacent to the spinal column.

As used herein, a "drill" may include a drill delivered via catheter or an over-the-wire drill delivered over a guidewire.

As used herein, "a cortex" refers to the hard outer layer of a bone that is composed of cortical bone that is denser than cancellous bone.

As used herein, a "through-and-through wire" is configured to provide medullary continuity and through-and-through access between two access holes to realign a rib (or other fractured bone).

As used herein, a "tension line" includes one or more wires configured to bear tension in response to force applied at respective ends of the tension line. In various embodiments, the wires of the tension line may be braided or helically wound, for example. In embodiments that include the alternating plurality of rods and beads, the rods and beads may be disposed over-the-wire. In some embodiments, the tension line may also be able to be placed into compression.

As used herein, a "stiffening compound" includes bone cement.

Referring now to <FIG>, a method <NUM> is illustrated using the elements shown in <FIG>. Method <NUM> includes, at block <NUM>, accessing a medullary canal <NUM> of a rib <NUM> having a fracture <NUM>. Then, at block <NUM>, a guidewire <NUM> is advanced into the medullary canal <NUM> across the fracture <NUM>. Next, at block <NUM>, a delivery catheter <NUM> containing a stent <NUM> is advanced over the guidewire <NUM> into the medullary canal <NUM> and across the fracture <NUM>. Then, the delivery catheter <NUM> is retracted relative to the stent <NUM>, at block <NUM>. At block <NUM>, the stent <NUM> is expanded in the medullary canal <NUM>.

In one optional embodiment, accessing the medullary canal <NUM> of the rib <NUM> having the fracture <NUM> includes creating an incision <NUM> in skin <NUM> of a subject (see, e.g., <FIG>). Next, blunt dissection down to the rib <NUM> is performed. And a hole is then drilled through a cortex <NUM> of the rib <NUM> on one side of the fracture <NUM> thereby creating an access hole <NUM> to the medullary canal <NUM>. In an optional embodiment, the access hole is at least <NUM> from the fracture <NUM>. In another optional embodiment, the access hole <NUM> is arranged at an acute angle relative to the medullary canal <NUM>, the acute angle ranging from <NUM> to <NUM> degrees. In another example embodiment, the access hole <NUM> is located a distance away from the fracture <NUM> and the fracture <NUM> is either located beneath a scapula or the fracture <NUM> is a paravertebral fracture.

In one optional embodiment, method <NUM> includes sizing the medullary canal <NUM> by displacing contents <NUM> of the medullary canal <NUM> such that the medullary canal <NUM> has a diameter of at least <NUM>. In a further embodiment, sizing the medullary canal <NUM> by displacing the contents <NUM> of the medullary canal <NUM> includes one or more of compressing, flushing or reaming one or more of the marrow or the bone.

In an alternative embodiment, sizing the medullary canal <NUM> by displacing the contents <NUM> of the medullary canal <NUM> includes advancing a catheter containing a drill bit through the access hole <NUM> to the medullary canal <NUM> (see, e.g., <FIG>). Then, the drill bit is advanced out of a first end of the catheter. Next, the drill bit is activated thereby causing the drill bit to rotate. And the contents <NUM> from the medullary canal <NUM> are advanced into the catheter via the rotating drill bit. The drill bit is then retracted into the catheter and the drill bit and the contents <NUM> from the medullary canal <NUM> are advanced out of an access port at the second end of the catheter. In a further optional embodiment, method <NUM> includes advancing the catheter containing the drill bit through the access hole <NUM> to the medullary canal <NUM> includes at least one of using fluoroscopy to visualize the catheter containing the drill bit or palpating the rib <NUM> and a surrounding tissue.

In another optional embodiment, the method <NUM> includes leaving the catheter in place in the medullary canal <NUM> after retraction of the drill bit. In a further embodiment, advancing the guidewire <NUM> into the medullary canal across the fracture includes advancing the guidewire <NUM> through the catheter in the medullary canal after retraction of the drill bit. And a further optional embodiment includes removing the catheter from the medullary canal <NUM> after advancing the guidewire <NUM> into the medullary canal <NUM> across the fracture <NUM>.

In one optional embodiment, as shown in <FIG>, method <NUM> includes advancing an injection catheter <NUM> over the guidewire <NUM> into the medullary canal <NUM> and across the fracture <NUM>. The medullary canal <NUM> is then injected with a stiffening compound or a polymer via the injection catheter <NUM>. In a further optional embodiment, the stent <NUM> has a lumen and the method includes advancing the injection catheter <NUM> into the lumen of the stent <NUM> to an end <NUM> of the stent <NUM> that is distal to the fracture <NUM>. Then, the injection catheter <NUM> is retracted through the lumen of the stent <NUM> while injecting the medullary canal <NUM> with the stiffening compound or the polymer. In an alternative embodiment, the stent includes an unstructured mesh, and method <NUM> includes advancing the injection catheter <NUM> to a proximal end <NUM> of the stent <NUM> in the medullary canal <NUM>. Then, the medullary canal <NUM> is injected with the stiffening compound or the polymer at the proximal end <NUM> of the stent <NUM> via the injection catheter <NUM>. In a further embodiment, method <NUM> includes retracting the injection catheter <NUM> and the guidewire <NUM> from the medullary canal <NUM>.

In one optional embodiment, method <NUM> includes manipulating the rib <NUM> to realign the medullary canal <NUM> across the fracture <NUM>.

In one optional embodiment, the stent <NUM> has a length ranging from <NUM> to <NUM>. In another optional embodiment, the stent <NUM> is permanent or bio-absorbable. In an alternative embodiment, the stent <NUM> includes magnesium, a metal, a metal alloy, or a polysaccharide. In a further example embodiment, the stent <NUM> includes a bio-absorbable polysaccharide scaffold mesh. In still another embodiment, the stent <NUM> is either balloon expandable or self-expanding.

In another optional embodiment, shown in <FIG>, a second access hole <NUM> is created through the cortex <NUM> of the rib <NUM> on a second side of the fracture <NUM>. The guidewire <NUM> is advanced out of the second access hole <NUM>. Then an injection catheter <NUM> is advanced along the guidewire <NUM> through a lumen of the stent <NUM> to a position between the second access hole <NUM> and a distal end <NUM> of the stent <NUM>. Bone cement may then be injected into the medullary canal <NUM> as the injection catheter <NUM> is retracted out of the medullary canal <NUM> through the first access hole <NUM>, injecting bone cement in the lumen of the stent <NUM> and between the proximal end <NUM> of the stent and the first access hole <NUM>.

Referring now to <FIG>, a method <NUM> is illustrated using the elements shown in <FIG>. Method <NUM> includes, at block <NUM>, creating a first access hole <NUM> through a cortex <NUM> of a rib <NUM> on a first side of a fracture <NUM> to a medullary canal <NUM> of the rib <NUM>. Then, at block <NUM>, a second access hole <NUM> is created through the cortex <NUM> of the rib <NUM> on a second side of the fracture <NUM> to the medullary canal <NUM>. Next, at block <NUM>, the medullary canal <NUM> is accessed through the first access hole <NUM>, via a first wire <NUM> having a first reciprocal coupling <NUM> at a free end <NUM> of the first wire <NUM>. And, at block <NUM>, the medullary canal <NUM> is accessed through the second access hole <NUM>, via a second wire <NUM> having second reciprocal coupling <NUM> at a free end <NUM> of the second wire <NUM>. Then, at block <NUM>, the free end <NUM> of the first wire <NUM> and the free end <NUM> of the second wire <NUM> are advanced through the medullary canal <NUM> until the first reciprocal coupling <NUM> and the second reciprocal coupling <NUM> engage with each other thereby providing a through-and-through wire <NUM>. In one optional embodiment, the first reciprocal coupling <NUM> and the second reciprocal coupling <NUM> comprise a pair of magnets, a pair of hooks, or a hook and a snare. A tension line <NUM> is then advanced through the first access hole <NUM> into the medullary canal <NUM> across the fracture <NUM> and out the second access hole <NUM>, at block <NUM>. As shown in <FIG>, the tension line <NUM> includes a wire <NUM> disposed through an alternating plurality of rods <NUM> and beads <NUM> arranged in series along at least a portion of the length of the tension line <NUM>. And method <NUM> includes, at block <NUM>, placing the tension line <NUM> under tension.

In one optional embodiment, a first end <NUM> of the tension line <NUM> is coupled to an end <NUM> of the through-and-through wire <NUM>. In this embodiment, advancing the tension line <NUM> through the first access hole <NUM> into the medullary canal <NUM> across the fracture <NUM> and out the second access hole <NUM> includes advancing the through-and-through wire <NUM> out of the medullary canal <NUM> via one of the first access hole <NUM> or the second access hole <NUM> and thereby pulling the tension line <NUM> through the medullary canal <NUM>. In a further optional embodiment, method <NUM> includes uncoupling the tension line <NUM> from the through-and-through wire <NUM>.

In another optional embodiment, method <NUM> includes advancing a delivery sleeve over the through-and-through wire <NUM> through the first access hole <NUM> into the medullary canal <NUM> across the fracture <NUM> and out the second access hole <NUM>. Then, the through-and-through wire <NUM> is removed from the medullary canal <NUM>. In this embodiment, advancing the tension line <NUM> through the first access hole <NUM> into the medullary canal <NUM> across the fracture <NUM> and out the second access hole <NUM> includes at least one of pushing and pulling the tension line <NUM> into a first end of the delivery sleeve until the tension line <NUM> advances out of a second end of the delivery sleeve. Then, the delivery sleeve is removed from the medullary canal <NUM> such that the tension line <NUM> remains in the medullary canal <NUM>.

In one optional embodiment, method <NUM> includes sizing the medullary canal by displacing contents <NUM> of the medullary canal <NUM> such that the medullary canal <NUM> has a diameter of at least <NUM>. In a further embodiment, sizing the medullary canal <NUM> by displacing the contents <NUM> of the medullary canal <NUM> includes one or more of compressing, flushing or reaming one or more of the marrow or the bone.

In an alternative embodiment, shown in <FIG>, sizing the medullary canal <NUM> by displacing the contents <NUM> of the medullary canal <NUM> includes advancing a flexible drill bit <NUM> over the through-and-through wire <NUM> into the medullary canal <NUM>. Then, the flexible drill bit <NUM> is activated thereby causing the flexible drill bit <NUM> to rotate. And the flexible drill bit <NUM> is removed from the medullary canal <NUM>. In one embodiment, the flexible drill bit is delivered to the medullary canal <NUM> via a delivery catheter <NUM>.

In one optional embodiment, method <NUM> further includes advancing a first anchoring hub <NUM> over a first end <NUM> of the tension line <NUM> down to the cortex <NUM> of the rib <NUM> surrounding the first access hole <NUM> and advancing a second anchoring hub <NUM> over a second end <NUM> of the tension line <NUM> down to the cortex <NUM> of the rib <NUM> surrounding the second access hole <NUM>. In this embodiment, a through-hole <NUM> in the first anchoring hub <NUM> has a diameter smaller than at least one of the alternating plurality of rods <NUM> and beads <NUM>, and a through-hole <NUM> in the second anchoring hub <NUM> has a diameter smaller than at least one of the alternating plurality of rods <NUM> and beads <NUM>. In a further embodiment, method <NUM> includes transferring tension from the tension line <NUM> to an outer cortex <NUM> of the rib <NUM> via the first anchoring hub <NUM> and the second anchoring hub <NUM>.

In one optional embodiment, method <NUM> includes applying a bone cement within the first access hole <NUM> and the second access hole <NUM> and surrounding the first end <NUM> and the second end <NUM> of the tension line <NUM>. In a further embodiment, applying the bone cement within the first access hole <NUM> and the second access hole <NUM> and surrounding the first end <NUM> and the second end <NUM> of the tension line <NUM> includes injecting the bone cement into one or more of the first access hole <NUM> and the second access hole <NUM> and the medullary canal <NUM> via syringe.

In another optional embodiment, method <NUM> includes bending the tension line <NUM> at one or more joints <NUM> between the alternating plurality of the rods <NUM> and beads <NUM> to conform to a native configuration of the rib <NUM>, while advancing the tension line <NUM> through the first access hole <NUM> into the medullary canal <NUM> across the fracture <NUM> and out the second access hole <NUM>.

In a further optional embodiment, method <NUM> includes anchoring the second end <NUM> of the tension line <NUM> to the cortex <NUM> of the bone <NUM> at the second access hole <NUM>. Then, the tension line <NUM> is cut adjacent to the first access hole <NUM>. And the first end <NUM> of the tension line <NUM> is anchored to the cortex <NUM> of the bone <NUM> at the first access hole <NUM>.

In an example embodiment, the alternating plurality of rods <NUM> and beads <NUM> form a support for the rib <NUM>, when the tension line <NUM> is placed under tension. In a further embodiment, placing the tension line <NUM> under tension creates a bending force. In still another embodiment, placing the tension line <NUM> under tension creates a lateral fixation and an axial fixation within the rib <NUM>.

In an optional embodiment, the alternating plurality of rods <NUM> and beads <NUM> include magnesium, titanium, nitinol, stainless steel or combinations thereof. In another example embodiment, the plurality of rods <NUM> have a length ranging from <NUM> to <NUM> and a diameter ranging from <NUM> to <NUM>, and the plurality of beads <NUM> have a diameter ranging from <NUM> to <NUM>.

In one optional embodiment, the first access hole and the second access hole are at least <NUM> from the fracture. In another example embodiment, the first access hole <NUM> and the second access hole <NUM> are arranged at an acute angle relative to the medullary canal <NUM>, the acute angle ranging from <NUM> to <NUM> degrees.

In one optional embodiment, the method <NUM> includes manipulating the rib to realign the medullary canal across the fracture.

Referring now to <FIG>, a method <NUM> is illustrated using various elements shown in <FIG>. Method <NUM> includes, at block <NUM>, creating a first access hole <NUM> through a cortex <NUM> of a rib <NUM> on a first side of a fracture <NUM> to a medullary canal <NUM> of the rib. Then, at block <NUM>, the medullary canal <NUM> is accessed through the first access hole <NUM>. Next, at block <NUM>, a catheter <NUM> advanced through the first access hole <NUM> into the medullary canal <NUM> across the fracture <NUM>. And then injecting the medullary canal <NUM> with a polymer, at block <NUM>.

In one optional embodiment, the method <NUM> includes sizing the medullary canal <NUM> by displacing contents of the medullary canal <NUM> such that the medullary canal <NUM> has a diameter of at least <NUM>. In a further embodiment, sizing the medullary canal <NUM> by displacing the contents <NUM> of the medullary canal <NUM> includes one or more of compressing, flushing or reaming one or more of the marrow or the bone.

In another embodiment, method <NUM> includes retracting the catheter through the medullary canal <NUM> while injecting the medullary canal <NUM> with the polymer.

In a still another optional embodiment, method <NUM> includes creating a second access hole <NUM> through the cortex <NUM> of the rib <NUM> on a second side of the fracture <NUM> to the medullary canal <NUM> of the rib <NUM>. And injecting the medullary canal <NUM> with the polymer until the polymer exits the medullary canal <NUM> through the second access hole <NUM>. In a further optional embodiment, after the polymer exits the medullary canal <NUM> through the second access hole <NUM>, the catheter <NUM> is retracted a distance and continues to inject the medullary canal <NUM> with the polymer.

In another optional embodiment, method <NUM> includes injecting the medullary canal <NUM> with the polymer until a flow resistance of the polymer is detected by an operator. Then, the catheter <NUM> is retracted through the medullary canal <NUM> a distance. And injection and retraction steps are repeated until the medullary canal <NUM> has been filled with the polymer. In still another optional embodiment, method <NUM> includes expanding the polymer due to exposure to fluid and then curing the polymer and thereby forming a support for the rib <NUM>.

In one optional embodiment, method <NUM> includes re-establishing the rib <NUM> in a near native position relative to the fracture <NUM>. In an alternative embodiment, method <NUM> includes manipulating the rib <NUM> to realign the medullary canal across the fracture <NUM>.

In one option embodiment, the first access hole is at least <NUM> from the fracture <NUM>. In another example embodiment, the first access hole <NUM> is arranged at an acute angle relative to the medullary canal <NUM>, the acute angle ranging from <NUM> to <NUM> degrees. In another embodiment, the first access hole is located a distance away from the fracture <NUM> and the fracture <NUM> is either located beneath a scapula or the fracture is a paravertebral fracture.

Referring now to <FIG>, a method <NUM> is illustrated using various elements shown in <FIG>. Method <NUM> includes, at block <NUM>, creating a first access hole <NUM> through a cortex <NUM> of a rib <NUM> on a first side of a fracture <NUM> to a medullary canal <NUM> of the rib <NUM>. Then, at block <NUM>, a second access hole <NUM> is created through the cortex <NUM> of the rib <NUM> on a second side of the fracture <NUM> to the medullary canal <NUM>. Next, at block <NUM>, the medullary canal <NUM> is accessed through the first access hole <NUM>, via a catheter <NUM>. The catheter <NUM> is then advanced across the fracture <NUM>, at block <NUM>. A free end <NUM> of a tension line <NUM> is next advanced out of the catheter <NUM> and into the medullary canal <NUM>, at block <NUM>, where the tension line <NUM> has a snare <NUM> at the free end <NUM>. The medullary canal <NUM> is then accessed through the second access hole <NUM>, via an extractor <NUM>, at block <NUM>. And the snare <NUM> of the tension line <NUM> is engaged with a hook <NUM> of the extractor <NUM> and the free end <NUM> of the tension line <NUM> is advanced out of the second access hole <NUM> such that the tension line <NUM> extends through the first access hole <NUM> into the medullary canal <NUM> across the fracture <NUM>, at block <NUM>, where the tension line <NUM> has threads <NUM>. Then, at block <NUM>, the snare <NUM> is removed from the free end <NUM> of the tension line <NUM>. At block <NUM>, a first plug <NUM> is advanced down the free end <NUM> of the tension line <NUM> and into the second access hole <NUM>, where the first plug <NUM> has a hole <NUM> extending longitudinally therethrough that has reciprocal threads to mate with the threads <NUM> of the tension line <NUM>. And the tension line <NUM> is then placed under tension, at block <NUM>.

In one optional embodiment, the first access hole <NUM> has a diameter of at least <NUM> and the second access hole <NUM> has a diameter of <NUM> to <NUM>. In another example embodiment, the first access hole <NUM> is arranged at an acute angle relative to the medullary canal <NUM>, the acute angle ranging from <NUM> to <NUM> degrees and where the second access hole <NUM> is arranged at an angle relative to the medullary canal <NUM> ranging from <NUM> to <NUM> degrees.

In another optional embodiment, an extramedullary side <NUM> of the first plug <NUM> has a diameter ranging from <NUM> to <NUM> and an intramedullary side <NUM> of the first plug <NUM> has a diameter ranging from about <NUM> to <NUM>. In a further example embodiment, walls <NUM> extending between the extramedullary side <NUM> and the intramedullary side <NUM> of the first plug <NUM> are concave.

In one optional embodiment, advancing the first plug <NUM> down the free end <NUM> of the tension line <NUM> and into the second access hole <NUM> includes rotating the first plug <NUM> about the tension line <NUM> and screwing the first plug <NUM> into the bone defining the second access hole <NUM>.

In one optional embodiment, the tension line <NUM> has a diameter ranging from <NUM> to <NUM>.

In one optional embodiment, the method <NUM> includes advancing a plurality of stents <NUM> over the tension line <NUM> through the first access hole <NUM> into the medullary canal <NUM> until a length of the medullary canal <NUM> between the first access hole <NUM> and the second access hole <NUM> is filled with the plurality of stents <NUM>. In a further optional embodiment, each of the plurality of stents <NUM> has a concave face at a first end <NUM> and a convex face at a second end <NUM> such that, when the plurality of stents <NUM> are arranged adjacent to each other along the tension line <NUM>, the concave face of the first end <NUM> of a first stent <NUM> will mate with the convex face of the second end <NUM> of an adjacent second stent <NUM>.

In another optional embodiment, the plurality of stents <NUM> each have a circular cross-section and a diameter ranging from <NUM> to <NUM>. In an alternative embodiment, the plurality of stents <NUM> each have an oval cross-section with a minor axis ranging from <NUM> to <NUM> and a major axis ranging from <NUM> to <NUM>. In a further example embodiment, the plurality of stents <NUM> each have a length ranging from <NUM> to <NUM>. In one optional embodiment, the second plug <NUM> has an extramedullary side <NUM> that is flat and an intramedullary side <NUM> that is convex.

In one optional embodiment, method <NUM> includes advancing a second plug <NUM> down an end of the tension line <NUM> extending out of the first access hole <NUM> and into the first access hole <NUM>, where the second plug <NUM> has a hole <NUM> extending longitudinally therethrough that has reciprocal threads to mate with the threads of the tension line <NUM>. In a further optional embodiment, advancing the second plug <NUM> down the end of the tension line <NUM> extending out of the first access hole <NUM> and into the first access hole <NUM> includes rotating the second plug <NUM> about the tension line <NUM> and screwing the second plug <NUM> into the bone defining the first access hole <NUM>.

In a further optional embodiment, method <NUM> includes injecting the medullary canal with a stiffening compound or a polymer.

In yet another optional embodiment, method <NUM> includes sizing the medullary canal <NUM> by displacing the contents <NUM> of the medullary canal <NUM>. In a further example, sizing the medullary canal <NUM> by displacing the contents <NUM> of the medullary canal <NUM> includes one or more of compressing, flushing or reaming one or more of the marrow or the bone.

A system, shown in <FIG>, that is utilized by method <NUM> includes a tension line <NUM> having a removable snare <NUM> at a free end <NUM>, where the tension line <NUM> has threads. The system also includes a first plug <NUM> configured to be advanced down the free end <NUM> of the tension line <NUM> and a second access hole <NUM> of a rib <NUM>, where the first plug <NUM> has a hole <NUM> extending longitudinally therethrough that has reciprocal threads to mate with the threads of the tension line <NUM>. The system further includes a plurality of stents <NUM> configured to be advanced over the tension line <NUM> through a first access hole <NUM> in the rib <NUM> into the medullary canal of the rib until a length of the medullary canal <NUM> between the first access hole <NUM> and the second access hole <NUM> is filled with the plurality of stents <NUM>. Each of the plurality of stents <NUM> has a concave face at a first end <NUM> and a convex face at a second end <NUM> such that, when the plurality of stents <NUM> are arranged adjacent to each other along the tension line <NUM>, the concave face of the first end <NUM> of a first stent <NUM> will mate with the convex face of the second end of an adjacent second stent <NUM>. And the system includes a second plug <NUM> configured to be advanced down an end of the tension line <NUM> and into the first access hole <NUM>, where the second plug <NUM> has a hole <NUM> extending longitudinally therethrough that has reciprocal threads to mate with the threads of the tension line <NUM>.

In one optional embodiment, an extramedullary side <NUM> of the first plug <NUM> has a diameter ranging from <NUM> to <NUM> and an intramedullary side <NUM> of the first plug <NUM> has a diameter ranging from about <NUM> to <NUM>. In a further example embodiment, walls <NUM> extending between the extramedullary side <NUM> and the intramedullary side <NUM> of the first plug <NUM> are concave. In one optional embodiment, the second plug <NUM> has an extramedullary side <NUM> that is flat and an intramedullary side <NUM> that is convex.

In one optional embodiment, the plurality of stents <NUM> each have a circular cross-section and a diameter ranging from <NUM> to <NUM>. In another example embodiment, the plurality of stents <NUM> each have an oval cross-section with a minor axis ranging from <NUM> to <NUM> and a major axis ranging from <NUM> to <NUM>. In a further example embodiment, the plurality of stents <NUM> each have a length ranging from <NUM> to <NUM>.

Referring now to <FIG>, a method <NUM> is illustrated using various elements shown in <FIG> and <FIG>. Method <NUM> includes, at block <NUM>, creating a first access hole <NUM> through a cortex <NUM> of a rib <NUM> on a first side of a fracture to a medullary canal <NUM> of the rib <NUM>. Next, at block <NUM>, a second access <NUM> hole is created through the cortex <NUM> of the rib <NUM> on a second side of the fracture <NUM> to the medullary canal <NUM>. Then, at block <NUM>, the medullary canal <NUM> is accessed through the first access hole <NUM>, via a catheter <NUM>. The catheter <NUM> is then advanced across the fracture <NUM>, at block <NUM>. The free end <NUM> of a tension line <NUM> is then advanced out of the catheter <NUM> and into the medullary canal <NUM>, where the tension line <NUM> has a snare <NUM> at the free end <NUM>, at block <NUM>. Then, at block <NUM>, the medullary canal <NUM> is accessed through the second access hole <NUM>, via an extractor <NUM>. Next, at block <NUM>, the snare <NUM> of the tension line <NUM> is engaged with a hook <NUM> of the extractor <NUM> and advancing the free end <NUM> of the tension line <NUM> out of the second access hole <NUM> such that the tension line <NUM> extends through the first access hole <NUM> into the medullary canal <NUM> across the fracture <NUM>, where the tension line <NUM> has threads. Then, at block <NUM>, the snare <NUM> is removed from the free end <NUM> of the tension line <NUM>. And, at block <NUM>, a stent <NUM> is advanced over the tension line through the first access hole and the medullary canal to the second access hole, where the stent <NUM> has a hole extending longitudinally therethrough that has reciprocal threads to mate with the threads of the tension line.

In one optional embodiment, any portion of the stent <NUM> extending out of either of the first access hole <NUM> and the second access hole <NUM> is cut.

In one optional embodiment, method <NUM> includes injecting the first access hole <NUM> and the second access hole <NUM> with a stiffening component or a polymer.

In one optional embodiment, a first end <NUM> of the stent <NUM> is tapered.

In one embodiment, method <NUM> includes sizing the medullary canal <NUM> by displacing the contents <NUM> of the medullary canal <NUM>. In one optional embodiment, sizing the medullary canal <NUM> by displacing the contents <NUM> of the medullary canal <NUM> includes one or more of compressing, flushing or reaming one or more of the marrow or the bone.

In <FIG>, an alternative to stent <NUM>, is to use the first plug <NUM> and the second plug <NUM> with tension line <NUM>, but without the plurality of stents <NUM>. The act of screwing the second plug <NUM> into the second access hole <NUM> over the threaded tension line <NUM> exerts a force across the rib that brings the segments of the rib together and into alignment.

Referring now to <FIG>, a method <NUM> is illustrated using various elements shown in <FIG>. Method <NUM> includes, at block <NUM>, creating a first access hole <NUM> through a cortex <NUM> of a rib <NUM> on a first side of a fracture <NUM> to a medullary canal <NUM> of the rib <NUM>. Then, at block <NUM>, the medullary canal <NUM> is accessed through the first access hole <NUM>. Next, at block <NUM>, a catheter is advanced through the first access hole <NUM> into the medullary canal <NUM> across the fracture <NUM> to a distal end <NUM> of the medullary canal <NUM>. And, at block <NUM>, a guidewire <NUM> is advanced through the catheter distal to the fracture <NUM> in the medullary canal <NUM> and an anchor <NUM> coupled to a distal end of the guidewire <NUM> is secured within the medullary canal <NUM>, where the guidewire <NUM> is configured as a tension line.

In one optional embodiment, method <NUM> includes injecting the medullary canal <NUM> with a polymer distal to the fracture <NUM>, the polymer configured to secure the anchor <NUM> within the medullary canal <NUM>. In one optional embodiment, an exterior surface <NUM> of the anchor <NUM> has a plurality of grooves, depressions or pores configured to receive the polymer. In a further optional embodiment, the anchor <NUM> is expandable and includes a stent or a plurality of radially extending barbs, where the anchor <NUM> is configured to be self-expanding or balloon-expandable. In yet another example embodiment, the anchor <NUM> is manually expandable and has a plurality of protrusions configured to engage bone material of the rib <NUM> containing the medullary canal <NUM>.

In another optional embodiment, method <NUM> includes retracting the catheter through the medullary canal <NUM> and out of the first access hole <NUM>. Then a plug <NUM> is advanced over a free end <NUM> of the guidewire <NUM> and along the guidewire <NUM> to the first access hole <NUM>. And then placing the guidewire <NUM> under tension. Application of tension to the guidewire <NUM> imparts a degree of reduction, compression and stabilization of the fracture <NUM>.

In one optional embodiment the guidewire <NUM> is threaded, and advancing the plug <NUM> down the free end <NUM> of the guidewire <NUM> and along the guidewire <NUM> to the first access hole <NUM> includes rotating the plug <NUM> about the guidewire <NUM> and screwing the first plug <NUM> into bone defining the first access hole <NUM>.

In one optional embodiment, the guidewire <NUM> has a diameter ranging from <NUM> to <NUM>.

In another optional embodiment, the method <NUM> includes sizing the medullary canal <NUM> by displacing contents <NUM> of the medullary canal <NUM> such that the medullary canal <NUM> has a diameter of at least <NUM>. In a further embodiment, sizing the medullary canal <NUM> by displacing the contents <NUM> of the medullary canal <NUM> includes one or more of compressing, flushing or reaming one or more of the marrow or the bone.

In one optional embodiment, the first access hole <NUM> is at least <NUM> from the fracture <NUM>. In another example embodiment, the first access hole is arranged at an acute angle relative to the medullary canal <NUM>, the acute angle ranging from <NUM> to <NUM> degrees. In another optional embodiment, the first access hole <NUM> is located a distance away from the fracture <NUM> and the fracture <NUM> is either located beneath a scapula or the fracture is a paravertebral fracture (see, e.g., <FIG>).

In one optional embodiment, manipulating the rib <NUM> to realign the medullary canal <NUM> across the fracture <NUM>.

Referring now to <FIG>, a method <NUM> is illustrated using various elements shown in <FIG>. Method <NUM> includes, at block <NUM>, creating a first access hole <NUM> through a cortex of a rib <NUM> on a first side of a fracture <NUM> to a medullary canal <NUM> of the rib <NUM>. Then, at block <NUM>, a first portion <NUM> of a first drill <NUM> bit is advanced through the first access hole <NUM> into the medullary canal <NUM> across the fracture <NUM> to a position distal to the fracture in the medullary canal <NUM> where the first drill bit <NUM> has a plurality of notches <NUM> configured to permit detachment from a drill. A force is applied to the first drill bit <NUM> and thereby causes a fracture <NUM> along one of the plurality of notches <NUM>, block <NUM>. And a second portion <NUM> of the first drill bit <NUM> detaches from the first portion <NUM> of the first drill bit <NUM> in the medullary canal <NUM>.

In one optional embodiment, the first access hole <NUM> is created via a second rigid drill bit. In an alternative embodiment, the first access hole <NUM> is created via the first drill bit.

In one optional embodiment, the fracture <NUM> along one of the plurality of notches <NUM> occurs adjacent to the first access hole <NUM>.

As shown in <FIG>, in one optional embodiment, the position distal to the fracture <NUM> in the medullary canal <NUM> is adjacent to a vertebra <NUM> or is subscapular. In one further embodiment, method <NUM> includes advancing the first portion <NUM> of the first drill bit <NUM> out of the cortex of the bone and into a transverse process <NUM> of the vertebra.

In one optional embodiment, the force applied to the first drill bit <NUM> is a transverse force.

In one example embodiment, the first drill bit <NUM> has a lumen extending from a first end to a second end and method <NUM> includes injecting bone cement through the lumen at the second end <NUM> and out of the first end <NUM> of the first drill bit <NUM> and into the medullary canal <NUM>.

In one optional example, the first drill bit <NUM> is in the form of a reamer. In another example embodiment, the first drill bit <NUM> includes metal or plastic.

In one optional embodiment, the first portion <NUM> of the first drill bit <NUM> has cutting edges <NUM> and the plurality of notches <NUM> are arranged every <NUM> to <NUM> along a length of the second portion <NUM> of the first drill bit <NUM>.

An apparatus, shown in <FIG>, that is utilized by method <NUM> includes a drill bit <NUM> having a first portion <NUM> and a second portion <NUM>. The first portion <NUM> of the drill bit <NUM> has threads <NUM> disposed along a length of the first portion <NUM>. The second portion <NUM> of the drill bit <NUM> has a plurality of notches <NUM> along a length of the second portion <NUM>. The plurality of notches <NUM> are configured to permit detachment from a drill <NUM> upon application of a force to the drill bit <NUM> such that a fracture <NUM> is caused along one of the plurality of notches <NUM>. The first portion <NUM> of the drill bit <NUM> and one or more notches <NUM> of the second portion <NUM> of the drill bit <NUM> are configured to remain in a medullary canal <NUM> of a rib <NUM>.

In one optional embodiment, the first drill bit <NUM> has a lumen extending from a first end <NUM> to a second end <NUM>, the lumen configured to receive bone cement through the lumen at the second end <NUM> and out of the first end <NUM> of the first drill bit <NUM> and into the medullary canal <NUM> of the rib <NUM>.

In one optional embodiment, the first drill bit <NUM> is in the form of a reamer.

In another example embodiment, the first drill bit <NUM> includes metal or plastic. In a further example, the first portion <NUM> of the first drill bit <NUM> has cutting edges <NUM> and the plurality of notches <NUM> are arranged every <NUM> to <NUM> along the length of the second portion <NUM> of the first drill bit <NUM>.

Referring now to <FIG>, a method <NUM> is illustrated using various elements shown in <FIG>. Method <NUM> is for placement of a rib plate <NUM> having a first portion <NUM> and a second portion <NUM> each having a plurality of holes <NUM> therethrough and a third portion <NUM> arranged between the first portion <NUM> and the second portion <NUM>, the third portion <NUM> of the rib plate <NUM> having a hole <NUM> configured to receive a protuberance <NUM> coupled to a porous tube <NUM> that has two open ends <NUM>, <NUM>. Method <NUM> includes, at block <NUM>, coupling the rib plate <NUM> to the porous tube <NUM>. Then, at block <NUM>, bone graft is placed in a lumen of the porous tube <NUM>. Next, at block <NUM>, the porous tube <NUM> is implanted in a gap <NUM> between a first segment of a rib <NUM> and a second segment <NUM> of the rib. And, at block <NUM>, the first portion <NUM> and the second portion <NUM> of the rib plate <NUM> are anchored to the first segment <NUM> and the second segment <NUM> of the rib such that the porous tube <NUM> is aligned with the first segment <NUM> and the second segment <NUM> of the rib.

In one optional embodiment, method <NUM> includes cutting the porous tube <NUM> to correspond to a length of the gap <NUM> between the first segment <NUM> and the second segment <NUM> of the rib.

In another optional embodiment, method <NUM> includes placing the bone graft in the lumen of the porous tube <NUM> after coupling the rib plate <NUM> to the porous tube <NUM>. In an alternative embodiment, method <NUM> includes placing the bone graft in the lumen of the porous tube <NUM> prior to coupling the rib plate <NUM> to the porous tube <NUM> coupling the rib plate to the porous tube comprises pressing the protuberance of the tube into the hole of the third portion of the rib plate.

In one optional embodiment, the third portion <NUM> of the rib plate <NUM> has a length that corresponds to a length of the gap <NUM> between the first segment <NUM> and the second segment <NUM> of the rib. In another example embodiment, the third portion <NUM> of the rib plate <NUM> has a width shorter than a width of either of the first portion <NUM> or the second portion <NUM> of the rib plate <NUM>.

In one optional embodiment, the porous tube <NUM> includes a metal alloy or bio-absorbable material. In another example embodiment, the porous tube <NUM> includes a polygonal or circular cross-section.

In one optional embodiment, prior to implanting the porous tube <NUM> in the gap <NUM> between the first segment <NUM> of the rib and the second segment <NUM> of the rib removing one or more bone fragments from between the first segment <NUM> and the second segment <NUM> of the rib.

In one optional embodiment, method <NUM> includes anchoring the first portion <NUM> and the second portion <NUM> of the rib plate to the first segment <NUM> and the second segment <NUM> of the rib such that the porous tube <NUM> is aligned with the first segment <NUM> and the second segment <NUM> of the rib comprises deploying each of a plurality of anchors through one of the plurality of holes <NUM> in the first portion <NUM> and the second portion <NUM> of the rib plate <NUM>.

In one optional embodiment, method <NUM> includes fusing the bone graft to the first segment <NUM> and the second segment <NUM> of the rib. In this embodiment, the bone graft will replace lost bone and augment the structural support of the rib plate <NUM> across the gap <NUM>.

A system, shown in <FIG>, that is utilized by method <NUM> includes a rib plate <NUM> having a first portion <NUM> and a second portion <NUM> each having a plurality of holes <NUM> therethrough and a third portion <NUM> arranged between the first portion <NUM> and the second portion <NUM>. The system also includes a porous tube <NUM> that has two open ends <NUM>, <NUM> and a protuberance <NUM> arranged between the two ends <NUM>, <NUM> that extends from an exterior surface <NUM> of the porous tube <NUM>. The third portion <NUM> of the rib plate <NUM> has a hole <NUM> configured to receive the protuberance <NUM> of the porous tube <NUM>. And the system includes bone graft disposed in a lumen of the porous tube <NUM>.

In one optional embodiment, the porous tube <NUM> is configured to be sized to correspond to a length of a gap <NUM> between a first segment <NUM> and a second segment <NUM> of a rib.

In another optional embodiment, the protuberance <NUM> has a diameter larger than a diameter of the hole <NUM> in the third portion <NUM> of the rib plate <NUM>. In another example embodiment, the protuberance <NUM> and the hole <NUM> of the third portion <NUM> of the rib plate <NUM> have reciprocal mating features to retain the protuberance <NUM> within the hole <NUM> of the third portion <NUM> of the rib plate <NUM>. In a further embodiment, the reciprocal mating features are in the form of a rib and a groove or two ribs.

In another example embodiment, the third portion <NUM> of the rib plate <NUM> has a length that corresponds to a length of a gap <NUM> between a first segment <NUM> and a second segment <NUM> of a rib. In one optional embodiment, the third portion <NUM> of the rib plate <NUM> has a width shorter than a width of either of the first portion <NUM> or the second portion <NUM> of the rib plate <NUM>.

Claim 1:
A system, comprising:
a tension line (<NUM>) having threads (<NUM>);
a first plug (<NUM>) configured to be advanced down a free end (<NUM>) of the tension line (<NUM>) and a second access hole (<NUM>) of a rib (<NUM>), wherein the first plug (<NUM>) has a hole (<NUM>) extending longitudinally therethrough that has reciprocal threads to mate with the threads (<NUM>) of the tension line (<NUM>);
a plurality of stents (<NUM>) configured to be advanced over the tension line (<NUM>) through a first access hole (<NUM>) in the rib (<NUM>) into the medullary canal (<NUM>) of the rib (<NUM>) until a length of the medullary canal (<NUM>) between the first access hole (<NUM>) and the second access hole (<NUM>) is filled with the plurality of stents (<NUM>); and
a second plug (<NUM>) configured to be advanced down an end of the tension line (<NUM>) and into the first access hole (<NUM>), wherein the second plug (<NUM>) has a hole (<NUM>) extending longitudinally therethrough that has reciprocal threads to mate with the threads (<NUM>) of the tension line (<NUM>),
wherein
the tension line (<NUM>) having a removable snare (<NUM>) at the free end (<NUM>),
and
wherein each of the plurality of stents (<NUM>) has a concave face at a first end (<NUM>) and a convex face at a second end (<NUM>) such that, when the plurality of stents (<NUM>) are arranged adjacent to each other along the tension line (<NUM>), the concave face of the first end (<NUM>) of a first stent (<NUM>) will mate with the convex face of the second end (<NUM>) of an adjacent second stent (<NUM>).