U.S. patent application number 13/970269 was filed with the patent office on 2013-12-12 for method and apparatus for internal fixation of an acromioclavicular joint dislocation of the shoulder.
This patent application is currently assigned to Arthrex, Inc.. The applicant listed for this patent is Arthrex, Inc.. Invention is credited to Brian Thornes.
Application Number | 20130331886 13/970269 |
Document ID | / |
Family ID | 37662606 |
Filed Date | 2013-12-12 |
United States Patent
Application |
20130331886 |
Kind Code |
A1 |
Thornes; Brian |
December 12, 2013 |
METHOD AND APPARATUS FOR INTERNAL FIXATION OF AN ACROMIOCLAVICULAR
JOINT DISLOCATION OF THE SHOULDER
Abstract
An apparatus for surgically reducing and internally fixing a
shoulder acromioclavicular joint dislocation. The apparatus
preferably comprises a button and a washer, the washer being
flexibly secured to the coracoid process of the scapula by means of
a bone screw, the button and washer being secured together by means
of a first suture. A second suture is provided and secured between
the button and a needle, such that the needle and associated
button, may be advanced through a hole drilled through the
clavicle. The button and the washer may then be tightened, reducing
the coracoclavicular distance, by means of the first suture
connected therebetween, to reduce and hold a desired
acromioclavicular joint dislocation.
Inventors: |
Thornes; Brian; (Dublin,
IE) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Arthrex, Inc. |
Naples |
FL |
US |
|
|
Assignee: |
Arthrex, Inc.
Naples
FL
|
Family ID: |
37662606 |
Appl. No.: |
13/970269 |
Filed: |
August 19, 2013 |
Related U.S. Patent Documents
|
|
|
|
|
|
Application
Number |
Filing Date |
Patent Number |
|
|
11482038 |
Jul 7, 2006 |
8512376 |
|
|
13970269 |
|
|
|
|
10233122 |
Aug 30, 2002 |
7235091 |
|
|
11482038 |
|
|
|
|
60697125 |
Jul 7, 2005 |
|
|
|
Current U.S.
Class: |
606/232 |
Current CPC
Class: |
A61B 2017/0404 20130101;
A61B 17/68 20130101; A61B 17/86 20130101; A61B 2017/044 20130101;
A61B 2017/564 20130101; A61B 17/0401 20130101; A61B 17/068
20130101 |
Class at
Publication: |
606/232 |
International
Class: |
A61B 17/04 20060101
A61B017/04 |
Foreign Application Data
Date |
Code |
Application Number |
Jun 20, 2002 |
IE |
S2002/0504 |
Claims
1. An apparatus for use in internal fixation of acromioclavicular
joint dislocations of a shoulder, the shoulder including a
clavicle, a coracoid process and an acromium, the apparatus
comprising: a first suture anchor; a second suture anchor, the
first and second suture anchors being adapted for engagement in or
on the clavicle and the coracoid process, respectively; a flexible
coupling mountable, in use, between the first and second suture
anchors; and a needle releasably securable to at least one of the
first and second suture anchors, in which the first and second
suture anchors each have at least first and second apertures and
the flexible coupling is a first suture which is double looped
through the first and second suture anchors.
2. The apparatus according to claim 1, in which the flexible
coupling is a first suture which is fed, in use, through a first
aperture of the second suture anchor, and through, in turn, the
second and first apertures of the first suture anchor and through,
in turn, second and first apertures of the second suture anchor,
and through, in turn the second and first apertures of the first
suture anchor and through the second aperture of the second suture
anchor.
3. The apparatus according to claim 1, in which the needle is
secured to at least one of the first and second suture anchors by
means of a second suture looped through one of the first or second
apertures of at least one of the first and second suture anchors
and operatively associated with the needle.
4. The apparatus according to claim 1, in which the first suture
anchor comprises a button and the second suture anchor comprises a
washer, the washer being adapted and dimensioned to engage with a
bone anchor.
5. The apparatus according to claim 1, in which the first suture
anchor is a button having an oblong body and first and second
apertures and the second suture anchor is a washer adapted to
engage with a bone anchor and having at least two, preferably at
least four, peripheral apertures.
6. The apparatus according to claim 5, in which the first suture is
fed through a first peripheral aperture of the washer and through,
in turn, the second and first apertures of the button and through,
in turn, second and third peripheral apertures of the washer, and
through, in turn the second and first apertures of the button and
through the fourth peripheral aperture of the washer.
7. An apparatus for use in internal fixation of acromioclavicular
joint dislocations of a shoulder, the shoulder including a
clavicle, a coracoid process and an acromium, the apparatus
comprising: a first member; a second member, the first and second
members being adapted for engagement in or on the clavicle and the
coracoid, respectively; and a flexible coupling between the first
and second members, the flexible coupling comprising a suture
strand which is double looped through the first and second members.
Description
[0001] This application is a divisional of application Ser. No.
11/482,038, filed Jul. 7, 2006, now U.S. Pat. No. 8,512,376, which
claims the benefit of U.S. Provisional Application Ser. No.
60/697,125 filed on Jul. 7, 2005, and which is a
continuation-in-part of application Ser. No. 10/233,122, filed Aug.
30, 2002, now U.S. Pat. No. 7,235,091, which claims priority under
35 U.S.C. .sctn.119 to IE S2002/0504, filed Jun. 20, 2002. The
entire disclosures of all priority application listed above are
incorporated herein by reference.
FIELD OF THE INVENTION
[0002] The present invention relates to an apparatus for internal
fixation of an acromioclavicular joint dislocation of the shoulder
with resultant superior migration of the lateral end of the
clavicle with respect to the acromium and the coracoid of the
scapula.
BACKGROUND OF THE INVENTION
[0003] Acromioclavicular ("AC") joint dislocations are
characterized by severe upward displacement of the lateral end of
the clavicle relative to the acromium of the scapula. Surgery is
recommended to reduce and internally fix the displacement, which
could otherwise lead to a painful deformity and loss of
function.
[0004] This invention relates to reconstruction surgery and
particularly to reconstruction surgery for Rockwood types II-VI AC
joint dislocations of the shoulder (Rockwood, Williams, &
Young, Injuries to the Acromioclavicular Joints, in FRACTURES IN
ADULTS 1341-1413 (Rockwood & Green, eds., 3.sup.rd ed., 1996)).
More particularly, the invention relates to the use of a first
suture anchor-suture-second suture anchor technique to reduce and
internally fix the dislocation between the clavicle and the
coracoid process.
[0005] Injuries to the AC joint are generally classified as types
I-VI, depending on the type and amount of disruption to the AC and
the coracoclavicular ligaments. A type III AC dislocation of the
shoulder is a common injury that occurs primarily from having a
fall to the point of the shoulder. A type III injury is
characterized by disruption of the AC and coracoclavicular
ligaments, the dislocation of the AC joint and the upward relative
displacement of the lateral end of the clavicle. The
coracoclavicular interspace is greater than in the normal
shoulder.
[0006] There are presently two basic treatment options available:
non-operative treatments and operative procedures.
[0007] The non-operative option includes external, closed
reduction. Various external, closed reduction procedures have been
tried in the past using straps, casts, and different taping
techniques. Generally, it has been believed that the procedures
would work if applied continuously. Unfortunately, it has been
found not to work as no one can wear them continuously because of
skin breakdown and discomfort. As a result, such treatment regimes
rarely have been successful. The patient must inevitably accept a
cosmetic deformity and suffer from pain and fatigue after prolonged
physical activity or heavy lifting.
[0008] Operative treatments to date have focused on open reduction
and direct repair or reconstruction of the ligaments. This
procedure corrects the deformity and is generally accepted as
providing the best results. However, this usually entails an
extensive open operation. The deltoid and trapezius muscles are
taken off the clavicle and dissected to expose the underside of the
clavicle and the coracoclavicular ligaments and the coracoid
process. The procedure requires an in-hospital stay, extended time
for the surgical wound to heal, and rehabilitation. The open
reduction procedure is generally recommended as the treatment of
choice for people involved in heavy lifting work or active
athletics. The remaining population is generally told to accept the
deformity and to accept the pain and fatigue after heavy lifting or
activity.
[0009] It is well-known in the art to fix the coracoclavicular
space by drilling a hole through the clavicle and into the coracoid
process and by then inserting a screw (a Bosworth screw, for
example) therebetween. It is also well-known to loop a flexible
coupling such as a nylon tape around both the coracoid and the
clavicle and to knot them together. This has the disadvantage of
requiring that all of the coracoid be exposed. It is also known to
drill a hole in the coracoid process and attach a single suture
anchor, with a pair of sutures extending therefrom, into the
coracoid. The free ends of the sutures are then looped about the
clavicle and tied to each other.
[0010] Non-operative treatment options generally provide
unacceptable results. The open reduction treatment, while providing
generally good results, has the disadvantage of an in-hospital stay
plus the extensive time required for healing and rehabilitation. A
surgical outpatient technique that would correct the deformity and
allow healing of the injury in a normal anatomic position without
extensive tissue dissection and less scarring would provide a
substantial improvement over current treatment methods.
[0011] It is an object of the present invention to overcome the
problems associated with the prior art, whilst permitting normal
physiological movement of the clavicle relative to the
coracoid.
BRIEF SUMMARY OF THE INVENTION
[0012] The present invention relates to a surprising use of a first
suture anchor-suture-second suture anchor technique. The method of
the present invention is simple and is performed by a mini-open
approach.
[0013] In a first aspect of the present invention there is provided
an apparatus for use in internal fixation of AC joint dislocations
of a shoulder. The apparatus of the first aspect of the present
invention is a kit of parts for internal fixation of an AC joint
dislocation of a shoulder, the shoulder including a clavicle, a
coracoid process and an acromium, the kit of parts comprising a
first suture anchor; a second suture anchor, the first and second
suture anchors being adapted for engagement in or on the clavicle
and the coracoid process, respectively; a flexible coupling
mountable, in use, between the first and second suture anchors; and
a needle releasably securable to at least one of the first and
second suture anchors, in which the first and second suture anchors
each have at least first and second apertures and the flexible
coupling is a first suture which is double looped through the first
and second suture anchors.
[0014] Preferably, the first suture is fed, in use, through a first
aperture of the second suture anchor, and through, in turn, the
second and first apertures of the first suture anchor and through,
in turn, second and first apertures of the second suture anchor,
and through, in turn, the second and first apertures of the first
suture anchor and through the second aperture of the second suture
anchor.
[0015] Preferably, the first suture anchor comprises a button and
the second suture anchor comprises a washer, the washer being
adapted and dimensioned to engage with a bone anchor.
Alternatively, each of the first and second suture anchors can be a
button. In another embodiment, each of the first and second suture
anchors can be a washer, the washer being adapted and dimensioned
to engage with a bone anchor. In yet another embodiment, the first
suture anchor is a washer and the second suture anchor is a button.
The bone anchor may be a bone screw, a bone nail, a bone staple or
an intraosseous bone anchor. A bone screw is preferred. Even more
preferably, the washer has a central aperture and at least two,
preferably at least four, peripheral apertures, the central
aperture being adapted and dimensioned to accept a bone screw.
[0016] More preferably, the first suture anchor is a button having
an oblong body and first and second apertures and the second suture
anchor is a washer adapted to engage with a bone anchor and having
at least two, preferably at least four, peripheral apertures. In
this embodiment, the first suture is fed through a first peripheral
aperture of the washer and through, in turn, the second and first
apertures of the button and through, in turn, second and third
peripheral apertures of the washer, and through, in turn, the
second and first apertures of the button and through the fourth
peripheral aperture of the washer. A loop is formed on the
underneath of the washer, by the path of the first suture between
the second and third peripheral apertures. If desired, the free
ends of the first suture may be fed under this loop, to provide a
self-tightening suture.
[0017] When one or both of the suture anchors is a button, the
needle is preferably secured to one or both of the first and second
buttons by means of a second suture looped through one of the first
or second apertures of the first and/or second buttons, the second
suture being operatively associated with the needle.
[0018] In a second aspect of the present invention there is
provided a method for internal fixation of AC joint dislocations.
The method of the present invention comprises the steps of
providing an apparatus according to the first aspect of the present
invention; securing the first and second suture anchors on or
adjacent the clavicle and the coracoid process, respectively; and
reducing and fixing the distance between the clavicle and the
coracoid process, by traction of the flexible coupling.
[0019] When the apparatus of the first aspect of the invention
comprises a button as the first suture anchor and a washer as the
second suture anchor, the method preferably comprises the steps of
drilling a clavicle hole through the clavicle and a coracoid hole
into the coracoid process; passing the needle through the clavicle
hole, so as to advance the button longitudinally through the
clavicle hole; pivoting the button so as to engage the button
against a superior surface of the clavicle; inserting a screw
through a central aperture of the washer into the coracoid hole in
a superior aspect of the coracoid process; and reducing and fixing
the distance between the clavicle and the coracoid process, by
traction of the flexible coupling. Preferably, the needle is
uncoupled from the button when the button has been advanced through
the clavicle hole and has engaged against the superior surface of
the clavicle.
[0020] It will be appreciated by those skilled in the art that
traction of the flexible coupling can be effected by hand traction
or by the use of a suture tensioner. Suitable suture tensioners are
well known in the art.
[0021] In a third aspect of the present invention there is provided
a button for use in the apparatus of the first aspect of the
invention and for use in the method of the second aspect of the
present invention. The button of the third aspect of the invention
can be used as either the first or second suture anchor or as each
of the first and second suture anchors. The button of the third
aspect of the present invention may comprise an oblong body
defining first and second apertures. Preferably, each of the first
and second apertures is oblong, their longitudinal mid-lines being
located substantially about a longitudinal mid-line of the oblong
body.
[0022] Alternatively, each of the first and second apertures is
substantially triangular in plan view. In this alternative
embodiment, each aperture is tapered and terminates in an apex, the
apices being directed away from each other. Preferably, each of the
apertures comprises first, second and third walls and the first
walls of the respective first and second apertures are
substantially parallel.
[0023] The button of the third aspect of the present invention may
have any suitable dimension (width, length and thickness). If the
button is oblong, for example, the button of the third aspect of
the present invention can have a width of 2.5 mm to 4.0 mm without
compromising implant strength, although a width of 3.0 mm to 4.0 mm
is preferred. The length of the button of the third aspect of the
present invention is less critical but may, for example, be in the
range 7.5 mm to 12.5 mm. A length in the range 9 mm to 11 mm is
preferred since the button of the third aspect of the present
invention is then slightly less palpable under the skin following
implantation.
[0024] Each of the first and second apertures of the button of the
third aspect of the present invention may have any shape or
geometry. For example, one embodiment is an aperture which is
substantially triangular in plan view. Another embodiment is an
egg-shaped or oval aperture, the curved narrower end comprising the
apex.
[0025] In a fourth aspect of the present invention there is
provided a washer for use in the apparatus of the first aspect of
the invention and for use in the method of the second aspect of the
present invention. The washer of the fourth aspect of the invention
can be used as either the first or second suture anchor or as each
of the first and second suture anchors. The washer of the fourth
aspect of the present invention comprises a body adapted for
engagement with a bone anchor and having at least two, preferably
at least four, peripheral apertures. The washer of the fourth
aspect of the present invention optionally comprises a disc-shaped
body defining a central aperture shaped and dimensioned to accept a
bone screw and having four peripheral apertures. Preferably, each
of the central and peripheral apertures is circular in plan
view.
[0026] The washer of the fourth aspect of the present invention can
have an external diameter of 6.5 mm to 13.0 mm and a thickness of
1.0 mm to 2.0 mm without compromising implant strength, although an
external diameter of 8 mm to 12 mm and a thickness of about 1.5 mm
is preferred. The central aperture of the washer of the fourth
aspect of the present invention can have an internal diameter of
2.5 mm to 6.5 mm, although an internal diameter of 3.5 mm to 5.5 mm
is preferred. In an optional embodiment, the four peripheral
apertures of the washer of the fourth aspect of the present
invention can have an internal diameter of 0.5 mm to 2.0 mm,
although an internal diameter of 0.8 mm to 1.2 mm is preferred.
[0027] As used herein, the term "button" or "washer" is intended to
mean any suitably shaped and dimensioned suture anchor or stress
bearing member which is capable of transmitting a force incident
thereon to any body with which the button or washer is in
contact.
BRIEF DESCRIPTION OF THE DRAWINGS
[0028] These and other features and advantages of the invention
will be more apparent from the following detailed description that
is provided in connection with the accompanying drawings and
illustrated exemplary embodiments of the invention, in which:
[0029] FIGS. 1 and 1a show an anterior view and a schematic view,
respectively, of a normal acromioclavicular joint;
[0030] FIGS. 2 and 2a show an anterior view and a schematic view,
respectively, of a Rockwood Type III acromioclavicular joint
dislocation, with superior migration of the clavicle with respect
to the acromium;
[0031] FIG. 3 shows a plan view of a first or second suture anchor
in the form of a button of the present invention;
[0032] FIG. 4 shows perspective, plan and sectional view of an
alternative embodiment of a button according to the invention;
[0033] FIGS. 5 and 5a show a plan and an undersurface view,
respectively, of a first or second suture anchor in the form of a
washer of the present invention;
[0034] FIG. 5b illustrates the mobile positioning of the washer
against an arcuate undersurface of the screw-head of a bone
anchor;
[0035] FIG. 6 shows a perspective view of the kit of parts
comprising an apparatus of the present invention; and
[0036] FIGS. 7a-7f illustrate, in sequence, the steps of a method
according to the present invention.
DETAILED DESCRIPTION OF THE INVENTION
[0037] In the following detailed description, reference is made to
the accompanying drawings, which form a part hereof and illustrate
specific embodiments in which the invention may be practiced. In
the drawings, like reference numerals describe substantially
similar components throughout the several views. These embodiments
are described in sufficient detail to enable those skilled in the
art to practice the invention, and it is to be understood that
other embodiments may be utilized, and that structural, logical and
electrical changes may be made without departing from the spirit
and scope of the present invention.
[0038] The present invention provides minimally invasive, flexible
fixation of the AC joint dislocation by resisting superior
migration of the clavicle with respect to the coracoid process. It
allows physiological micromotion at the AC joint. There should be
no need for routine removal of the implant.
[0039] The present invention is indicated for use in the fixation
of AC joint dislocation. These are typically seen in Rockwood type
III AC joint dislocations, usually caused by severe downward blunt
trauma to the point of the shoulder, or acromium. Typically, the
clavicle is upwardly displaced as a result of the injury because of
disruption to the AC and coracoclavicular ligaments. Reduction and
fixation of displaced AC joint dislocations are necessary to
prevent painful deformity and loss of function.
[0040] FIGS. 1 and 1a show anterior and schematic views of a normal
shoulder 10. FIGS. 2 and 2a show anterior and schematic views of a
shoulder 10 that has suffered a Rockwood type III AC joint
dislocation injury.
[0041] Referring to FIGS. 1 and 2, the structure of a shoulder 10
relevant to a Rockwood type III dislocation injury includes the
clavicle 12, the coracoid process 14 and the acromium 16. The
acromium 16 and the clavicle 12 are connected by the
acromioclavicular ligament 18. The acromioclavicular ligament 18
extends from the lateral end 20 of the clavicle 12 to the medial
surface 22 of the acromium 16. The coracoid process 14 is connected
to the clavicle 12 by the coracoclavicular ligaments 24, which
comprise the trapezoid ligament 26 and the conoid ligament 28. The
coracoclavicular ligaments 24 extend from the inferior surface 30
of the clavicle 12 to the superior surface 32 of the coracoid
process 14.
[0042] A Rockwood type III AC joint dislocation is characterized by
the disruption of the AC and the coracoclavicular ligaments 18, 24,
respectively. As shown in FIGS. 2 and 2a, the clavicle 12 separates
from, and moves away from, the coracoid process 14 and the acromium
16, accompanied by disruption of the coracoclavicular and the AC
ligaments 18, 24, respectively. The acromioclavicular joint 34
(FIG. 2) is dislocated and the clavicle 12 is relatively displaced
upwardly. The coraco-acromial ligament 36 (FIG. 1) is not impacted
in the type III shoulder dislocation.
[0043] Repair of the type III shoulder dislocation according to the
present invention is an out-patient procedure performed with a
general anesthetic. The procedure is done with the patient lying
supine on the operating table, preferably in the "deck-chair"
position to allow the surgeon full access to the affected
shoulder.
[0044] Referring to FIG. 3, the apparatus of the present invention
comprises a first or second suture anchor in the form of a button
50, which, in the embodiment illustrated, is about 10.0 mm in
length by about 3.5 mm in width. The button 50 is preferably formed
from titanium or stainless steel, although it will be appreciated
that any other suitable material could be used, in particular any
suitable bioabsorbable material. The button 50 has a first aperture
52 and a second aperture 54 which, in the embodiment illustrated,
are oblong in shape, the longitudinal mid-line of each of the first
and second apertures 52, 54 being located substantially about a
longitudinal mid-line of the button 50.
[0045] Referring to FIG. 4, there is illustrated an alternative
first or second suture anchor, generally indicated as 150. In the
illustrated alternative embodiment, the button 150 is about 9.0 mm
in length by about 3.5 mm in width, with a thickness of about 1.5
mm. The button 150 has first and second apertures 152 and 154,
respectively. In the illustrated alternative embodiment, each of
the apertures 152, 154 are triangular in shape, the respective
apices 155 being directed away from each other and being located
substantially about a longitudinal mid-line of the button 150.
[0046] Reference is now made to FIGS. 5 and 5a which illustrate a
first or second suture anchor in the form of a washer 60. In the
illustrated embodiment, the washer 60 has an external diameter of
about 10.0 mm. While the illustrated washer is disc-shaped, the
washer is not so limited. The washer 60 is preferably formed from
titanium or stainless steel although, as will be appreciated by
those skilled in the art, any other suitable material, in
particular any suitable bioabsorbable materials, may be used. The
washer 62 also has at least two flexible coupling-locating
apertures 64. In the illustrated embodiment, there are four
apertures 64 circumferentially arranged about the aperture 62. In
the illustrated embodiment, each of the apertures 64 has a diameter
of about 1.0 mm. Each of the apertures 64 have beveled edges, above
and below, while the aperture 62 has beveled edges above.
[0047] The washer 60 also has a substantially centrally located
bone screw-retaining aperture 62. In the illustrated embodiment,
the aperture 62 has a diameter of about 4.6 mm and the washer 60 is
adapted to allow mobile positioning against an arcuate undersurface
69 of the head of the bone screw 68 (illustrated in FIG. 5b).
[0048] Referring to FIGS. 5 and 5a, the washer 60 of the fourth
aspect of the present invention is provided with a screw-retaining
aperture 62 and at least two flexible coupling-locating apertures
64 which are preferably countersunk so as to allow easier threading
passage of the flexible coupling 70 (not shown in FIGS. 5-5b). Care
needs to be taken in such countersinking, to avoid compromising the
mechanical strength of the apertures 62, 64 of the washer 60.
[0049] FIG. 6 illustrates the implant apparatus used for fixation
of the AC joint dislocation. The button 50 and the washer 60 are
secured or pre-threaded together by means of a flexible coupling in
the form of first suture 70, preferably of number 5-strength
braided polyester, which is double looped through the first and
second apertures 52, 54 of the button 50 and the peripheral
apertures 64 of the washer 60, as will now be described in greater
detail. Specifically, the first suture 70 is fed through to
aperture 64a of the washer 60; through the second and first
apertures 54, 52 of the button 50; through the aperture 64b, under
the washer 60 and back out the aperture 64c; through the second and
first apertures 54, 52 of the button 50 again; and finally through
the aperture 64d of the washer 60. A needle 72, which may be
straight or curved, with a second, pull-through suture 74 is also
looped through either the first or second apertures 52, 54 of the
button 50. The second suture 74 is looped through the first
aperture 52 of the button 50.
[0050] The first suture 70 used in the apparatus can be made from
any material which is suitable for this purpose, whether absorbable
or non-absorbable, provided it is sufficiently strong. A number
5-strength braided polyester (FIBERWIRE.RTM.) suture is preferred.
This is a non-absorbable suture which knots easily without
slipping. The second suture 74 can be made from any material which
is suitable for this purpose, and preferably should be at least
0-strength.
[0051] The pull through needle 72 can be of any dimensions,
provided it is long enough to span the clavicle 12 or the coracoid
process 14 of the shoulder 10. The needle 72 is preferably about
100 mm in length. The needle's body can either be straight or
curved. The needle's tip can be either "taper cut" or
"cutting."
[0052] In the present embodiment, leading and trailing edges of the
button 50 are substantially symmetrical, although it will be
appreciated that this is not a requirement of the present
invention. Specifically, the leading edge 56 (illustrated in FIG.
6) of the button 50 should be blunt and should have a width
sufficient to reduce the possibility that the leading edge 56 of
the button 50 follows the second or pull-through suture 74 through
the intact skin or to catch or skewer any soft tissue structures
between the bone and the skin, as will be described in detail
hereinafter.
[0053] FIG. 6 also illustrates a bone screw 68 as part of the
implant apparatus. The bone screw 68 is used for engaging the
washer 60 with the coracoid process 14 (FIG. 7f). As discussed
below in detail and with reference to FIG. 5b, the bone screw 68
has an arcuate undersurface 69 for defining the movement of the
washer 60 between the coracoid process 14 and the arcuate
undersurface 69.
TABLE-US-00001 TABLE 1 Apparatus/Button of FIGS. 3 and 6 Button 50
overall 10.0 mm (length) .times. 3.5 mm (width) .times. 1.5 mm
dimensions: (thickness) Basic shape: Oblong in plan shape, with
chamfered or rounded corners and edges - this reduces the chance of
the button 50 being palpated under the skin and, in addition, eases
the passage of the button 50 through a drill hole as will be
explained hereinafter. Button 50 material: Preferably titanium or
stainless steel Button apertures Two apertures 52, 54 (oblong in
plan shape) 52, 54: Apertures 52, 54 2 mm height .times. 3 mm
length (oblong with dimensions: chamfered edges), preferably 1 mm
distance between first and second apertures Suture 70 Number
5-strength braided polyester suture, (first suture): looped twice
through the first and second apertures 52, 54 of the button 50 and
each of the four peripheral apertures 64 (64a, 64b, 64c, 64d) of
the washer 60, leaving the two free ends of suture 70 free for
tying adjacent the undersurface of the washer 60. Pull-through
needle 100 mm long straight, or curved, needle 72 with 72:
pull-through, or second suture 74 attached. Pull-through suture 74:
Minimum 0-strength suture 74 looped through the aperture 52 of the
button 50, second suture 74 being secured to needle 72.
[0054] The following sets out the procedure, as shown in FIGS.
7a-7f, to be followed for Rockwood Type III dislocations. Surgeons
skilled in the art will appreciate the modifications that might be
needed in addressing Rockwood Type II and IV-VI dislocations.
Set-up
[0055] The patient is positioned in a "deck-chair" position on the
operating table (not shown). A sandbag (not shown) can be placed
under the scapula to ease access to the shoulder region. A
longitudinal or horizontal incision of about 5 cm is made on the
skin, at the front of the shoulder, overlying the coracoid process
14 and the clavicle 12. The clavicle 12 and the superior surface of
the coracoid process 14 are exposed by blunt dissection. As
explained in detail below, if the clavicle hole 80 is to be drilled
(FIG. 7a) from above and substantially downwardly through the
clavicle 12, it will also be necessary to retract the skin about
the clavicle 12, in order to expose the superior surface 33 of the
clavicle 12.
Instrumentation
[0056] A 3.5 mm drill bit is required for drilling a hole 80
through the clavicle 12. A 2.5 mm drill bit is required for
drilling a hole 82 into the base of the coracoid process 14 of the
scapula (FIG. 7a). It is not necessary that the drill holes 80, 82
be aligned with each other. In addition, it is not necessary, when
the coracoclavicular interspace is reduced to normal, that the
longitudinal axes of the respective drill holes 80, 82 be co-linear
or even substantially parallel with each other.
Button Placement
[0057] As illustrated in FIG. 7b, the long straight needle 72 with
pull-through, second suture 74 is passed upwards through the 3.5 mm
drill hole 80 in the clavicle 12 and can be passed through the
intact skin on the superior aspect of the clavicle 12 or through
the open surgical wound. In FIG. 7c, the pull-through suture 74,
which engages the first aperture 52 (not shown) of the button 50,
can now advance the button 50, substantially longitudinally through
the drill hole 80. Engagement of the second suture 74 in the
aperture 52 (not shown) ensures that the second suture 74 is
located adjacent the longitudinal mid-line of the button 50 so that
the second suture 74 stays central in the first aperture 52.
[0058] In FIG. 7d, once the button 50 has exited the superior
surface 33 of the clavicle 12, the angle of traction on the
pull-through, or second, suture 74 is changed and counter-traction
is exerted on the first suture 70, in order to flip (pivot) the
button 50 and engage the button 50 against the superior surface 33
of the clavicle 12. Once the button 50 is anchored, the
pull-through, or second, suture 74 can be cut and removed (FIGS. 7d
and 7e). In FIG. 7f, the screw 68 containing the washer 60 is
inserted into the 2.5 mm drill hole 82 (FIG. 7e) in the base of the
coracoid process 14 of the scapula. Before the washer 60/bone screw
68 is fully seated into the drill hole 82, the acromioclavicular
joint 34 is reduced by downward manual pressure on the lateral end
20 of the clavicle 12 (FIGS. 7e and 7f).
[0059] The two trailing ends of the first suture 70 (FIG. 7e) are
pulled to approximate the desired distance between the button 50
and the washer 60, and hence reduce the interval between the
clavicle 12 and the coracoid process 14. The first suture 70 is
then secured to itself with a knot, tied tight by hand. The free
ends of the first suture 70 can then be cut approximately lcm long,
to avoid knot slippage. The screw 68 can then be fully seated into
the drill hole 82 in the coracoid process 14 to maximize suture
tension, or may be advanced or retracted accordingly to fine tune
the suture tension, according to the surgeon's preference.
[0060] The volume between the arcuate undersurface 69 of the bone
screw 68 and the coracoid process 14 defines the maximum
flexibility of the washer 60 therebetween. The designed flexibility
is helpful in increasing the tolerance for non-aligned drill holes
and the like.
Post-operative Management
[0061] Following wound closure, the shoulder should be placed in a
shoulder immobilizer for three weeks. Gentle range of motion
exercises can begin after three weeks. Full range exercises can be
allowed after six weeks.
Implant Removal
[0062] Routine removal of the first suture anchor-suture-second
suture anchor construct is not required. If, for any reason, it
needs to be removed, this can be performed simply by re-opening the
surgical incision, cutting the first suture 70 as it loops through
the button 50 and removing the button 50. The screw 68 and washer
60 can be removed easily using the screwdriver.
[0063] It is noted that the above description and drawings are
exemplary and illustrate preferred embodiments that achieve the
objects, features and advantages of the present invention. It is
not intended that the present invention be limited to the
illustrated embodiments. Any modification of the present invention
which comes within the spirit and scope of the following claims
should be considered part of the present invention.
* * * * *