U.S. patent application number 14/804523 was filed with the patent office on 2016-03-31 for method and apparatus for performing a less invasive shoulder procedure.
The applicant listed for this patent is Biomet Manufacturing, LLC.. Invention is credited to Paul E. Schwartz, Nathan A. Winslow.
Application Number | 20160089164 14/804523 |
Document ID | / |
Family ID | 48086478 |
Filed Date | 2016-03-31 |
United States Patent
Application |
20160089164 |
Kind Code |
A1 |
Winslow; Nathan A. ; et
al. |
March 31, 2016 |
METHOD AND APPARATUS FOR PERFORMING A LESS INVASIVE SHOULDER
PROCEDURE
Abstract
A method and apparatus of performing a procedure relative to the
glenohumeral joint. Resection of the glenoid and/or the humerus can
proceed through an incision formed near the glenohumeral joint. The
incision can be formed generally near a superior-lateral portion
near the glenohumeral joint and allow less invasive access to the
glenohumeral joint and the portions that form the glenohumeral
joint. The procedure can be performed with no or little detaching
of the subscapularis, and with no or little dislocating of the
glenohumeral joint.
Inventors: |
Winslow; Nathan A.; (Warsaw,
IN) ; Schwartz; Paul E.; (Palo Cedro, CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Biomet Manufacturing, LLC. |
Warsaw |
IN |
US |
|
|
Family ID: |
48086478 |
Appl. No.: |
14/804523 |
Filed: |
July 21, 2015 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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13707636 |
Dec 7, 2012 |
9119643 |
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14804523 |
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11096202 |
Mar 31, 2005 |
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13707636 |
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Current U.S.
Class: |
606/80 |
Current CPC
Class: |
A61B 17/15 20130101;
A61B 17/1778 20161101; A61B 17/1739 20130101 |
International
Class: |
A61B 17/17 20060101
A61B017/17; A61B 17/15 20060101 A61B017/15 |
Claims
1.-8. (canceled)
9. A glenoid resection guide for guiding the formation of various
resections of a glenoid when performing a procedure relative to the
glenoid, the glenoid resection guide comprising: a superior
surface; an inferior surface shaped to fit within a reamed glenoid;
a bore extending between a first opening on the superior surface
and a second opening on the interior surface and positioned on the
glenoid resection guide to guide a resection instrument to form a
bore in the glenoid; a connection portion positioned along an edge
of the superior surface; and a handle to interconnect with the
connection portion to assist in positioning the glenoid resection
guide relative to the glenoid.
10. The glenoid resection guide of claim 9, wherein the connection
portion is positioned along a central axis of the glenoid resection
guide.
11. The glenoid resection guide of claim 10, wherein the connection
portion is positioned at an angle relative to the superior
surface.
12. The glenoid resection guide of claim 9, wherein the connection
portion includes a threaded bore to interconnect with the
handle.
13. The glenoid resection guide of claim 9, wherein the connection
portion is positioned offset from the central axis.
14. The glenoid resection guide of claim 9, wherein the connection
portion includes at least one of a first connection portion
positioned along a periphery of the glenoid resection guide
centered on a central axis, a second connection portion positioned
along the periphery of the glenoid resection guide offset in a
first direction from the central axis, a third connection portion
positioned along the periphery of the glenoid resection guide
offset in a second direction from the central axis, or a
combination the first connection portion, the second connection
portion, and the third connection portion along a periphery of the
glenoid resection guide.
15. The glenoid resection guide of claim 14, wherein the handle is
selectively interconnected with one of the first connection
portion, the second connection portion, or the third connection
portion.
16. The glenoid resection guide of claim 9, further comprising a
centering post extending from the inferior surface to assist in
positioning the glenoid resection guide after initial reaming of
the glenoid.
17. The glenoid resection guide of claim 17, wherein the bore is
offset from the centering post.
18. The glenoid resection guide of claim 9, further comprising a
plurality of bores to guide multiple resections of the glenoid.
19. A system for guiding the formation of various resections of a
glenoid when performing a procedure relative to the glenoid, the
system comprising: a positioning arm; and a plurality of glenoid
resection guides, wherein each glenoid resection guide of the
plurality of glenoid resection guides comprises: a superior
surface; an inferior surface shaped to fit within a reamed glenoid;
a bore extending between a first opening on the superior surface
and a second opening on the interior surface, and positioned on the
glenoid resection guide to guide a resection instrument to form a
bore in the glenoid; and a connection portion positioned along an
edge of the superior surface to received the positioning arm.
20. The system of claim 19, wherein each glenoid resection guide of
the plurality of glenoid resection guides has a different size or
shape.
21. The system of claim 20, wherein the connection portion is
positioned along a central axis of the glenoid resection guide.
22. The system of claim 22, wherein any one of the connection
portions is positioned at an angle relative to the superior
surface.
23. The system of claim 20, wherein any one of the connection
portions includes a threaded bore to interconnect with the
handle.
24. The system of claim 20, wherein any one of the connection
portions is positioned offset from the central axis.
Description
CROSS REFERENCE TO RELATED APPLICATIONS
[0001] This application is a divisional application of U.S.
application Ser. No. 11/096,202 filed on Mar. 31, 2005. The
disclosure of the above application is incorporated herein by
reference.
FIELD
[0002] The teachings herein are directed toward an orthopedic
procedure, and particularly to a less invasive orthopedic procedure
relating to the shoulder.
BACKGROUND
[0003] An anatomy, such as a human anatomy, includes various
articulations, soft tissues, and hard tissues to perform various
functions. Generally, these functions are carried out pain-free and
with a substantial range of motion. Nevertheless, various functions
may deteriorate over time as soft tissue or hard tissue
deteriorates and articulations deteriorate. At a selected time,
various portions of the anatomy may be replaced with artificial
portions to restore substantially normal or anatomical motion and
functionality.
[0004] For example, the articulation of the humerus with the
glenoid (the glenohumeral or shoulder joint) may deteriorate. The
humeral head or the glenoid may deteriorate and become rough or
lose their anatomical shapes and reduce motion, increase pain, or
the like. This may happen for various reasons, such as injury,
disease, or lack of motion. This may lead to replacement of the
selected portions of the anatomy with a prosthesis to achieve a
substantially normal or anatomical range of motion.
[0005] Although it is known to replace various portions of the
anatomy, such as a humeral head and a glenoid, many procedures
generally require large incisions through soft tissue. Further,
various procedures require that many muscle and muscle attachments
be cut to achieve access to selected portions of the anatomy.
Although it may be selected or necessary to perform many procedures
in this manner, it may also be desirable to achieve a less invasive
procedure.
[0006] Further areas of applicability of the present teachings will
become apparent from the description provided hereinafter. It
should be understood that the description and various examples,
while indicating various embodiments, are intended for purposes of
illustration only and are not intended to limit the scope of the
teachings.
SUMMARY
[0007] A less invasive or minimally invasive procedure to achieve
access to the articulation region, and the capsule surrounding the
humeral head and the glenoid, to allow for replacement of at least
one of the glenoid or the humeral head. The procedure can be
performed by accessing the rotator cuff capsule by an incision near
the shoulder and separating various muscle bundles and then
incising the capsule. The procedure may be performed without
substantial removal or resection of the subscapularis muscle or its
attachment near the glenohumeral joint. Also other muscles forming
the rotator cuff can remain intact as well. The procedure can allow
for access to the rotator interval without a substantial
dislocation or with no dislocation of the humeral head from the
glenoid during the procedure.
[0008] According to various embodiments a method of performing an
arthroplasty on at least one of a glenoid or a humeral head of a
humerus through soft tissue of an anatomy is disclosed. According
to various embodiments of the method an incision is formed in the
soft tissue near a superior-lateral portion of the glenohumeral
joint and portions the deltoid muscle are separated substantially
superior and lateral of the glenohumeral joint. The humeral head
can be resected and a prosthetic humeral head can be positioned to
replace the resected humeral head. Also, the glenoid can be
prepared and a glenoid implant can be inserted into the prepared
glenoid. The separated muscle tissue and the incision in the soft
tissue can be closed. The rotator cuff muscles, including the
subscapularis muscle can remain substantially or completely
connected during the arthroplasty procedure.
[0009] According to various embodiments a retractor to hold
portions of an incision through soft tissue formed in an anatomy is
disclosed. The retractor can includes a separation member extending
between a first end and a second end. A second member can extend
from near one of the first end or the second end of the separation
member and a third member can extend from near one of the other of
the first end or the second end of the separation member. A first
spreading member can extend from the second member and a second
spreading member can extend from the third member. A connecting
member can be interconnected with one of the second member or the
third member. The connecting member can allow selected movement of
at least one of the first spreading member or the second spreading
member relative to the other of the first spreading member or the
second spreading member.
[0010] According to various embodiments, a glenoid protection
device to protect a portion of the glenoid in an anatomy is
disclosed. The glenoid protection device can include a graspable
portion operable to extend through an opening in the anatomy.
Extending from the graspable portion can be a shield member. The
shield member is can be positioned near the glenoid when a portion
of the anatomy is resected.
[0011] According to various embodiments, a humeral head resection
guide is disclosed. The resection guide can includes a resection
member defining a guide surface. Also, a first positioning member
can be interconnected with the resection guide member and a second
positioning member can be interconnected with the first positioning
member.
[0012] According to various embodiments a glenoid resection guide
for guiding the formation of various resections of a glenoid when
performing a procedure relative to the glenoid is disclosed. The
guide can include a member defining a perimeter including a top
portion and a bottom portion and a bore defined by the member
operable to guide a resection instrument to form a bore in the
glenoid. A connection portion can be positioned at a top of the
member. A handle can interconnect with the connection portion to
assist in positioning the member relative to the glenoid. A user
can grasp the handle and hold the handle during a resection
procedure.
[0013] Further, various instruments are provided that allow for
ease of accessing the anatomical portions and performing the less
invasive procedure. For example, cutting guides, according to
various embodiments, can be provided that interconnect with
selected portions, such as reamer bodies, for positioning the
cutting guide to perform a procedure. Further, various retractors,
reamers, and the like can be provided to achieve a selected
result.
BRIEF DESCRIPTION OF THE DRAWINGS
[0014] The present teachings will become more fully understood from
the description and the accompanying drawings, wherein:
[0015] FIG. 1 is an elevational view of a reamer according to
various embodiments;
[0016] FIG. 2 is an elevational view of a drill motor according to
various embodiments;
[0017] FIG. 3A is a front elevational view of a resection guard
according to various embodiments;
[0018] FIG. 3B is a side elevational view of a resection guard of
FIG. 3A;
[0019] FIG. 4 is a side elevational view of a tool according to
various embodiments;
[0020] FIG. 5A is a top elevational view of a retractor according
to various embodiments;
[0021] FIG. 5B is a front elevational view of a retractor of FIG.
5A;
[0022] FIG. 6A is a front elevational view of a resection guide
assembly according to various embodiments;
[0023] FIG. 6B is a side elevational view of a resection guide
assembly of FIG. 6A;
[0024] FIG. 7A is a top elevational view of a resection guide
according to various embodiments;
[0025] FIG. 7B is a side cross-section view of a resection guide of
FIG. 7A;
[0026] FIG. 8 is a perspective view of a saw and saw motor
according to various embodiments;
[0027] FIG. 9 is a top elevational view of a reamer according to
various embodiments;
[0028] FIG. 10 is a side elevational view of an anatomy;
[0029] FIG. 11 is a side elevational view of an anatomy including
an incision according to various embodiments;
[0030] FIG. 12 is a side elevational view of an anatomy including
an incision and exposure of anatomical portions according to
various embodiments;
[0031] FIG. 13 is a detail cross-section view of an anatomy
including an incision and positioning of various instruments
according to various embodiments;
[0032] FIG. 14 is a detail cross-section view of an anatomy
including an incision and positioning of various instruments
according to various embodiments;
[0033] FIG. 15 is a detail cross-section view of an anatomy
including an incision and positioning of various instruments
according to various embodiments;
[0034] FIG. 16 is a detail cross-section view of an anatomy
including an incision and positioning of various instruments
according to various embodiments; and
[0035] FIG. 17 is a kit of various instruments according to various
embodiments.
DETAILED DESCRIPTION OF VARIOUS EMBODIMENTS
[0036] The following description of various embodiments is merely
exemplary in nature and is in no way intended to limit the
teachings herein, its application, or uses. Although the following
description is discussed specifically for performing a procedure of
a shoulder of the human anatomy, it will understood that the
procedure and instruments described herein may be augmented and
used for various other procedures or in other anatomies. Therefore,
although the following description is related to a shoulder
procedure, it will be understood that the teachings herein are not
so limited.
[0037] Various instruments can be used in performing a selected
procedure, such as a shoulder arthoplasty. It will be understood
that various instruments and procedures may be used to perform a
hemi-arthoplasty, such as replacement of only one of a humeral head
or a glenoid. A total arthoplasty can be the replacement of a
humeral head and a glenoid where the humeral head and the glenoid
can articulate with one another after implantation. Nevertheless,
instruments can generally include a reamer 20 (FIG. 1), a drill
motor 30 (FIG. 2), a resection shield 40 (FIG. 3), an
inserter/broach instrument 50 (FIG. 4), a retractor 60 (FIGS. 5A
and 5B), a resection guide 70 (FIGS. 6A and 6B), a glenoid guide 80
(7A and 7B), a resection saw and motor 90 (FIG. 8) and a glenoid
reamer 100 (FIG. 9). It will be understood that various other
instruments may be provided for using or performing a selected
procedure and the described instruments are merely exemplary.
Nevertheless, the instruments taught herein can be used to achieve
selected results in a selected procedure.
[0038] With reference to FIG. 1, the reamer 20 can include a
reaming body 102 and a drive shaft 104. The reaming body 102 can
include a plurality of cutting sections 106 and may be formed in
any selected manner. As discussed herein, the reamer 20 may be used
to ream a selected portion of the anatomy such as a humerus, and
may, therefore, include an extended body including the cutting
sections 106 extending along the extended body 102. The reamer 20
may ream an intramedullary (IM) canal of a selected bone, such as
the humerus.
[0039] The reamer shaft 104 may include a quick connect section 108
that can interconnect with a selected portion, such as a chuck 110
of the drill motor 30 (FIG. 2). The drill motor 30 may be any
appropriate drill motor such as those generally known in the art.
Nevertheless, the drill motor 30 may be electrically powered,
hydraulic powered, or use any appropriate power source. It will be
understood that the chuck 110 of the drill motor 30 may
interconnect with the reamer 20 in any appropriate manner and the
quick connect 108 is merely exemplary. Regardless, the quick
connect 108 may allow for a quick and efficient procedure and may
allow for easy connection and disconnection of the reamer 20 from
the drill motor 30 so that the drill motor 30 may be used for other
instruments. Also the reamer 20 need not be powered or driven with
a motor. The reamer 20 can be manually driven into a bone, such as
with impaction or twisting.
[0040] With any appropriate power, the reamer 20 can be used to
ream a selected portion of the anatomy and various instruments can
be interconnected with the reamer 20, as discussed herein. It will
be understood that the instruments may be interconnected with any
appropriate portion of the reamer 20 such as the shaft 104 or the
quick connect 108.
[0041] With reference to FIG. 3, the resection or glenoid protector
40 can be used in a procedure for protecting various portions of an
anatomy that are selected to be engaged with an instrument at a
selected time. The resection protector 40 may include a handle 112
that is connected through a shaft 114 to a protector or protective
paddle 116. The protective paddle 116 can include any appropriate
profile, such as a substantially curved profile that may rest on an
unresected or resected glenoid. The protective shield 116 can
engage a portion of a glenoid 314 (FIG. 13) to protect the glenoid
314 when a humeral head 310a (FIG. 13) is being resected, as
discussed herein. Therefore, the protective shield 116 can protect
a selected portion of the anatomy from a resection procedure that
is not intended to resect that selected portion of the anatomy.
[0042] The shaft 114 may include a selected geometry, such as a
bent area 118 to assist in positioning the protective shield 116 in
an appropriate position. The protective shield 116 may be formed of
any appropriate material, and the material may generally be
biocompatible. For example, the shield 16 may be formed of a metal,
such as stainless steel or titanium, that can resist at least a
short period of engagement with a cutting apparatus. Alternatively,
or in addition thereto, the protective shield 116 may be formed of
a polymer or other material. The handle 112 allows a user to hold
the protective shield 116 in a selected position.
[0043] With reference to FIG. 4, an instrument 50 may be comprised
of various portions to assist in performing a selected procedure.
The instrument 50 may include a handle 122 that is interconnected
with a shaft 124 that includes a distal engagement region 126. The
shaft 124 may also include a bent or unaligned portion 128. The
unaligned portion 128 can include a portion that extends along an
axis A that can be parallel, but displaced from an axis B that
extends through another portion of the shaft 124. It will be
understood that the axis A of the offset portion 128 may also be at
any appropriate angle relative to the axis B and being
substantially parallel is merely exemplary.
[0044] The engagement region 126 of the shaft 124 can be used to
engage various elements. For example, the engagement end 126 can
engage an inserter 129. The inserter 129 may be used to insert
various portions, such as a glenoid implant, described herein.
Alternatively, or in addition thereto, the engagement end 126 may
engage a broach 130. The broach 130 may be used for broaching
various portions of the anatomy, such as the glenoid 314, for
receiving a glenoid implant. For example, the broach 130 may
include a broaching portion 132 that can broach an area of the
glenoid to receive a keel of a selected glenoid implant. It will be
understood that various other portions may be engaged to the
engagement end 126 of the tool 50 and the inserter 129 or the
broach 130 are merely exemplary.
[0045] Further, the handle 122 can be used to be struck by a hammer
or other appropriate instrument to assist in using the broach 130
or the implant inserter 129. Alternatively, the handle 122 may be
simply pressed or pushed by a user to engage the selected portion
of the anatomy with the portions engaged on the engagement end
126.
[0046] With reference to FIGS. 5A and 5B, the retractor 60 may be
used to retract or position a selected portion of the anatomy. As
discussed herein, an incision 316 (FIG. 10) can be formed in
selected soft tissue portions of an anatomy and the retractor 60
may be used to hold the edges of the incision apart or to spread
the incisions apart to obtain access to a selected portion of the
anatomy. The retractor 60 can also be used to retract or hold
tissue that is deep within the incision. For example, the retractor
60 can be used to allow clear access to a selected anatomical
position, such as a humeral head 310a. The retractor 60 can be used
in any appropriate procedure, and its description for use in a
shoulder procedure is merely exemplary.
[0047] The retractor 60 can include a retractor body 140 that is a
substantially U-shaped or any other appropriate shape. The body 140
generally includes a spacing portion 142 that separates a first arm
144 from a second arm 146. The spacing portion 142 can define a
selected distance between the arms 144, 146 to allow for
positioning of a first retracting element 148 from a second
retracting element 150. Although the retracting elements 148, 150
can be moved relative to the retractor body 140, the spacing
portion 142 of the body 140 may assist in the initial positioning
the retracting elements 148, 150.
[0048] The retracting elements 148, 150 may be substantially
similar to each other. Alternatively, the retracting elements 148,
150 can be formed differently for various purposes. Nevertheless,
retracting elements 148, 150 can generally include soft tissue
engagement portions 152a, 152b. The soft tissue engagement portions
152a, 152b can be interconnected with retracting portions 154a,
154b respectively. The soft tissue engagement portions 152a, 152b
can be shaped to cooperate with a selected portion of the anatomy,
such as the humeral head 310a.
[0049] The retracting portions 154a, 154b can be interconnected
with retractor body 140 in any appropriate manner. For example, the
retracting elements 148, 150 can be engaged in holding members
156a, 156b, respectively. Each of the holding members 156a, 156b
can allow the retracting elements 148, 150, respectively, to move
relative to the body 140. Alternatively, either one of the
retracting elements 148, 150 can be fixed relative to the retractor
body 140 while only the other one can move.
[0050] At least one of the connecting portions 156a or 156b can
include a set or holding screw 158 that can be moved through a
threaded portion in the holding section 156a to engage a track or
portion 160 of the retracting element 148. The track 160 can be a
flat or any appropriately shaped portion of the retracting element
148 that can be engaged with the set screw 158. In this way, the
retracting element 148 can move relative to the connecting portion
156a and be held in the selected position with the set screw 158.
It will be understood that the second connecting portion 156b may
include a similar apparatus and the retracting element 150 may also
include a similar geometry and only one is illustrated for
discussion purposes.
[0051] The retractor 60 can be used to retract a selected portion
of the anatomy to hold it in a selected position to allow access to
various portions of the anatomy. It will be understood that various
other retractors may be used for selected procedures and the
retractor 60 is merely exemplary.
[0052] With reference to FIGS. 6A-6B, a cutting guide 70 can be
used to guide a cutting instrument, such as a saw blade, relative
to a selected portion of the anatomy. The cutting guide 70
generally includes a guiding member 160 and an attachment portion
162. The attachment portion 162 includes a rod attachment portion
164 that can interconnect with a rod or any appropriate member,
such as the shaft 104 (shown in phantom for illustration). A set
screw or locking screw 166 can be provided to lock the mounting
portion 162 relative to the shaft 104. It will be understood that
any appropriate locking mechanism can be provided and that set
screw 166 is merely exemplary.
[0053] The set screw 166, however, may be interconnected through
any one of a plurality of bores 167 formed in the connection member
164. In this way, the engagement member 162 can be interconnected
with the shaft 104 in a plurality of locations to achieve an
appropriate or selected orientation. As discussed herein, the guide
block 160 can be oriented relative to a selected portion of the
anatomy, such as the humerus. The cutting block 70 can be
interconnected with the shaft 104 in a plurality of positions that
may assist in appropriately orientating the guiding block 160
relative to the portion of the anatomy. Also version bores 168 can,
for example, be used for version rod control to select an angle for
the resection. The version rod can be interconnected with one of
the bores 168 depending upon a selected angle for the cutting guide
70. The various version bore 168 can relate to differing degrees of
version.
[0054] It will be understood that the attaching portion 164 may
also attach to a member, such as the shaft 104 in a plurality of
manners. For example, the connecting member 164 may be
interconnected with the shaft 104 using the quick connect portion
108 of the reamer 10. This can allow the connecting portion 162 to
be efficiently and quickly interconnected with the reamer 10
according to various embodiments. Nevertheless, the set screw may
also allow for easy and selectable orientation of the cutting guide
160 relative to a selected portion of the anatomy.
[0055] Extending from the attachment portion 164 is an arm 170 that
interconnects with a second orientating arm 172. The second
orientating arm 172 can include a connection region 174 that
defines a bore through which the connection arm 170 may extend. A
second set screw 176 can be provided to assist in holding the
second orientation arm 172 relative to the arm 170 of the
connection portion 162. Therefore, the orientating arm 172 can be
moved relative to the connecting region 164 of the positioning
member 162.
[0056] The orientating arm 172 can define a groove or track 178 in
which a third set screw 180 can be moved. The third set screw 180
can interconnect the cutting guide 160 with the second orientating
arm 172. This allows the cutting guide 160 to be moved relative to
the first orientating member 162 in a plurality of orientations.
Therefore, the cutting guide 160 can be moved in several degrees of
freedom relative to the shaft 104, or any appropriate member, to
achieve a selected orientation of the cutting guide160 relative to
a selected portion of the anatomy.
[0057] The guide member 160 can include or define a plurality of
guide surfaces. For example, an exterior portion 182 of the guide
member 160 can define a guide surface. Alternatively, or in
addition thereto, a groove or slot 184 can be defined by the
cutting guide that can also define a guide surface. It will be
understood that the guide member 160 can include a plurality of
guide surfaces and those illustrated are merely exemplary.
[0058] The guide member 160 can also define a plurality of fixation
bores 186 that allow for fixation of the cutting guide 160 relative
to a selected portion of the anatomy, such as discussed herein.
Therefore, the apparatus 70 can assist in positioning and
orientating the cutting guide 160 relative to a selected portion of
the anatomy, such as a humerus, and various fixation members can be
used to hold the cutting guide 160 relative to a selected portion
of the anatomy during a resection process. It will be understood,
however, that the apparatus 70 may also hold the cutting guide 160
relative to a selected portion of the anatomy during a resection
process.
[0059] With reference to FIGS. 7A and 7B, a glenoid guide 80 is
illustrated. The glenoid guide 80 can be shaped and include a
plurality of shapes and sizes for inclusion in a kit or system and
an individual guide may be selected by a user, such as a physician,
for a selected procedure. The various guides may include different
guide portions, different guide bores, different sizes, different
shapes, or other appropriate differences that may be chosen for a
selected patient or use by a physician. The glenoid guide 80,
however, generally includes a guide bore or channel 190. The
glenoid guide 80 may also include a plurality of the bores 190 for
forming a plurality of bores or tunnels in a selected portion of
the anatomy, such as a glenoid. The glenoid guide 80 also generally
includes a selected orientation or exterior geometry that can
assist in determining appropriate fit of the guide 80 relative to
the glenoid. A centering or positioning post 192 can extend from
the glenoid guide 80. The post 192 can be positioned in a bore
formed by an initial guide member, such as that generally known in
the art. The projection 192 helps to assure an appropriate
orientation of the guide 80 relative to the glenoid when forming
the plurality of bores defined by the guide bores 190.
[0060] The glenoid guide 80 is generally held in a selected
position by a user with a positioning arm 194 or tool that is
interconnected with the glenoid guide 80 at a connection region
196. The connection region 196 can be positioned generally along a
central axis C defined by the glenoid guide 80. The positioning of
the attachment region 196 along the axis C can allow for ease of
use by a user and allow for a plurality of orientations of the
guide 80 relative to a selected portion of the anatomy. It will be
understood that the connection region 196 may also be positioned in
other orientations on the glenoid guide. For example, the
attachment region 196 can be positioned at a top and first side of
the glenoid guide 80 to form a first alternative connection region
196a. Alternatively, or in addition thereto, a second attachment
portion 196b can be provided on a second side of the glenoid guide
80. Therefore, the glenoid guides 80 can be substantially size
specific or can be universal where a user may move the holding
member 194 between the various connection regions 196 to achieve a
selected orientation of the handle 194 for ease of use by a
user.
[0061] With reference to FIG. 8, the resection instrument 90 can be
any appropriate resection instrument. For example, the resection
instrument 90 can be a resection saw generally known in the art.
The resection saw 90 can include a saw blade 200 that is operated
by a saw motor 202. The saw blade 200 can include a motor
attachment region 204 and a tooth or cutting region 206. The saw
blade 200 can be used with the guide member 160 to resect a
selected portion of the anatomy, as described herein. It will be
understood, however, that any appropriate resection instrument may
be used to achieve a selected result and the resection saw 90 is
merely exemplary.
[0062] With reference to FIG. 9, the reamer 100 can be used to ream
a selected portion of the anatomy, such as a glenoid. The reamer
100 can be used to ream the glenoid, such as that described herein,
to achieve an appropriate position of a glenoid implant or to
expose bone that is strong enough to support a glenoid implant. The
reamer 100 can be any appropriate reamer, such as those generally
known in the art, that include a tool attachment 210, a rim 212,
and cutting edges 214. The tool attachment region 210 can
interconnect with any appropriate tool, such as a manual tool or a
power tool. The reamer 100 can be powered with any appropriate
motor, such as the drill motor 30. The reamer 100, however, can be
used to ream a selected portion of the anatomy, such as the
glenoid, to allow for positioning of an implant.
[0063] All of the instruments described above are exemplary. They
can be used in a plurality of procedures to assist a user in an
orthopedic procedure. For example, the instruments described above
can be used to assist in resecting a selected portion of a humerus
and a glenoid to allow for implantation of a shoulder implant,
including a humeral implant and a glenoid implant. Described below
and illustrated in FIGS. 10-16 is a procedure performed relative to
a human anatomy 300. It will be understood that the following
method is merely exemplary and is not intended to limit the scope
of the above-described instruments. Similarly, the procedure herein
is exemplary of a procedure that may be performed relative to a
selected portion of the anatomy and, although a shoulder procedure
is described, it is not intended to limit the teachings herein.
[0064] With initial reference to FIG. 10, a human anatomy 300 can
be augmented with the use of the instruments illustrated in FIGS.
1-9. The human anatomy 300 generally includes an external skin
layer 302 and soft tissue there below, such as muscle 304. Below
the soft tissue, and the soft tissue may be interconnected
therewith, includes bony portions such as an acromion 306, a
clavicle 308, a humerus 310, and a scapula 312, which can define a
glenoid 314. Various portions of the anatomy, including the humerus
310 and the glenoid 314, can be accessed by forming an incision 316
in the soft tissue, including the skin 302.
[0065] Also, various subdermal portions, such as subdermal adipose
tissue, can be incised along the incision 316. It will be
understood that the incision 316 can be orientated in any
appropriate direction such as anterior to posterior, which is
generally parallel to a sagittal plane. Alternatively, or in
addition thereto, a superior-inferior incision illustrated in
phantom 316a, which is generally along the coronal plane, can be
made. The skin incision can made parallel with Langerhan's lines at
the superior aspect of the shoulder, just even with the lateral
border of the acromion 306. The incision 316 can also be medialized
slightly. The incision 316 can be any appropriate length, and may
depend upon surgeon preference, patient type, prosthetics to be
used, or other indications. Nevertheless the incision can be about
3 cm (about 1 in) to about 20 cm (8 in) in length such as about 7.5
cm (about 3 in) to about 10 cm (4 in). It will be understood that
the incision 316 through the skin may be shorter than the area
opened in the muscle 304. The incision 316 can be used to achieve
access to the muscle 304 that is around the various portions of the
anatomy that are selected to be resected, including the humerus 310
and the glenoid 314. The incision can be used to obtain access to a
deltoid muscle 304a.
[0066] The retractor 60a can be any appropriate retractor such as a
Gelpi Style Retractor. It will be understood that the retractor 60
may also be used to retract the soft tissue, such as the muscles
surrounding the glenohumeral joint, including the deltoid muscle
304a, but the Gelpi Style Retractor may also be used to expand the
incision 316 to gain access to the muscle. The retractor 60, as
illustrated herein, can be used to retract or position the deep
tissue that is generally near the glenohumeral joints.
[0067] Through the incision 316, which can be expanded with the
Gelpi Style Retractor 60a, the deltoid muscle 304a can be seen. The
deltoid muscle 304a can include various muscle fibers and bundles
that interconnect the humerus 310 with other portions of the
anatomy, such as the clavicle 308 or the acromion 306. A muscular
split or incision 320 can be formed between the various fibers of
the deltoid muscle to obtain deeper access into the anatomy 300.
The separation 320 can be a passage formed through the cuff
internal of subscapularis and the supraspinatus. It will be
understood that the separation 320 in the muscle can be formed in
any appropriate manner according to various selected methods and
preferences of a physician. Nevertheless, the separation 320 can be
made to separate various muscle fiber bundles to allow for ease of
access to the muscle regions. The deltoid 304a can be split in line
with its fibers along the anterior border of the acromion 306, and
laterally along the raphe between anterior and middle thirds of the
deltoid. Laterally, the split 320 can go as far as about 7 cm, with
care taken to avoid the axillary nerve, and medially can be taken
along the anterior aspect of the distal clavicle, medial to the
acromion/clavicle (A/C) joint. An incision can be formed from the
distal clavicle about 1/2 cm medial to the A/C joint, out to about
4 cm past the lateral border of the acromion 306. A Gelpi retractor
60a or the retractor 60 can be placed to open the interval.
[0068] The passage 320 through the deltoid 304a can achieve access
to various deeper soft tissue portions, such as the sub-deltoid
bursa and the subacromial bursa. Further, various other deep soft
tissue can be incised and/or moved to achieve access to the capsule
surrounding the shoulder or glenohumeral joint. After moving and/or
incising all of these portions, access to the humerus 310 or the
humeral head 310a can be achieved.
[0069] The retractor 60 can be used to hold the various soft
tissues portions open, such as the cuff interval, capsule and the
like. It will be understood that the retractor 60 may be any
appropriate retractor and may include a scissor retractor or the
like. Various other soft tissue portions may be near the capsule
and may also be incised or resected. For example, the bicep tendon
that interconnects to a portion or near the humeral head 310a may
be resected or may be moved, if already detached, to achieve better
access to the humeral head 310a. Further, access to the glenoid 314
can also be seen once the soft tissue has been incised.
[0070] Although the incision 316 on the shoulder or near the
glenohumeral joint allows access to the deltoid muscle 304a and
access to the capsule and soft tissue surrounding the glenohumeral
joints, various muscles and ligaments need not be resected or
incised when obtaining access to the glenohumeral joint according
to the process discussed herein. For example, the subscapularis
muscle and the ligaments attaching it to the portions of the
glenohumeral joint need not be incised when obtaining access to the
glenohumeral joint according to embodiments of the teachings
herein. The subscapularis muscle can be left intact because it is
generally anterior from the approach described. Also the
supraspinatus can remain intact, as may all the muscles of the
rotator cuff. Rather the passage 320 can be formed by separating
the cuff interval rather than detaching or incising various soft
tissue portions. Further, the humeral head 310a need not be
substantially dislocated or dislocated at all from the glenohumeral
joint according to various embodiments. Rather, the humeral head
310a can be moved to allow access to various portions of the
anatomy, however, major dislocation of the humeral head 310a from
the glenoid 314 is not necessary. The humerus can be left in its
generally anatomical position or retracted any appropriate
distance, such as about 2 cm to about 8 cm.
[0071] If the rotator cuff is intact, but there is significant
prominence of the anterior acromion 306, a routine acromioplasty is
performed at this stage. If significant A/C joint arthritis is
present, a distal clavicle resection is commonly performed. This
relieves pain from the arthritis, and further opens the exposure to
the glenohumeral joint. If the cuff is torn, but appears
repairable, an acromioplasty is similarly performed, and a cuff
repair is accomplished upon completion of the arthroplasty. If, on
the other hand, there is a massive, irreparable cuff lesion, then
an acromioplasty may not be performed, and the coracoacromial
ligament is preserved, and repaired along with the deltoid at the
end of the procedure.
[0072] The lesser tuberosity and the bicepital groove are palpated,
and the rotator interval over the top of the biceps tendon is
incised. The cuff incision follows over the top of the biceps along
the anterior border of the supraspinatus as far medially as can be
exposed. The biceps tendon is then detached from the superior
labrum and tagged for later tenodesis.
[0073] The soft tissue over the biceps laterally is sharply
dissected off the humerus down to the top of the subscapularis
tendon, but the tendon can be left undisturbed. The supraspinatus
may be stripped back off the anterior portion of the greater
tuberosity for a distance of about 5 mm to about 10 mm to further
enhance the exposure. More than 1 cm may not be detached, and the
basic integrity of the tendon can remain. This exposure of the
rotator interval typically gives about a 1.5 cm to about 2 cm gap
at the lateral edge, without disrupting the rotator cuff mechanism.
The Gelpi retractor 60a can be moved from the deltoid 304a to the
rotator interval and this can provide greater exposure of the
glenohumeral joint for instrumentation and implants.
[0074] Further, the person or the anatomy 300 can be positioned on
an operating table or bed 321. An arm 301 of the anatomy 300 can be
positioned on the positioning board 322 that can be interconnected
with the bed 321. This can assist in holding the arm 301 in a
selected position to obtain a desired orientation of the
glenohumeral joint. Further, the arm 301, including the humerus
310, can be moved in a selected orientation to assist in achieving
a selected access to the glenohumeral joint or various portions of
the anatomy, such as the humeral head 310a and the glenoid 314.
[0075] Once access to the humeral head 310a and/or the glenoid 314
has been achieved, various resection procedures can occur. Although
the muscles have been incised to obtain access to the glenular
humeral joint, various muscular portions, such as the subscapularis
muscle, may not have been incised or disconnected from the various
boney portions. Therefore, the instruments, such as those described
above, can be used to assist in achieving a selected resection of
the anatomy through the incision made and allowing various portions
of the muscle to remain intact.
[0076] Once access has been obtained to the glenohumeral joint,
various instruments according to various embodiments can be used in
the procedure. It will be understood that according to various
embodiments, any, all, or none of the instruments may be used in a
procedure. With reference to FIG. 13 (detailed view of the
glenohumeral joint), the reamer 20 can be reamed into the humerus
310 near the humeral head 310a. Humeral reaming can occur from the
superior, lateral humeral head. The entrance to the head 310a can
be just underneath the previous location (i.e. the natural
location) of the biceps tendon. The arm 301 can be extended
slightly, and the elbow can be placed against the patient's side to
bring the top of the humeral head 310a forward, and allow the
reamer to pass the front of the acromion 306. This can allow the
humeral head 310a to be retracted, but remain substantially or
completely undislocated. This can reduce trauma in the surrounding
soft tissue. The superior approach allows easy centering of the
reamer in the humeral head and proximal shaft, and decrease the
initial incidence of varus stem placement and/or eccentric head
utilization.
[0077] The reamer 20 includes the shaft 104 that can extend from
the humerus 310. The reamer 20 can be positioned into the humerus
and interconnected with various portions, such as the guide
apparatus 70. The guide apparatus 70 can be interconnected with the
shaft 104 of the reamer 20 while the reamer remains in the humerus
310. This allows for positioning the cutting guide 160 relative to
the humerus 310 and the humeral head 310a.
[0078] As discussed above, the various portions of the apparatus
70, including the guide movement arm 172, can be used to orient the
cutting guide 160 in a proper orientation relative to the humeral
head 310a. Generally, it is selected to obtain or position an axis
of the cutting guide 160, such as a central axis, relatively in
line with the humerus 310. This can help position the guide
surface, along which the saw blade 200 (shown in phantom in FIG.
13) can be guided), generally perpendicular to an axis C of the
humeral head 310a.
[0079] The cutting guide 70 can generally be positioned at about 20
degrees to about 30 degrees of retroversion. Once the cutting guide
160 is positioned in a selected position, it may be held in place
with a fixation pin 326. It will be understood that more than one
of the fixation pins 326 can be provided and pass through the bores
186, defined by the guide 160. The pins can include any appropriate
type of pin and can be drilled into the humerus 310 to hold the
cutting guide 160 relative thereto. The various other portions of
the guide apparatus, including the guiding arm 172 and the fixation
arm 170 can then removed from the reamer 20. In addition, the
reamer 20 can be removed from the humerus to allow for a resection
of the humeral head 310a.
[0080] The cutting guide 160 can be held in place with the pin 326
when all the other portions of the apparatus are removed. The saw
90 can then be used to resect the humeral head and the blade 200
can ride along a portion of the cutting guide 160. The cutting
guide 160 can insure a proper orientation and/or position of the
saw blade 200 relative to the humeral head 310a. Further, the
glenoid shield 116 can be positioned relative to the glenoid 314
and other portions of the anatomy to assist in ensuring that the
saw 200 does not engage portions of the anatomy not desired to be
cut.
[0081] It will be also understood that the cut of the glenoid head
310a can be begun with the cutting guide 160 and then finished
without the cutting guide 160. For example, an initial portion of
the humeral head 310a can be resected with use of the cutting guide
160. After an initial portion of the cut is formed the cutting
guide 160 and the fixation pins 326 can also be removed. The
remainder of the cut of the humeral head 310a can then be performed
using the initial portion of the cut formed with the saw blade 200
to guide the remaining portion of the cut. Therefore, it will be
understood, that the cutting guide 160 need not be present to form
the entire cut of the glenoid head 310a.
[0082] Osteophytes and soft tissue contractures can also be
addressed. A one-half inch curved osteotomes (not shown) can be
utilized to remove anterior, posterior, and inferior osteophytes
from the proximal humerus 310. If the capsule is contracted
anterior and posterior, it can be excised, and care can be taken
not to disrupt the insertions of supraspinatus, infraspinatus, and
subscapularis. The most common contracture, internal rotation
contracture of the anterior capsule, can be easily visualized and
resected without disrupting the overlying subscapularis muscle.
Once the contracted capsule has been removed, the subscapularis may
not need lengthening, as the muscle can stretch nicely, and is
typically much more compliant than the retracted capsule which was
excised. In an instance of significant tightness in the muscle
itself, blunt dissection along the anterior neck of the glenoid
with a Langenbach or Cobb retractor (not shown) can improve motion
in an acceptable manner.
[0083] The glenoid condition can also be assessed, and a decision
can be made for hemiarthroplasty or total shoulder arthroplasty.
The glenoid is well visualized, and directly approached, as the
surgical exposure is lateral as compared to other techniques.
Glenoid version, glenoid erosions, and glenoid osteophytes are all
easily assessed. Labral tissue is cleared from around the margins,
and glenoid preparation can be carried out with a selection of
straight reamers and drills. A keeled glenoid implant or pegged
glenoid implant can be utilized, per the surgeons preference as
discussed herein. Although the procedure can proceed according to
any appropriate technique, glenoid preparation and implantation can
occur prior to humeral broaching, but the humerus could be prepared
first if desired.
[0084] With reference to FIG. 14, once the humeral head 310a has
been resected, thus forming the resected humeral head 310a', the
glenoid 314 can be reamed with reamer 100. It will be understood
that the glenoid 314 may be first prepared with the various
procedures according to those commonly known in the art.
Nevertheless, it will be understood that the various guides, such
as those described herein, can be used to assist in achieving these
procedures. For example, a glenoid sizer or central drill guide can
be used for positions near the glenoid 314 to assist in forming a
central drill bore or sizing the glenoid 314. As discussed above,
various connecting portions can be positioned at a superior or top
portion of the cisor or other instrument to assist in achieving the
superior approach described herein. The reamer 100 can be
interconnected with a reamer shaft 330 and a drill motor 30. This
allows the reamer 100 to be rotated relative to the glenoid 314 to
form the glenoid into a selected shape and orientation. The glenoid
314 may need to be shaped to allow for implantation of a selected
glenoid implant. Nevertheless, it will be understood that the
glenoid 314 need not necessarily be resected and may articulate
with an implant positioned in the resected humerus 310.
[0085] Regardless, the reamer 100 can be positioned relative to the
glenoid 314 and the shaft 313 extend through the incision 316 to
allow for interconnection with the drill motor 30. After a selected
period of reaming, the glenoid 314 can be prepared for implantation
of a glenoid implant. As discussed above, the glenoid template 80
can be positioned relative to the reamed glenoid 314 to assist in
further glenoid preparation.
[0086] With reference to FIG. 15, the glenoid template 80 can be
positioned relative to the reamed glenoid 314a. The shaft 194 that
can interconnect with a connection region 196 and can extend
through the incision 316 to allow access and manipulation by a
user. The guide 80 allows for drilling or forming a plurality of
bores in the resected glenoid 314a with a bit 334 that can be
interconnected to the drill motor 30 with a shaft 332. The various
bores formed in the resected glenoid 314a allow for interconnection
and positioning of portions of a glenoid implant, such as pegs
extending therefrom, into the glenoid 314. The pegs can be used to
resist various motions of the glenoid implant, such as rotation,
translation and the like. Further, the pegs allow for cementation
points to cement the glenoid implant to the glenoid 314, if
selected. Regardless, the guide 80 can be used relative to the
glenoid 314 to form various bores, openings, and the like in the
glenoid 314.
[0087] It will also be understood that other procedures generally
known in the art may be used. For example, boring or drilling of
inferior and superior holes can be formed in the glenoid 314 before
the broach 130 is used. Nevertheless, these procedures are
generally known and are not described here in detail. Further, the
glenoid broach 130 can be used to form a keel opening in the
glenoid 314, if selected. It may be selected to first form the
bores in the glenoid 314, before attempting to form a keel opening.
This may be selected for various reasons and may allow for a
procedure to achieve a selected and superior result. Regardless, a
glenoid implant may include one or both of a peg or a keel
depending upon the selected glenoid implant.
[0088] Once the various bones of the anatomy have been resected,
including the glenoid 314 and the humerus 310, the various implants
can be implanted. Although the humerus 310 may need to be further
prepared, such as broaching the IM canal of the humerus 310.
Therefore, a broach may be provided and used to broach a selected
portion of the IM canal of the humerus 310. Various sizes of
broaches may be used to progressively enlarge the broached area of
the humerus 310, as is generally known in the art.
[0089] A broach 350 can be formed in a plurality of sizes and
include an attachment region 352. The attachment region 352 can
interconnect with an inserter 360 and specifically a connection
region 362 of the inserter 360. The inserter 360 can include an
impaction head or portion 364 to allow for impacting the broach 350
into the humerus 310. The humerus 310 can be broached with
increasing sized broaches. Also the humerus 310 can be trialed by
interconnecting a humeral implant with a trial humeral head. This
can first soft tissue laxity and resection accuracy.
[0090] The inserter 360 can also be used to implant a humeral
implant 370. The broached IM canal in the humerus 310 can also be
irrigated prior to inserting the humeral stem 372. The humeral
implant 370 can also include a connection region 372 that is
operable to interconnect with the connection portion 362 of the
inserter 360. The humeral implant 370 further includes a head
attachment portion 374 and a stem 376. The stem 376 is generally
formed to fit into the broached portion of the humerus and further
can be connected to the humerus with a selected cement or other
portion. It will be understood, however, that the humeral implant
370 can include various bone ingrowth portions or other attachment
regions to allow for interconnection of the humeral implant 370
with the humerus 310. Further, the humeral head implant 380 can be
provided to interconnect with the humeral implant 370. The humeral
head implant 380 can include a connection portion to interconnect
with the humeral stem 370 to allow for the formation of a
prosthetic humeral head.
[0091] It will be understood that although the humerus 310 can be
implanted with a selected implant, including the humeral stem
portion 370 and the humeral head 380, other appropriate implants
can be positioned on the humerus 310 according to various
embodiments of the presently described procedure. For example, a
resurfacing implant that will replace an articulating portion of
the humeral head can be positioned relative to the humerus 310 and
the humeral head 310a using the above-described method.
[0092] Following implantation, the soft tissue balance can again be
assessed, and then the split in the rotator interval can be closed.
The deltoid can be repaired back to the acromion. Subcutaneous
tissues and skin can then be closed per the surgeon's usual
routine.
[0093] Further, a glenoid implant 390 including a keel 398 can be
implanted in the glenoid. Alternatively, a glenoid implant 400
including at least a peg 402 can be implanted into the glenoid 314.
Regardless, it will be understood that any appropriate glenoid
implant including the glenoid implant 390, 400 can be positioned
into the glenoid 314. The glenoid implants 390, 400 can be
implanted with the glenoid positioner 194 that can be
interconnected with the tool 50 to allow for positioning the
glenoid 390, 400 relative to the glenoid 314.
[0094] Various portions described herein can be provided in a kit
500 as illustrated in FIG. 17. The kit 500 can include any
appropriate portions that can be used in a selected procedure, such
as a glenoid and/or humeral procedure and can include a plurality
of the broaches 350, a plurality of the humeral implants 370, a
plurality of humeral heads 380, a plurality of the glenoid implants
390, 400, and any other appropriate portion. Therefore, the kit 500
can be used for a plurality of procedures and need not be
customized for a particular procedure or patient. Further, the kit
500 can include a plurality of portions that allow it to be used in
several procedures for many differing anatomies, sizes, and the
like. Further, various other portions, such as the reamer 100, the
glenoid template 80, or other appropriate portions can be provided
for a plurality of different patients.
[0095] Further, it will be understood that the procedure described
above may be augmented slightly and still be within the scope of
the teachings thereof. For example, an angled shaft may be used to
interconnect the reamer 100 with the drill motor 30 to assist in
moving the reamer 100 relative to the glenoid 314. The angled shaft
may assist in positioning the drill motor 30 in an appropriate
orientation relative to the glenoid 314 to achieve a selected
resection. Further, the humerus 310 and the humeral head 310a can
be repositioned by moving the humerus to assist in achieving access
to the humeral head 310a or the glenoid 314. The arm positioning
board 322 can further assist in holding the arm 301, and the bones
therein, in a selected orientation to assist in performing the
procedure. This can allow the user or the physician to achieve the
procedure in the selected manner and further the movement of the
arm 301, the arm board 322 or by an assistant, can assist in
achieving access to the various portions of the anatomy without
major dislocations of the various joints.
[0096] The description is merely exemplary in nature and, thus,
variations that do not depart from the gist of the teachings are
intended to be within the scope of the teachings. Such variations
are not to be regarded as a departure from the spirit and scope of
the teachings.
* * * * *