U.S. patent application number 15/144264 was filed with the patent office on 2016-08-25 for patient selectable joint arthroplasty devices and surgical tools incorporating anatomical relief.
The applicant listed for this patent is ConforMIS, Inc.. Invention is credited to Raymond A. Bojarski, Philipp Lang, Daniel Steines, Terrance Wong.
Application Number | 20160242931 15/144264 |
Document ID | / |
Family ID | 50881769 |
Filed Date | 2016-08-25 |
United States Patent
Application |
20160242931 |
Kind Code |
A1 |
Wong; Terrance ; et
al. |
August 25, 2016 |
Patient Selectable Joint Arthroplasty Devices and Surgical Tools
Incorporating Anatomical Relief
Abstract
Disclosed herein are methods, compositions and tools for
repairing articular surfaces repair materials and for repairing an
articular surface. The articular surface repairs are customizable
or highly selectable by patient and geared toward providing optimal
fit and function. The surgical tools are designed to be
customizable or highly selectable by patient to increase the speed,
accuracy and simplicity of performing total or partial
arthroplasty.
Inventors: |
Wong; Terrance; (Needham,
MA) ; Bojarski; Raymond A.; (Attleboro, MA) ;
Steines; Daniel; (Lexington, MA) ; Lang; Philipp;
(Lexington, MA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
ConforMIS, Inc. |
Bedford |
MA |
US |
|
|
Family ID: |
50881769 |
Appl. No.: |
15/144264 |
Filed: |
May 2, 2016 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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14148067 |
Jan 6, 2014 |
9326780 |
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15144264 |
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13207396 |
Aug 10, 2011 |
8623026 |
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14148067 |
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11671745 |
Feb 6, 2007 |
8066708 |
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13207396 |
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12660529 |
Feb 25, 2010 |
8480754 |
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13207396 |
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61491162 |
May 27, 2011 |
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61443155 |
Feb 15, 2011 |
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60765592 |
Feb 6, 2006 |
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60785168 |
Mar 23, 2006 |
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60788339 |
Mar 31, 2006 |
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61155362 |
Feb 25, 2009 |
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61269405 |
Jun 24, 2009 |
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61273216 |
Jul 31, 2009 |
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61275174 |
Aug 26, 2009 |
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61280493 |
Nov 4, 2009 |
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61284458 |
Dec 18, 2009 |
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61155359 |
Feb 25, 2009 |
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61220726 |
Jun 26, 2009 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61B 2034/108 20160201;
A61B 5/4523 20130101; A61B 5/4528 20130101; A61B 5/4514 20130101;
A61B 34/20 20160201; A61B 17/175 20130101; A61B 2017/568 20130101;
A61B 17/1666 20130101; A61B 5/4533 20130101; A61B 34/10 20160201;
A61F 2/30756 20130101; A61F 2/38 20130101; A61B 17/158 20130101;
A61B 17/157 20130101; A61B 2034/2065 20160201; A61F 2/389 20130101;
A61B 17/1675 20130101; A61F 2002/3069 20130101; A61B 2034/105
20160201; A61B 2034/104 20160201; B33Y 80/00 20141201; A61B 17/155
20130101; B33Y 70/00 20141201; A61F 2/46 20130101; A61F 2/30942
20130101; Y10T 29/49 20150115; A61B 2034/102 20160201; A61B 17/154
20130101; A61F 2/3859 20130101; A61B 17/1778 20161101; A61B 17/1703
20130101; A61B 17/1746 20130101 |
International
Class: |
A61F 2/46 20060101
A61F002/46; A61B 34/20 20060101 A61B034/20 |
Claims
1. A system for joint arthroplasty, the system comprising: a first
template, the first template including: at least one surface for
engaging a first surface of a joint, the at least one surface being
substantially a negative of portions or all of the first surface;
at least a portion of the at least one surface further including an
anatomical relief, wherein the anatomical relief is configured
based on an offset surface derived from electronic image data of
the first surface of the joint; and at least one guide for
directing movement of a surgical instrument.
2. The system of claim 1, wherein the offset surface is configured
based on the electronic image data of the first surface of the
joint using a pre-set offset value.
3. The system of claim 2, wherein the electronic image data of the
first surface of the joint includes electronic image data of a bone
surface and the pre-set offset value is based on an expected
cartilage thickness for the joint.
4. The system of claim 1, wherein the offset surface is configured
based on the electronic image data of the first surface of the
joint using a patient-specific offset value.
5. The system of claim 1, wherein the patient-specific offset value
is based on patient-specific parameters including gender, weight,
and/or height.
6. A system for joint arthroplasty, the system comprising: a first
template, the first template including: at least one surface for
engaging a first surface of a joint, the at least one surface
substantially conforming to portions or all of the first surface;
at least a portion of the at least one surface further including an
anatomical relief, wherein the anatomical relief is configured
based on an offset surface derived from electronic image data of
the first surface of the joint; and at least one guide for
directing movement of a surgical instrument.
7. The system of claim 6, wherein the offset surface is configured
based on the electronic image data of the first surface of the
joint using a pre-set offset value.
8. The system of claim 7, wherein the electronic image data of the
first surface of the joint includes electronic image data of a bone
surface and the pre-set offset value is based on an expected
cartilage thickness for the joint.
9. The system of claim 6, wherein the offset surface is configured
based on the electronic image data of the first surface of the
joint using a patient-specific offset value.
10. The system of claim 6, wherein the patient-specific offset
value is based on patient-specific parameters including gender,
weight, and/or height.
11. A system for joint arthroplasty, the system comprising: a first
template, the first template including: at least one surface for
engaging a first surface of a joint, the at least one surface is
shaped using shape information derived from electronic image data
of portions or all of the first surface; at least a portion of the
at least one surface further including an anatomical relief,
wherein the anatomical relief is configured based on an offset
surface derived from the electronic image data of the first surface
of the joint; and at least one guide for directing movement of a
surgical instrument.
12. The system of claim 11, wherein the offset surface is
configured based on the electronic image data of the first surface
of the joint using a pre-set offset value.
13. The system of claim 12, wherein the electronic image data of
the first surface of the joint includes electronic image data of a
bone surface and the pre-set offset value is based on an expected
cartilage thickness for the joint.
14. The system of claim 11, wherein the offset surface is
configured based on the electronic image data of the first surface
of the joint using a patient-specific offset value.
15. The system of claim 11, wherein the patient-specific offset
value is based on patient-specific parameters including gender,
weight, and/or height.
Description
RELATED APPLICATIONS
[0001] This application is a continuation of U.S. Ser. No.
14/148,067, filed Jan. 6, 2014, entitled "Patient Selectable Joint
Arthroplasty Devices and Surgical Tools Incorporating Anatomical
Relief," which in turn continuation of U.S. Ser. No. 13/207,396,
filed Aug. 10, 2011, entitled "Patient Selectable Joint
Arthroplasty Devices and Surgical Tools Incorporating Anatomical
Relief," which in turn claims the benefit of both U.S. Provisional
Patent Application Ser. No. 61/491,162 to Wong et al, filed May 27,
2011, entitled "Patient Selectable Joint Arthroplasty Devices and
Surgical Tools Incorporating Anatomical Relief," and U.S.
Provisional Patent Application Ser. No. 61/443,155 to Bojarski et
al, filed Feb. 15, 2011, and entitled "Patient-Adapted and Improved
Articular Implants, Designs and Related Guide Tools." Each of the
above-described applications are hereby incorporated by reference
in their entireties.
[0002] U.S. Ser. No. 13/207,396 is also a continuation-in-part of
U.S. Ser. No. 11/671,745, entitled "Patient Selectable Joint
Arthroplasty Devices and Surgical Tools," filed Feb. 6, 2007, which
in turn claims the benefit of U.S. Ser. No. 60/765,592 entitled
"Surgical Tools for Performing Joint Arthroplasty" filed Feb. 6,
2006; U.S. Ser. No. 60/785,168, entitled "Surgical Tools for
Performing Joint Arthroplasty" filed Mar. 23, 2006; and U.S. Ser.
No. 60/788,339, entitled "Surgical Tools for Performing Joint
Arthroplasty" filed Mar. 31, 2006.
[0003] U.S. Ser. No. 13/207,396 is also a continuation-in-part of
U.S. Ser. No. 12/660,529 filed Feb. 25, 2010, entitled
"Patient-Adapted and Improved Articular Implants, Designs and
Related Guide Tools," which claims the benefit of: U.S. Ser. No.
61/155,362, entitled "Patient-Specific Orthopedic Implants And
Models," filed Feb. 25, 2009; U.S. Ser. No. 61/269,405, entitled
"Patient-Specific Orthopedic Implants And Models," filed Jun. 24,
2009; U.S. Ser. No. 61/273,216, entitled "Patient-Specific
Orthopedic Implants And Models," filed Jul. 31, 2009; U.S. Ser. No.
61/275,174, entitled "Patient-Specific Orthopedic Implants And
Models," filed Aug. 26, 2009; U.S. Ser. No. 61/280,493, entitled
"Patient-Adapted and Improved Orthopedic Implants, Designs and
Related Tools," filed Nov. 4, 2009; U.S. Ser. No. 61/284,458,
entitled "Patient-Adapted And Improved Orthopedic Implants, Designs
And Related Tools," filed Dec. 18, 2009; U.S. Ser. No. 61/155,359,
entitled "Patient Selectable Joint Arthroplasty Devices and
Surgical Tools," filed Feb. 25, 2009; and U.S. Ser. No. 61/220,726,
entitled "Patient-Specific Orthopedic Implants And Models," filed
Jun. 26, 2009.
FIELD OF THE INVENTION
[0004] The present disclosure relates to orthopedic methods,
systems and prosthetic devices and more particularly relates to
methods, systems and devices for joint replacement and articular
resurfacing that incorporate anatomical relief surfaces and/or
other features. The present disclosure also includes surgical tools
and/or molds, incorporating anatomical relief features that are
designed to achieve optimal cut planes in a joint in preparation
for installation of a joint implant.
BACKGROUND OF THE INVENTION
[0005] There are various types of cartilage, e.g., hyaline
cartilage and fibrocartilage. Hyaline cartilage is found at the
articular surfaces of bones, e.g., in the joints, and is
responsible for providing the smooth gliding motion characteristic
of moveable joints. Articular cartilage is firmly attached to the
underlying bones and measures typically less than 5 mm in thickness
in human joints, with considerable variation depending on joint and
site within the joint. In addition, articular cartilage is aneural,
avascular, and alymphatic. In adult humans, this cartilage derives
its nutrition by a double diffusion system through the synovial
membrane and through the dense matrix of the cartilage to reach the
chondrocyte, the cells that are found in the connective tissue of
cartilage.
[0006] Adult cartilage has a limited ability of repair; thus,
damage to cartilage produced by disease, such as rheumatoid and/or
osteoarthritis, or trauma can lead to serious physical deformity
and debilitation. Furthermore, as human articular cartilage ages,
its tensile properties change. The superficial zone of the knee
articular cartilage exhibits an increase in tensile strength up to
the third decade of life, after which it decreases markedly with
age as detectable damage to type II collagen occurs at the
articular surface. The deep zone cartilage also exhibits a
progressive decrease in tensile strength with increasing age,
although collagen content does not appear to decrease. These
observations indicate that there are changes in mechanical and,
hence, structural organization of cartilage with aging that, if
sufficiently developed, can predispose cartilage to traumatic
damage.
[0007] For example, the superficial zone of the knee articular
cartilage exhibits an increase in tensile strength up to the third
decade of life, after which it decreases markedly with age as
detectable damage to type II collagen occurs at the articular
surface. The deep zone cartilage also exhibits a progressive
decrease in tensile strength with increasing age, although collagen
content does not appear to decrease. These observations indicate
that there are changes in mechanical and, hence, structural
organization of cartilage with aging that, if sufficiently
developed, can predispose cartilage to traumatic damage.
[0008] Once damage occurs, joint repair can be addressed through a
number of approaches. One approach includes the use of matrices,
tissue scaffolds or other carriers implanted with cells (e.g.,
chondrocytes, chondrocyte progenitors, stromal cells, mesenchymal
stem cells, etc.). These solutions have been described as a
potential treatment for cartilage and meniscal repair or
replacement. However, clinical outcomes with biologic replacement
materials such as allograft and autograft systems and tissue
scaffolds have been uncertain since most of these materials cannot
achieve a morphologic arrangement or structure similar to or
identical to that of normal, disease-free human tissue it is
intended to replace. Moreover, the mechanical durability of these
biologic replacement materials remains uncertain.
[0009] Usually, severe damage or loss of cartilage is treated by
replacement of the joint with a prosthetic material, for example,
silicone, e.g. for cosmetic repairs, or metal alloys. See, e.g.,
U.S. Pat. No. 6,383,228 to Schmotzer, issued May 7, 2002; U.S. Pat.
No. 6,203,576 to Afriat et al., issued Mar. 20, 2001; U.S. Pat. No.
6,126,690 to Ateshian, et al., issued Oct. 3, 2000. Implantation of
these prosthetic devices is usually associated with loss of
underlying tissue and bone without recovery of the full function
allowed by the original cartilage and, with some devices, serious
long-term complications associated with the loss of significant
amount of tissue and bone can include infection, osteolysis and
also loosening of the implant.
[0010] Further, joint arthroplasties are highly invasive and often
require surgical resection of the entirety or the majority of the
articular surface of one or more bones. With these procedures, the
marrow space is often reamed in order to fit the stem of the
prosthesis. The reaming results in a loss of the patient's bone
stock. U.S. Pat. No. 5,593,450 to Scott et al. issued Jan. 14, 1997
discloses an oval domed shaped patella prosthesis. The prosthesis
has a femoral component that includes two condyles as articulating
surfaces. The two condyles meet to form a second trochlear groove
and ride on a tibial component that articulates with respect to the
femoral component. A patella component is provided to engage the
trochlear groove. U.S. Pat. No. 6,090,144 to Letot et al. issued
Jul. 18, 2000 discloses a knee prosthesis that includes a tibial
component and a meniscal component that is adapted to be engaged
with the tibial component through an asymmetrical engagement.
[0011] Another joint subject to invasive joint procedures is the
hip. U.S. Pat. No. 6,262,948 to Storer et al. issued Sep. 30, 2003
discloses a femoral hip prosthesis that replaces the natural
femoral head. U.S. Patent Publications 2002/0143402 A1 and
2003/0120347 to Steinberg published Oct. 3, 2002 and Jun. 26, 2003,
respectively, also disclose a hip prosthesis that replaces the
femoral head and provides a member for communicating with the ball
portion of the socket within the hip joint.
[0012] A variety of materials can be used in replacing a joint with
a prosthetic, for example, silicone, e.g. for cosmetic repairs, or
suitable metal alloys are appropriate. Implantation of these
prosthetic devices is usually associated with loss of underlying
tissue and bone and, with some devices, serious long-term
complications associated with the loss of significant amounts of
tissue and bone can cause loosening of the implant. One such
complication is osteolysis. Once the prosthesis becomes loosened
from the joint, regardless of the cause, the prosthesis will then
often be required to be replaced. Since the patient's bone stock is
limited, the number of possible replacement surgeries is also
limited for joint arthroplasty.
[0013] As can be appreciated, joint arthroplasties are generally
highly invasive procedures and can require surgical resection of
the entirety, or a majority of, the articular surface of one or
more bones involved in the repair. In many procedures, the marrow
space can be fairly extensively reamed in order to fit the stem of
the prosthesis within the bone. Reaming results in a loss of the
patient's bone stock and over time subsequent osteolysis will
frequently lead to loosening of the prosthesis. Further, the area
where the implant and the bone mate degrades over time requiring
the prosthesis to eventually be replaced. Since the patient's bone
stock is limited, the number of possible replacement surgeries can
be limited for joint arthroplasty. In short, over the course of 15
to 20 years, and in some cases even shorter time periods, the
patient can run out of therapeutic options ultimately resulting in
a painful, non-functional joint.
[0014] In the past, a diseased, injured or defective joint, such
as, for example, a joint exhibiting osteoarthritis, was repaired
using standard off-the-shelf implants and other surgical devices.
Specific off-the-shelf implant designs have been altered over the
years to address particular issues. For example, several existing
designs include implant components having rotating parts to enhance
joint motion. Ries et al. describes design changes to the distal or
posterior condyles of a femoral implant component to enhance axial
rotation of the implant component during flexion. See U.S. Pat.
Nos. 5,549,688 and 5,824,105. Andriacchi et al. describes a design
change to the heights of the posterior condyles to enhance high
flexion motion. See also U.S. Pat. No. 6,770,099. However, in
altering a design to address a particular issue, historical design
changes frequently have created one or more additional issues for
future designs to address. Collectively, many of these issues have
arisen from one or more differences between a patient's existing
joint anatomy and the corresponding features of an implant
component.
[0015] Joint implants have historically employed a
one-size-fits-all (or a few-sizes-fit-all) approach to implant
design. A series of one or more "standard" implant shapes and/or
sizes is pre-manufactured and stockpiled, and then one or more of
these implants selected for implantation in the patient. It has
been common practice to modify the patient's anatomical support
structures (e.g., cut supporting bones and/or other structures) to
accommodate a chosen implant, and with a limited number of shapes
and sizes to of implants choose from, it is virtually guaranteed
that the chosen implant will not be a "perfect fit" to the
patient's anatomy. Rather, the chosen implant is likely the "best
fit" or best compromise available, with the surgical procedure
still requiring removal of significant bone and/or other support
tissues to accommodate the chosen implant size. Accordingly,
advanced implant designs and related devices and methods that
address the needs of individual patient's are needed.
[0016] Moreover, currently available devices do not optimally
provide ideal alignment with the articular surfaces and the
resultant joint congruity. Poor alignment and poor joint congruity
can, for example, lead to instability of the joint. In the knee
joint, instability typically manifests as a lateral instability of
the joint.
[0017] Thus, there remains a need for compositions for joint
repair, including methods and compositions that facilitate the
integration between the cartilage replacement system and the
surrounding cartilage. There is also a need for tools that increase
the accuracy of cuts made to the bone in a joint in preparation for
surgical implantation of, for example, an artificial joint.
SUMMARY OF THE INVENTION
[0018] The embodiments described herein include advancements in or
that arise out of the area of patient-adapted articular implants
that are tailored to address the needs of individual, single
patients. Such patient-adapted articular implants offer advantages
over the traditional one-size-fits-all approach, or a
few-sizes-fit-all approach. The advantages include, for example,
better fit, more natural movement of the joint, reduction in the
amount of bone removed during surgery and a less invasive
procedure. Such patient-adapted or patient-specific articular
implants can be created from images of the patient's joint. Based
on the images, patient-adapted and/or patient-specific implant
components can be selected and/or designed to include features
(e.g., surface contours, curvatures, shapes, widths, lengths,
thicknesses, and other features) that match existing features in
the single, individual patient's joint as well as features that
approximate an ideal and/or healthy feature or a combination of
patient-adapted or patient-specific and engineered features that
may not exist in the patient prior to a procedure.
[0019] Patient-adapted features can include patient-specific and/or
patient-engineered features. Patient-specific (or patient-matched)
implant component or guide tool features can include features
adapted to match one or more of the patient's biological features,
for example, one or more biological/anatomical structures,
alignments, kinematics, and/or soft tissue features.
Patient-adapted can include one or more implant/tool features that
are modified to accommodate various patient anatomical features, or
features that are designed or chosen to substantially match a
patient's anatomical features. Patient-specific can include surface
features that are a substantial negative of, substantially mirror
and/or substantially conform to some of all of a patient's native
anatomical features. Patient-engineered (or patient-derived)
features of an implant component can be designed and/or
manufactured (e.g., preoperatively designed and manufactured) based
on patient-specific data to substantially enhance or improve one or
more of the patient's anatomical and/or biological features,
Patient-engineered features can include implants and/or surgical
tools having features based on information derived from the
patient's anatomy combined with information derived from
non-patient-specific sources, including anatomical databases of one
or more individuals (including averaged data) from general
population groups of similar age, medical condition, age, activity
level, ethnicity, geographic location, height, weight, occupation,
etc. Patient-engineered features can also include implants and/or
surgical tools having some features based on information derived
from the patient's anatomy combined with other features designed or
derived from non-patient-specific data, including general
engineering or performance knowledge and/or criteria as well as
general biomechanical data.
[0020] The patient-adapted (e.g., patient-specific and/or
patient-engineered) implant components and guide tools described
herein can be selected (e.g., from a library), designed (e.g.,
preoperatively designed including, optionally, manufacturing the
components, instruments, or tools), and/or selected and designed
and/or modified (e.g., by selecting a blank component or tool
having certain blank features and then altering the blank features
to be patient-adapted or patient-specific or patient-engineered).
Moreover, related methods, such as designs and strategies for
resectioning a patient's biological structure also can be selected
and/or designed. For example, an implant component bone-facing
surface and a resectioning strategy for the corresponding
bone-facing surface can be selected and/or designed together so
that an implant component's bone-facing surface matches the
resected surface. Such resectioning approaches can be performed
with saws, blades, burrs, curettes and any other tool known in the
art or designed in the future. The resectioning approaches can be
implemented using free hand, surgical navigation, custom cutting
jig or robot assisted approaches. In addition, one or more guide
tools optionally can be selected and/or designed to facilitate the
resection cuts that are predetermined in accordance with
resectioning strategy and implant component selection and/or
design.
[0021] In various exemplary embodiments, the implants and
associated surgical tools incorporate surface features that can
accommodate unusual, unknown, uncertain or distinctive anatomical
features in addition to including surfaces that conform to
corresponding patient-specific and/or surgically-modified
anatomical surfaces of the patient's underlying anatomical support
structures. For example, an implant and/or surgical tool can
include surfaces conforming to patient-specific and/or
surgically-modified anatomical surfaces of the patient's joint, and
further include a surface opening, void and/or other "anatomical
relief" feature that accommodates or avoids one or more osteophytes
on the surface of the targeted anatomical region. In various
embodiments, the "anatomical relief" surface of the implant/tool
can desirably avoid direct contact with the
unusual/unknown/distinctive feature of the anatomical support
structure. In other embodiments, the anatomical relief surface can
contact or otherwise engage with the unusual/unknown/distinctive
surface feature.
[0022] In various instances it may be desirous to avoid, eliminate,
minimize and/or reduce implant/tool contact with
unusual/unknown/distinctive anatomical surface features such as
osteophytes, voids, soft tissues and/or other anatomical
structures. Avoidance may be desirable because of load bearing
constraints of the surface feature, imaging difficulties that
render surface characterizations inaccurate, a desire to allow the
features to heal or otherwise remodel, or for many other reasons
desired by the physician and/or implant designers.
[0023] In various other instances it may be desirous to increase,
enhance and/or augment implant/tool contact with
unusual/distinctive anatomical surface features such as
osteophytes, voids, soft tissues and/or other anatomical
structures. Enhancement may be desirable because of load bearing
abilities of the surface feature, ability of the feature to
increase securement of the implant/tool against lateral or sliding
movement and/or due to other desires to contact the implant/tool as
desired by the physician and/or implant designers. Enhancement may
further be desirable to engage the feature in a manner similar to a
"puzzle piece fit" (e.g., the mold or other tool or implant only
fits one way onto the anatomical surface with the feature).
[0024] Various embodiments could also incorporate anatomical relief
features that correspond to non-surface features of the bone,
including features below the surface of the bone (i.e., subsurface
voids or cysts) and/or non-surface features above the bone (i.e.,
adjacent and/or surrounding bones, ligaments, tendons, muscles
and/or other soft tissues, etc.).
[0025] The present disclosure describes novel devices and methods
for replacing a portion (e.g., diseased area and/or area slightly
larger than the diseased area) of a joint (e.g., cartilage and/or
bone) with a non-pliable, non-liquid (e.g., hard) implant material,
where the implant and/or surgical tools achieve a near anatomic fit
with the surrounding structures and tissues, and where the implant
and/or tool further includes at least one anatomical relief. In
cases where the devices and/or methods include an element
associated with the underlying articular bone, various embodiments
also provide that the bone-associated element achieves a near
anatomic alignment with the subchondral bone. Various embodiments
optionally provide for the preparation of an implantation site with
a single cut, or a few relatively small cuts.
[0026] In various aspects, the anatomical relief can be completely
encompassed by the patient-specific or patient-engineered surfaces
(i.e., the periphery of the anatomical relief is completely
surrounded by patient-specific and/or patient-engineered surfaces
of the implant/tool). In other embodiments, the anatomical relief
can be located along one or more edges of an implant/tool's
patient-specific or patient-engineered surfaces, such that at least
a portion of a periphery of the anatomical relief is not bounded by
a patient-specific and/or patient-engineered surface of the
implant/tool. The anatomical relief can extend inward relative to
the implant/tool and/or the patient-specific or patient-engineered
surfaces, can extend outward relative to the implant/tool and/or
the patient-specific or patient-engineered surfaces, or can extend
both inward and outward relative to the implant/tool and/or the
patient-specific or patient-engineered surfaces. In various
embodiments the anatomical relief can be positioned on an outer or
non-bone facing surface of the implant to accommodate other soft
and hard tissues adjacent to the implant.
[0027] Various embodiments disclose a method for providing
articular replacement material, the method comprising the step of
producing articular replacement (e.g., cartilage replacement
material) of selected dimensions (e.g., size, thickness and/or
curvature). The method can include the steps of (a) measuring the
dimensions (e.g., thickness, curvature and/or size) of the intended
implantation site or the dimensions of the area surrounding the
intended implantation site; and (b) providing cartilage replacement
material that conforms to the measurements obtained in step (a). In
certain aspects, step (a) comprises measuring the thickness of the
cartilage surrounding the intended implantation site and measuring
the curvature of the cartilage surrounding the intended
implantation site. In other embodiments, step (a) comprises
measuring the size of the intended implantation site and measuring
the curvature of the cartilage surrounding the intended
implantation site. In other embodiments, step (a) comprises
measuring the thickness of the cartilage surrounding the intended
implantation site, measuring the size of the intended implantation
site, and measuring the curvature of the cartilage surrounding the
intended implantation site. In other embodiments, step (a)
comprises reconstructing the shape of healthy cartilage surface at
the intended implantation site.
[0028] In any of the methods described herein, one or more
components of the articular replacement material (e.g., the
cartilage replacement material) can be non-pliable, non-liquid,
solid or hard. The dimensions of the replacement material can be
selected following intraoperative measurements. Measurements can
also be made using imaging techniques such as ultrasound, MRI, CT
scan, x-ray imaging obtained with x-ray dye and fluoroscopic
imaging. A mechanical probe (with or without imaging capabilities)
can also be used to select dimensions, for example an ultrasound
probe, a laser, an optical probe and a deformable material or
device.
[0029] In any of the methods described herein, the replacement
material can be selected (for example, from a pre-existing library
of repair systems), grown from cells and/or hardened from various
materials. Thus, the material can be produced pre- or
post-operatively. Furthermore, in any of the methods described
herein the repair material can also be shaped (e.g., manually,
automatically or by machine), for example using mechanical
abrasion, laser ablation, radiofrequency ablation, cryoablation
and/or enzymatic digestion.
[0030] In any of the methods described herein, the articular
replacement material can comprise synthetic materials (e.g.,
metals, liquid metals, polymers, alloys or combinations thereof) or
biological materials such as stem cells, fetal cells or chondrocyte
cells.
[0031] In a still further aspect, various embodiments describe a
partial or full articular prosthesis comprising a first component
comprising a cartilage replacement material; and an optional second
component comprising one or more metals, wherein said second
component can have a curvature similar to subchondral bone, wherein
said prosthesis comprises less than about 80% of the articular
surface. In certain embodiments, the first and/or second component
comprises a non-pliable material (e.g., a metal, a polymer, a metal
alloy, a solid biological material). Other materials that can be
included in the first and/or second components include polymers,
biological materials, metals, metal alloys or combinations thereof.
Furthermore, one or both components can be smooth or porous (or
porous coated) using any methods or mechanisms to achieve in-growth
of bone known in the art. In certain embodiments, the first
component exhibits biomechanical properties (e.g., elasticity,
resistance to axial loading or shear forces) similar to articular
cartilage. The first and/or second component can be bioresorbable
and, in addition, the first or second components can be adapted to
receive injections.
[0032] In another aspect, an articular prosthesis comprising an
external surface located in the load bearing area of an articular
surface, wherein the dimensions of said external surface achieve a
near anatomic fit with the adjacent, underlying or opposing
cartilage is provided. The prosthesis can comprise one or more
metals or metal alloys.
[0033] In a still further embodiment, a partial articular
prosthesis comprising (a) a metal or metal alloy; and (b) an
external surface located in the load bearing area of an articular
surface, wherein the external surface designed to achieve a near
anatomic fit with the adjacent surrounding, underlying or opposing
cartilage is provided.
[0034] Any of the repair systems or prostheses described herein
(e.g., the external surface) can comprise a polymeric material, for
example attached to said metal or metal alloy. Any of the repair
systems can be entirely composed of polymer. Further, any of the
systems or prostheses described herein can be adapted to receive
injections, for example, through an opening in the external surface
of said cartilage replacement material (e.g., an opening in the
external surface terminates in a plurality of openings on the bone
surface). Bone cement, polymers, Liquid Metal, therapeutics, and/or
other bioactive substances can be injected through the opening(s).
In certain embodiments, bone cement is injected under pressure in
order to achieve permeation of portions of the marrow space with
bone cement. In addition, any of the repair systems or prostheses
described herein can be anchored in bone marrow or in the
subchondral bone itself. One or more anchoring extensions (e.g.,
pegs, pins, etc.) can extend through the bone and/or bone
marrow.
[0035] In another aspect, a method of designing an articular
implant comprising the steps of obtaining an image of a joint,
wherein the image includes both normal cartilage and diseased
cartilage; reconstructing dimensions of the diseased cartilage
surface to correspond to normal cartilage; and designing the
articular implant to match the dimensions of the reconstructed
diseased cartilage surface or to match an area slightly greater
than the diseased cartilage surface is provided. The image can be,
for example, an intraoperative image including a surface detection
method using any techniques known in the art, e.g., mechanical,
optical, ultrasound, and known devices such as MRI, CT, ultrasound,
digital tomosynthesis and/or optical coherence tomography images.
In certain embodiments, reconstruction is performed by obtaining a
surface that follows the contour of the normal cartilage. The
surface can be parametric and include control points that extend
the contour of the normal cartilage to the diseased cartilage
and/or a B-spline surface. In other embodiments, the reconstruction
is performed by obtaining a binary image of cartilage by extracting
cartilage from the image, wherein diseased cartilage appears as
indentations in the binary image; and performing, for example, a
morphological closing operation (e.g., performed in two or three
dimensions using a structuring element and/or a dilation operation
followed by an erosion operation) to determine the shape of an
implant to fill the areas of diseased cartilage.
[0036] In yet another aspect, described herein are systems for
evaluating the fit of an articular repair system into a joint, the
systems comprising one or more computing means capable of
superimposing a three-dimensional (e.g., three-dimensional
representations of at least one articular structure and of the
articular repair system) or a two-dimensional cross-sectional image
(e.g., cross-sectional images reconstructed in multiple planes) of
a joint and an image of an articular repair system to determine the
fit of the articular repair system. The computing means can be:
capable of merging the images of the joint and the articular repair
system into a common coordinate system; capable of selecting an
articular repair system having the best fit; capable of rotating or
moving the images with respect to each other; and/or capable of
highlighting areas of poor alignment between the articular repair
system and the surrounding articular surfaces. The
three-dimensional representations can be generated using a
parametric surface representation.
[0037] In yet another aspect, surgical tools for preparing a joint
to receive an implant are described, for example a tool comprising
one or more surfaces or members that conform at least partially to
the shape of the articular surfaces of the joint (e.g., a femoral
condyle and/or tibial plateau of a knee joint). In certain
embodiments, the tool comprises Lucite silastic and/or other
polymers or suitable materials. The tool can be re-useable or
single-use. The tool can be comprised of a single component or
multiple components. In certain embodiments, the tool comprises an
array of adjustable, closely spaced pins. In any embodiments
described herein, the surgical tool can be designed to further
comprise an aperture therein, for example one or more apertures
having dimensions (e.g., diameter, depth, etc.) smaller or equal to
one or more dimensions of the implant and/or one or more apertures
adapted to receive one or more injectables. Any of the tools
described herein can further include one or more curable
(hardening) materials or compositions, for example that are
injected through one or more apertures in the tool and which
solidify to form an impression of the articular surface.
[0038] In still another aspect, a method of evaluating the fit of
an articular repair system into a joint is described herein, the
method comprising obtaining one or more three-dimensional images
(e.g., three-dimensional representations of at least one articular
structure and of the articular repair system) or two-dimensional
cross-sectional images (e.g., cross-sectional images reconstructed
in multiple planes) of a joint, wherein the joint includes at least
one defect or diseased area; obtaining one or more images of one or
more articular repair systems designed to repair the defect or
diseased area; and evaluating the images to determine the articular
repair system that best fits the defect (e.g., by superimposing the
images to determine the fit of the articular repair system into the
joint). In certain embodiments, the images of the joint and the
articular repair system are merged into a common coordinate system.
The three-dimensional representations can be generated using a
parametric surface representation. In any of these methods, the
evaluation can be performed by manual visual inspection and/or by
computer (e.g., automated). The images can be obtained, for
example, using a C-arm system and/or radiographic contrast.
[0039] The present disclosure also describes tools. In accordance
with various embodiments, a surgical tool includes a template. The
template has at least one contact surface for engaging a surface
associated with a joint. The at least one contact surface
substantially conforms with the surface and, optionally,
incorporates a least one anatomical relief surface or other
feature. The template further includes at least one guide aperture
for directing movement of a surgical instrument.
[0040] In accordance with related embodiments, the surface may be
an articular surface, a non-articular surface, a cartilage surface,
a weight bearing surface, a non-weight surface and/or a bone
surface. The joint has a joint space, with the surface either
within the joint space or external to the joint space. The template
may include a mold. The template may include at least two pieces,
the at least two pieces including a first piece that includes one
or more of the at least one contact surfaces, the second piece
including one or more of the at least one guide apertures or guide
surfaces. The at least one contact surface may include a plurality
of discrete contact surfaces, optionally including at least one
anatomical relief surface or other feature. In other embodiments
the at least one contact surface may include a plurality anatomical
relief surfaces or other features.
[0041] In accordance with further embodiments, the contact surface
may be made of a biocompatible material, such as acylonitrile
butadiene styrene, polyphenylsulfone, and polycarbonate. The
contact surface may be capable of heat sterilization without
deforming. For example, the contact surface may be capable of heat
sterilization without deforming at temperatures lower than 207
degrees Celsius, such as a contact surface made of
polyphenylsulfone. The contact surface may be substantially
transparent or semi-transparent, such as a contact surface made of
Somos 11120.
[0042] In still further embodiments, the template may include a
reference element, such as a pin or aiming device, for establishing
a reference plane relative to at least one of a biomechanical axis
and an anatomical axis of a limb. In other embodiments, the
reference element may be used for establishing an axis to assist in
correcting an axis deformity.
[0043] In various embodiments, the joint surface is at least one of
an articular surface, a non-articular surface, a cartilage surface,
a weight bearing surface, a non-weight bearing surface, and a bone
surface. The joint has a joint space, wherein the surface may be
within the joint space or external to the joint space. The at least
one contact surface may include a plurality of discrete contact
surfaces. Creating the template may include rapid prototyping,
milling and/or creating a mold, the template furthermore may be
sterilizable and/or biocompatible. The rapid prototyping may
include laying down successive layers of plastic. The template may
be a multi-piece template. The multi-piece template may include a
first piece that includes one or more of the at least one contact
surfaces, and a second piece that includes one or more of the at
least one guide apertures or guide surface or element. Obtaining
the image may include determining dimensions of bone underlying the
cartilage, and adding a predefined thickness to the bone
dimensions, the predefined thickness representing the cartilage
thickness. Adding the predefined thickness may be a function of at
least one of an anatomic reference database, an age, a gender, and
race matching. Obtaining the imaging may include performing an
optical imaging technique, an ultrasound, a CT, a spiral CT, and/or
an MRI.
[0044] In accordance with another embodiment, a surgical tool
includes a template. The template has at least one contact surface
for engaging a surface associated with a joint, the at least one
contact surface substantially conforming with the surface and,
optionally, at least one anatomical relief surface or other
feature. The contact surface is optionally substantially
transparent or semi-transparent. The template further includes at
least one guide aperture for directing movement of a surgical
instrument.
[0045] In accordance with another embodiment, a method of joint
arthroplasty is presented. The method includes obtaining an image
associated with a joint. A template is created having at least one
contact surface that conforms with a surface associated with the
joint as well as, optionally, at least one anatomical relief
surface of other feature, the template including a reference
element and at least one guide aperture or guide surface or element
for directing movement of a surgical instrument. The template is
aligned in an orientation on the joint such that the reference
element establishes a reference plane relative to a biomechanical
axis of a limb. The template is anchored to the joint such that the
contact surface abuts the joint in said orientation. The
biomechanical axis may extend, for example, from a center of a hip
to a center of an ankle. A surgical tool is aligned using the
reference element to correct an axis deformity.
[0046] In accordance with another embodiment, a surgical tool
includes a template. The template includes a mold having at least
one contact surface for engaging a surface associated with a joint
and, optionally, at least one anatomical relief surface or other
feature. The at least one contact surface substantially conforms
with the surface. The mold is made of a biocompatible material. The
template further includes at least one guide aperture or guide
surface or guide element for directing movement of a surgical
instrument. The mold may be sterilizable and/or substantially
transparent or semi-transparent.
[0047] In accordance with other embodiments, methods of using a
surgical tool are presented. The surgical tool includes a first
template removably attached to a second template. The method
includes anchoring the first template to a femoral joint surface,
the first template having a first contact surface for engaging the
femoral joint surface and, optionally, at least one anatomical
relief surface or other feature. The second template is anchored to
a tibial joint surface, the second template having a second contact
surface for engaging a tibial joint surface. After anchoring the
first template and the second template, the second template is
released from the first template, such that the second template is
capable of moving independent of the first template.
[0048] In accordance with related embodiments, the disclosed
methods may further include using the second template to direct a
surgical cut on the tibia. Anchoring the second template may occur
subsequent or prior to anchoring the first template. At least one
of the first and second templates may include a mold. The first
contact surface may substantially conform with the femoral joint
surface and include optionally at least one anatomical relief
surface or other feature. The second contact surface may
substantially conform with the tibial joint surface.
[0049] In accordance with another embodiment, a method of
performing joint arthroplasty includes obtaining a computer image
of a surface associated with a first joint. At least one deformity
or other surface feature seen in the computer image can be
modified, enhanced, increased, decrease and/or reshaped. The at
least one deformity or other surface feature is used, at least in
part, to create a template. The template includes at least one
contact surface for engaging the surface, with optionally at least
one anatomical relief surface of other feature for engaging,
avoiding and/or encompassing the surface feature, the at least one
contact surface substantially conforming with the surface.
[0050] In accordance with another embodiment, a method of
performing joint arthroplasty includes obtaining a computer image
of a surface associated with a first joint. At least one deformity
seen in the computer image is removed such as a biomechanical or
anatomical axis deformity, so as to form an improved anatomic or
functional result. The at least one deformity is removed in the
surgical planning by modifying the shape or position of a template
including the shape and/or position of guide apertures, guide
surface or guide elements. A template is provided based, at least
in part, on the removal of the deformity. The template includes at
least one contact surface for engaging the joint surface as well as
optionally at least one anatomical relief surface of other feature
for engaging and/or encompassing at least one surface feature of
the joint. The shape and/or position of guide apertures, guide
surface or guide elements is selected or designed to achieve a
correction of the deformity.
[0051] In accordance with related embodiments, the template may be
used in a surgical procedure. The template may include at least one
guide aperture, guide surface or guide elements, the method further
including using the at least one guide aperture, guide surface or
guide elements to direct movement of a surgical instrument. The at
least one surface feature may include a osteophyte, a subchondral
cyst, and/or an arthritic deformation.
[0052] In accordance with another embodiment, a method of
performing joint arthroplasty includes obtaining an image of a
surface associated with a first joint, the image including at least
two surface features. A template is provided, based at least in
part on the image, the template having at least one contact surface
for engaging portions of the surface free of one of the surface
features (such as, for example, where the surface feature has been
removed or modified surgically), while the template has optionally
at least one anatomical relief surface or other feature for
accommodating at least the other surface feature. The at least one
contact surface substantially conforms with the portions of the
surface. The template is used in a surgical procedure.
[0053] In accordance with related embodiments, the template may
include at least one guide aperture, guide surface or guide
elements, the method further including using the at least one guide
aperture, guide surface or guide elements to direct movement of a
surgical instrument. The at least one surface feature and/or
deformity may include a osteophyte, a subchondral cyst, and/or an
arthritic deformation.
[0054] In accordance with another embodiment, a method of
performing joint arthroplasty includes providing a template. The
template is fixated to bone associated with a joint without
performing any cuts to the joint. The template may be used in a
surgical procedure.
[0055] In accordance with another embodiment, a system for joint
arthroplasty includes a first template. The first template includes
at least one surface for engaging a first surface of a joint as
well as optionally at least one anatomical relief surface or other
feature, the at least one surface being a mirror and/or negative
image of portions or all of the first surface. The first template
further includes at least one guide for directing movement of a
surgical instrument. A linkage cross-references at least one
surgical tool relative to said guide and relative to one of an
anatomical and a biomechanical axis.
[0056] In accordance with related embodiments, the surgical tool
may be a second template, the second template including at least
one guide for directing movement of a surgical instrument. The
second template may include a surface that is a mirror and/or
negative image of a second surface of the joint. The second joint
surface may oppose the first joint surface. At least one guide of
the second template may direct the surgical instrument in at least
one of a cut, a milling, and a drilling oriented in a predefined
location relative to said first template and adapted in shape, size
or orientation to an implant shape. The shape and/or position of
the at least one guide of the first template may be based, at least
in part, on one or more axis related to said joint. The linkage may
be an attachment mechanism, which may cause the first template to
directly contact the at least one surgical tool, or alternatively,
attaches the first template and the at least one surgical tool such
that the first template and the at least one surgical tool do not
directly contact each other. The linkage may allow for rotation
relative to one of an anatomical and a biomechanical axis. The
first template may include a removably attached block, the block
including the at least one guide of the first template.
[0057] In accordance with another embodiment, a system for joint
arthroplasty is presented that includes a first template. The first
template includes at least one first template surface for engaging
a first surface of a joint and optionally at least one anatomical
relief surface or other feature, the first template surface being a
mirror and/or negative image of portions or all of the first
surface. The first template further includes at least one guide for
directing movement of a surgical instrument. A second template
includes at least one second template surface for engaging a second
surface of a joint, the second template being a mirror and/or
negative image of portions or all of the second surface. The second
template further includes at least one guide for directing movement
of a surgical instrument. A linkage cross-references the first
template and the second template. The linkage may optionally allow
for rotation relative to one of an anatomical and a biomechanical
axis.
[0058] In accordance with related embodiments, the at least one
contact surface of the first template is substantially a mirror
and/or negative image of the first surface. The method may further
include obtaining electronic image data of the joint, and
determining a shape of the at least one contact surface of the
first template based, at least in part, on electronic image data.
In accordance with other related embodiments, the method may
further include, prior to directing movement of the surgical
instrument, positioning at least one contact surface of the second
template to the second joint surface. The at least one contact
surface of the second template may be substantially a mirror and/or
negative image of the second surface. The method may further
include obtaining electronic image data of the joint, and
determining a shape of the at least one contact surface of the
second template based, at least in part, on electronic image
data.
[0059] In accordance with yet further related embodiments,
cross-referencing the second template to the first template may
includes attaching the second template to the first template.
Attaching the second template to the first template may include
performing intraoperative adjustments. The second template is
attached to the first template via a pin, and wherein performing
intraoperative adjustments includes rotating the second template
around the pin. The method may further include performing an
intraoperative adjustment on the position of the second template on
the second surface of the joint, wherein performing the
intraoperative adjustment includes using one of spacers, ratchets,
and telescoping devices. The method may further include performing
an intraoperative adjustment on the position of the second template
on the second surface of the joint, wherein performing the
intraoperative adjustment includes adjusting for at least one of
joint flexion, joint extension, joint abduction, and joint
rotation. Directing movement of the surgical instrument using the
at least one guide of the second template may include making one or
more cuts or drill holes, the method further comprising implanting
a joint prosthesis as a function of the one or more cuts or drill
holes. The first template may include at least one guide, the
method further comprising directing movement of a surgical
instrument using the at least one guide of the first template.
Directing movement of the surgical instrument using the at least
one guide of the first template may include making one or more cuts
or drill holes, the method further comprising implanting a joint
prosthesis as a function of the one or more cuts or drill holes.
Directing movement of the surgical instrument using the at least
one guide of the second template may include making at least one of
a cut, a drill hole, and a reaming, the method further comprising
implanting a joint prosthesis.
[0060] In still further embodiments, the first surface of the joint
may be a femoral surface, and the second surface of the joint may
be a tibial surface. The method may further include obtaining
electronic image data of a joint, determining the at least one of a
biomechanical axis and an anatomical axis of the joint based, at
least in part, on the electronic image data, wherein the shape
and/or position of the guide of the second template is based, at
least in part, on the at least one of the biomechanical axis and
the anatomical axis. The electronic image data may be obtained
pre-operatively, intraoperatively, optically, an MRI, a CT, and/or
a spiral CT. The first template may include a thickness based, at
least in part, on at least one of a thickness of an implant to be
attached to the first surface of the joint and a desired space
between two opposing surfaces of the joint.
[0061] In accordance with another embodiment, a method of joint
arthroplasty includes positioning at least one contact surface of a
first template onto a first surface of a joint and, optionally, at
least one anatomical relief surface of other feature to encompass,
avoid and/or engage at least a portion of a surface feature of the
joint, wherein the at least one contact surface of the first
template is substantially a mirror and/or negative image of the
first surface. A second template is cross-referenced to the first
template to align position of the second template onto a second
surface of the joint, the at least one contact surface of the
second template substantially a mirror and/or negative image of the
second surface of the joint. The second template includes at least
one guide. Movement of the surgical instrument is directed using
the at least one guide of the second template.
[0062] In accordance with another embodiment, a method of joint
arthroplasty includes positioning at least one contact surface of a
first template onto a first surface of a joint and, optionally, at
least one anatomical relief surface or other feature to encompass,
avoid and/or engage at least a portion of a surface feature of the
joint. A second template is cross-referenced to the first template
to align position of the second template on a second surface of the
joint, the second template including at least one guide.
Cross-referencing allows rotation of the second template relative
to one of a biomechanical and an anatomical axis. Movement of the
surgical instrument is directed using the at least one guide of the
second template.
[0063] In accordance with another embodiment, the template may
include at least one surface for engaging a surface of a joint and,
optionally, at least one anatomical relief surface or other feature
to encompass, avoid and/or engage at least a portion of a surface
feature of the joint, the surface being a mirror and/or negative
image of portions or all of the surface. Obtaining electronic image
data may include at least one of a CT scan, MRI scan, optical scan,
and a ultrasound imaging. Obtaining electronic image data may
include obtaining image data of a medial space, a lateral space, an
anterior space, and/or a posterior space of the joint. At least two
of the lateral space, anterior space, and posterior space of the
joint may be compared. Obtaining image data may be performed in two
dimensions or three dimensions. Determining width of the joint may
include measuring the distance from the subchondral bone plate of
one articular surface to the subchondral bone plate of the opposing
articular surface. Alternatively, determining width of the joint
may include measuring the distance from the subchondral bone plate
of one articular surface to the subchondral bone plate of the
opposing articular surface. Obtaining the image data of the joint
may be performed in at least one of joint flexion, joint extension,
and joint rotation. At least one of the shape and position of the
guide may be further based, at least in part, on the anatomical or
biomechanical axis alignment of the joint.
[0064] In accordance with related embodiments, the method may
further include measuring at least one axis associated with the
joint. Measuring may include a standing x-ray, a weight bearing
x-ray, a CT scout scan, a MRI localizer scan, a CT scan, and/or a
MRI scan. The axis may include a plurality of axis measurements,
plurality of planes, or a combination of an axis and a plane.
Obtaining image data may include a spiral CT, spiral CT
arthography, MRI, optical imaging, optical coherence tomography,
and/or ultrasound. The template may include at least one contact
surface for engaging a surface of the joint and optionally at least
one anatomical relief surface or other feature to encompass, avoid
and/or engage at least a portion of a surface feature of the joint,
the contact surface being a mirror and/or negative image of
portions or all of the joint surface.
[0065] In accordance with another embodiment, a surgical tool
includes a template having a surface for engaging a joint surface
and optionally at least one anatomical relief surface or other
feature to encompass, avoid and/or engage at least a portion of a
surface feature of the joint, the surface being a mirror and/or
negative image of a portion or all of the joint surface. The
template further includes two or more guides for directing movement
of a surgical instrument, wherein the shape and/or position of at
least one of the guides is based, at least in part, on at least one
axis related to said joint.
[0066] In accordance with related embodiments, the template further
includes a block removably attached to the surface, the block
including the two or more guides. The two or more guides may
include at least one guide for a cut, a milling, and a drilling. A
second surgical tool may be attached to the template, the second
tool including at least one guide aperture for guiding a surgical
instrument. At least one guide of the second surgical tool may
guide a surgical instrument to make cuts that are parallel,
non-parallel, perpendicular, or non-perpendicular to cuts guided by
the first template.
[0067] In accordance with another embodiment, a method for joint
arthroplasty includes performing a first cut on a joint to create a
first cut joint surface. Performing the first cut includes
positioning at least one contact surface of a first template onto a
first surface of a joint and optionally at least one anatomical
relief surface or other feature to encompass, avoid and/or engage
at least a portion of a surface feature of the joint, the at least
one contact surface being a mirror and/or negative image of the
first surface of the joint. The first template includes a guide for
directing movement of a surgical instrument to perform the first
cut. The first cut is cross-referenced to perform a second cut
associated with an opposing surface of the joint.
[0068] In accordance with related embodiments, cross-referencing
the first cut to make the second cut may include attaching a second
template to the first template so as to assist positioning at least
one contact surface of the second template onto a second surface of
the joint. The second template includes a guide for directing
movement of a surgical instrument to perform the second cut. The
second template may include at least one contact surface being a
mirror and/or negative image of the second surface of the joint.
Cross-referencing the first cut to make the second cut may include
positioning at least one contact surface of a third template onto
at least a portion of the first cut surface, and attaching a second
template to the third template so as to position at least one
contact surface of the second template onto a second surface of the
joint. The at least one contact surface of the third template may
be a mirror and/or negative image of the first cut surface. The
first cut may be a horizontal femoral cut, with the second cut
being a vertical femoral cut. The first cut may be femoral cut with
the second cut being a tibial cut. The first cut may be a femoral
cut, and the second cut is a patellar cut. The first cut may be an
acetabular reaming and the second cut is a femoral cut.
[0069] In accordance with another embodiment, a method for joint
arthroplasty includes positioning at least one contact surface of a
template onto a surface of a joint and optionally at least one
anatomical relief surface or other feature to encompass, avoid
and/or engage at least a portion of a surface feature of the joint,
the at least one contact surface being a mirror and/or negative
image of at least a portion of the surface of the joint. The
template includes a guide for directing movement of a surgical
instrument. The first template is stabilized onto the first
surface.
[0070] In accordance with related embodiments, the method may
further include obtaining electronic image data of the joint, and
determining a shape of the at least one contact surface of the
first template based, at least in part, on electronic image data,
and optionally determining a shape of the at least one anatomical
relief surface or other feature, at least in part, on electronic
image data of the surface feature of the joint (or an estimated
area of imaging uncertainty). Stabilizing may include using
k-wires, a screw, an anchor, and/or a drill bit left in place on
the joint. Stabilizing may includes positioning the contact surface
and/or anatomical relief surface(s) on at least one or more
concavities and convexities on the joint. Stabilizing may include
positioning the contact surface on at least one concavity and at
least convexity on the joint. Stabilizing may include positioning
the contact surface, at least partially, on an arthritic portion of
the joint. Stabilizing may include positioning the contact surface,
at least partially, on an interface between a normal and an
arthritic portion of the joint. Stabilizing may include positioning
the contact surface, at least partially, against an anatomic
feature. The anatomic feature may be a trochlea, an intercondylar
notch, a medial condyle and a lateral condyle, a medial trochlea
and a lateral trochlea, a medial tibial plateau and a lateral
tibial plateau, a fovea capities, an acetabular fossa, a
tri-radiate cartilage, an acetabular wall, or an acetabular rim.
Positioning the contact surface on the surface of the joint may
include positioning the contact surface on, at least partially, a
normal portion of the joint. Positioning the at least one
anatomical relief surface or other feature on the surface feature
of the joint may include encompassing and/or engaging at least a
portion of a surface feature of the joint. Determining the position
of the guide on the template may be based, at least in part, on
ligament balancing and/or to optimize at least one of flexion and
extension gap. The method may further include adjusting the
position of the guide relative to the joint intraoperatively, using
for example, a spacer, a ratchet device, and a pin that allows
rotation.
[0071] In accordance with another embodiment, a method for joint
arthroplasty includes positioning at least one contact surface of a
template onto a surface of a joint and optionally at least one
anatomical relief surface or other feature to encompass, avoid
and/or engage at least a portion of a surface feature of the joint,
such that the contact surface, at least partially, rests on, and is
a mirror and/or negative image of, an interface between an
arthritic and a normal portion of the joint surface. The template
includes a guide for directing movement of a surgical instrument. A
surgical intervention is made on the joint with the surgical
instrument based, at least in part, on the guide.
[0072] In accordance with another embodiment, a template includes
at least one contact surface for positioning onto a surface of a
joint and optionally at least one anatomical relief surface or
other feature to encompass, avoid and/or engage at least a portion
of a surface feature of the joint, the contact surface at least
partially being a mirror and/or negative image of an interface
between an arthritic and a normal portion of the joint surface. A
guide directs movement of a surgical instrument.
[0073] In accordance with another embodiment, a method for joint
arthroplasty includes providing a template that includes at least
one surface for engaging a surface of a joint and, optionally, at
least one anatomical relief surface or other feature to encompass,
avoid and/or engage at least a portion of a surface feature of the
joint based, at least in part, on substantially isotropic input
data. The surface is a mirror and/or negative image of portions or
all of the joint surface. The template includes at least one guide
for directing movement of a surgical instrument.
[0074] In accordance with another embodiment, a method for ligament
repair includes obtaining electronic image data of at least one
surface associated with a ligament. A first template is created
based, at least in part, on the image data. The first template has
at least one contact surface that conforms with at least a portion
of the surface and, optionally, at least one anatomical relief
surface of other feature to accommodate the ligament. The first
template includes at least one guide for directing movement of a
surgical instrument involved with the ligament repair.
[0075] In related embodiments, the ligament may be an anterior
cruciate ligament or a posterior cruciate ligament. The method may
further include determining a tunnel site for a ligament graft.
Determining the tunnel site may include identifying an origin of
the ligament on a first articular surface, and an insertion
position onto a second articular surface opposing the first
articular surface. Determining the tunnel site may include
identifying at least one of a bony landmark and a remainder of a
ligament based on the image data. The surface or anatomical relief
surface may be adjacent to the tunnel site, or a non-weight bearing
surface. The first template may includes a drill guide aperture,
the method further including positioning the template such that the
at least one contact surface contacts the at least a portion of the
surface and, optionally, at least one anatomical relief surface of
other feature encompasses, avoids and/or engages at least a portion
of a surface feature of the joint, and drilling a ligament tunnel,
wherein the drilling is guided by the drill guide aperture. At
least one of the shape, position and orientation of the drill guide
aperture on the first template may be based, at least in part, on a
distance of the tunnel to adjacent cortical bone. The drill guide
aperture may includes a stop, such that a desired drill depth is
obtained. The image data may be obtained preoperatively. The image
data may be obtained by a CT scan or an MRI scan. The image data
may be obtained in joint flexion, joint extension, joint abduction,
joint adduction, and/or joint rotation. The method may further
include identifying a graft harvest site based on the image data,
and using the first template to guide harvesting of at least one of
ligament and bone form the graft harvest site. The method may
further include cross-referencing a second template to the first
template to align position of the second template on a second
surface associated with the ligament, the second template including
at least one guide, and directing movement of the instrument using
the at least one guide of the second template relative to said
guide. The first and second surfaces may be opposing articular
surfaces. The first surface may be a femoral surface and the second
surface may be a tibial surface. The first template may include a
tissue retractor. The tissue retractor may be a flange or an
extender on the template. The template may be used for single
bundle or a double bundle ligament reconstruction.
[0076] In any of the embodiments and aspects described herein, the
joint can be, without limitation, a knee, shoulder, hip, vertebrae,
elbow, ankle, foot, toe, hand, wrist or finger.
BRIEF DESCRIPTION OF THE DRAWINGS
[0077] The foregoing features disclosed herein will be more readily
understood by reference to the following detailed description,
taken with reference to the accompanying drawings, in which:
[0078] FIG. 1 is a flowchart depicting various disclosed methods
including, measuring the size of an area of diseased cartilage or
cartilage loss, measuring the thickness of the adjacent cartilage,
and measuring the curvature of the articular surface and/or
subchondral bone. Based on this information, a best-fitting implant
can be selected from a library of implants or a patient specific
custom implant can be generated. The implantation site is
subsequently prepared and the implantation is performed.
[0079] FIGS. 2A-H illustrate, in cross-section, various stages of
knee resurfacing, in accordance with various embodiments disclosed
herein. FIG. 2A shows an example of normal thickness cartilage and
a cartilage defect. FIG. 2B shows an imaging technique or a
mechanical, optical, laser or ultrasound device measuring the
thickness and detecting a sudden change in thickness indicating the
margins of a cartilage defect. FIG. 2C shows a weight-bearing
surface mapped onto the articular cartilage. FIG. 2D shows an
intended implantation site and cartilage defect. FIG. 2E depicts
placement of an exemplary single component articular surface repair
system. FIG. 2F shows an exemplary multi-component articular
surface repair system. FIG. 2G shows an exemplary single component
articular surface repair system. FIG. 2H shows an exemplary
multi-component articular surface repair system.
[0080] FIGS. 3A-E, illustrate, in cross-section, exemplary knee
imaging and resurfacing, in accordance with various embodiments.
FIG. 3A shows a magnified view of an area of diseased cartilage.
FIG. 3B shows a measurement of cartilage thickness adjacent to the
defect. FIG. 3C depicts placement of a multi-component
mini-prosthesis for articular resurfacing. FIG. 3D is a schematic
depicting placement of a single component mini-prosthesis utilizing
stems or pegs. FIG. 3E depicts placement of a single component
mini-prosthesis utilizing stems and an opening for injection of
bone cement.
[0081] FIGS. 4A-C, illustrate, in cross-section, other exemplary
knee resurfacing devices and methods, in accordance with various
embodiments. FIG. 4A depicts normal thickness cartilage in the
anterior and central and posterior portion of a femoral condyle and
a large area of diseased cartilage in the posterior portion of the
femoral condyle. FIG. 4B depicts placement of a single component
articular surface repair system. FIG. 4C depicts a multi-component
articular surface repair system.
[0082] FIGS. 5A-B show single and multiple component devices, in
accordance with various embodiments. FIG. 5A shows an exemplary
single component articular surface repair system with varying
curvature and radii. FIG. 5B depicts a multi-component articular
surface repair system with a second component that mirror and/or
negatives the shape of the subchondral bone and a first component
closely matches the shape and curvature of the surrounding normal
cartilage.
[0083] FIGS. 6A-B show exemplary articular repair systems having an
outer contour matching the surrounding normal cartilage, in
accordance with various embodiments disclosed herein. The systems
are implanted into the underlying bone using one or more pegs.
[0084] FIG. 7 shows a perspective view of an exemplary articular
repair device including a flat surface to control depth and prevent
toggle; an exterior surface having the contour of normal cartilage;
flanges to prevent rotation and control toggle; a groove to
facilitate tissue in-growth, in accordance with one embodiment.
[0085] FIGS. 8A-D depict, in cross-section, another example of an
implant with multiple anchoring pegs, in accordance with various
embodiments. FIG. 8A shows the implant implanted into the
underlying bone using multiple anchoring pegs. FIG. 8B-D show
various cross-sectional representations of the pegs: FIG. 8B shows
a peg having a groove; FIG. 8C shows a peg with radially-extending
arms that help anchor the device in the underlying bone; and FIG.
8D shows a peg with multiple grooves or flanges.
[0086] FIG. 9A-B depict an external view of an exemplary implant
with multiple anchoring pegs and depict how the pegs are not
necessarily linearly aligned along the longitudinal axis of the
device, in accordance with various embodiments.
[0087] FIGS. 10A-E depict an exemplary implant having radially
extending arms, in accordance with various embodiments. FIG. 10A
shows the implant implanted into the underlying bone using an
anchoring peg. FIGS. 10B-E are overhead views of the implant
showing that the shape of the peg need not be conical.
[0088] FIG. 11A illustrates a femur, tibia and fibula along with
the mechanical and anatomic axes. FIGS. 11B-E illustrate the tibia
with the anatomic and mechanical axis used to create a cutting
plane along with a cut femur and tibia. FIG. 11F illustrates the
proximal end of the femur including the head of the femur.
[0089] FIG. 12 shows an example of a surgical tool having one
surface matching the geometry of an articular surface of the joint,
in accordance with one embodiment. Also shown is an aperture in the
tool capable of controlling drill depth and width of the hole and
allowing implantation of an insertion of implant having a press-fit
design.
[0090] FIG. 13 is a flow chart depicting various methods described
and used to create a mold for preparing a patient's joint for
arthroscopic surgery, in accordance with one embodiment.
[0091] FIG. 14A depicts, in cross-section, an example of a surgical
tool containing an aperture through which a surgical drill or saw
can fit, in accordance with one embodiment. The aperture guides the
drill or saw to make the proper hole or cut in the underlying bone.
Dotted lines represent where the cut corresponding to the aperture
will be made in bone.
[0092] FIG. 14B depicts, in cross-section, an example of a surgical
tool containing apertures through which a surgical drill or saw can
fit and which guide the drill or saw to make cuts or holes in the
bone, in accordance with one embodiment. Dotted lines represent
where the cuts corresponding to the apertures will be made in
bone.
[0093] FIGS. 15A-R illustrate tibial cutting blocks and molds used
to create a surface perpendicular to the anatomic axis for
receiving the tibial portion of a knee implant, in accordance with
various embodiments.
[0094] FIGS. 16A-O illustrate femur cutting blocks and molds used
to create a surface for receiving the femoral portion of a knee
implant, in accordance with various embodiments. FIG. 16P
illustrates an axis defined by the center of the tibial plateau and
the center of the distal tibia. FIG. 16q shows an axis defining the
center of the tibial plateau to the femoral head. FIGS. 16R and 16S
show isometric views of a femoral template and a tibial template,
respectively. FIG. 16T illustrates a femoral guide reference tool
attached to the femoral template. FIG. 16U illustrates a sample
implant template positioned on the condyle. FIG. 16V is an
isometric view of the interior surface of the sample implant
template. FIG. 16W is an isometric view of the tibial template
attached to the sample implant. FIG. 16X shows a tibial template
that may be used, after the tibial cut has been made, to further
guide surgical tools. FIG. 16Y shows a tibial implant and femoral
implant inserted onto the tibia and femur, respectively.
[0095] FIG. 17A-G illustrate patellar cutting blocks and molds used
to prepare the patella for receiving a portion of a knee
implant.
[0096] FIG. 18A-H illustrate femoral head cutting blocks and molds
used to create a surface for receiving the femoral portion of a
knee implant.
[0097] FIG. 19A-D illustrate acetabulum cutting blocks and molds
used to create a surface for a hip implant.
[0098] FIG. 20 illustrates a 3D guidance template in a hip joint,
wherein the surface of the template facing the joint is a mirror
and/or negative image of a portion of the joint that is not
affected by the arthritic process.
[0099] FIG. 21 illustrates a 3D guidance template for an
acetabulum, wherein the surface of the template facing the joint is
a mirror and/or negative image of a portion of the joint that is
affected by the arthritic process.
[0100] FIG. 22 illustrates a 3D guidance template designed to guide
a posterior cut using a posterior reference plane. The joint facing
surface of the template is, at least in part, a mirror image of
portions of the joint that are not altered by the arthritic
process.
[0101] FIG. 23 illustrates a 3D guidance template designed to guide
an anterior cut using an anterior reference plane. The joint facing
surface of the template is, at least in part, a mirror image of
portions of the joint that are altered by the arthritic
process.
[0102] FIG. 24 illustrates a 3D guidance template for guiding a
tibial cut (not shown), wherein the tibia includes an anatomic
relief surface to span an arthritic portion. The template is
designed to avoid the arthritic process by spanning across the
defect or cyst.
[0103] FIG. 25 illustrates a 3D guidance template for guiding a
tibial cut, in accordance with an alternative embodiment. The
interface between normal and arthritic tissue is included in the
shape of the template.
[0104] FIG. 26A illustrates a 3D guidance template wherein the
surface of the template facing the joint is a mirror image of at
least portions of the surface of a joint that is healthy or
substantially unaffected by the arthritic process. FIG. 26B
illustrates the 3D guidance template wherein the surface of the
template facing the joint is a mirror image of at least portions of
the surface of the joint that is healthy or substantially
unaffected by the arthritic process. The diseased area is covered
by the template, but the mold is not substantially in contact with
it. FIG. 26C illustrates the 3D guidance template wherein the
surface of the template facing the joint is a mirror image of at
least portions of the surface of the joint that are arthritic. FIG.
26D illustrates the 3D guidance template wherein the template
closely mirrors the shape of the interface between substantially
normal or near normal and diseased joint tissue.
[0105] FIGS. 27A-D show multiple molds with linkages on the same
articular surface (A-C) and to an opposing articular surface (D),
in accordance with various embodiments.
[0106] FIG. 28 illustrates a deviation in the AP plane of the
femoral and tibial axes in a patient.
[0107] FIG. 29 is a flow diagram showing a method wherein measured
leg length discrepancy is utilized to determine the optimal cut
height of a femoral neck cut for total hip arthroplasty.
[0108] FIGS. 30A-C illustrate the use of 3D guidance templates for
performing ligament repair.
[0109] FIG. 31 shows an example of treatment of CAM impingement
using a 3D guidance template.
[0110] FIG. 32 shows an example of treatment of Pincer impingement
using a 3D guidance template.
[0111] FIG. 33 shows an example of an intended site for placement
of a femoral neck mold for total hip arthroplasty.
[0112] FIG. 34 shows an example of a femoral neck mold with handle
and slot.
[0113] FIG. 35 shows an example of a posterior acetabular approach
for total hip replacement.
[0114] FIG. 36 shows an example of a guidance mold used for reaming
the site for an acetabular cup.
[0115] FIG. 37 illustrates a surface of a femur prior to derivation
of an articular offset surface;
[0116] FIG. 38 illustrates an offset surface created using the
femur surface of FIG. 37;
[0117] FIG. 39 illustrates a solid model of a surgical tool
overlaid over the offset surface;
[0118] FIG. 40 illustrates merging of the offset surface to a
relevant portion of the solid model;
[0119] FIG. 41 illustrate the solid model after incorporating the
derived offset surface;
[0120] FIG. 42 illustrates a surface of a femur prior to derivation
of an articular offset surface in accordance with an alternate
embodiment;
[0121] FIG. 43 illustrates a trochlear curve sketch derived using
the femur surface of FIG. 42;
[0122] FIG. 44 illustrates the trochlear curve sketch of FIG. 43
laterally expanded and overlaid onto a solid model of a surgical
tool;
[0123] FIG. 45 illustrates the solid model incorporating the
derived trochlear curve sketch;
[0124] FIG. 46 illustrates the trochlear curve sketch of FIG. 43
laterally expanded and overlaid onto an alternate embodiment of a
surgical tool;
[0125] FIG. 47 illustrates the solid model of FIG. 46 incorporating
the derived trochlear curve sketch;
[0126] FIG. 48 illustrates the trochlear curve sketch of FIG. 43
laterally expanded and overlaid onto another alternate embodiment
of a surgical tool;
[0127] FIG. 49 illustrates the solid model of FIG. 48 incorporating
the derived trochlear curve sketch;
[0128] FIG. 50 illustrates the trochlear curve sketch of FIG. 43
laterally expanded and overlaid onto another alternate embodiment
of a surgical tool;
[0129] FIG. 51A illustrates the solid model of FIG. 50
incorporating the derived trochlear curve sketch;
[0130] FIG. 51B illustrates an alternative embodiment of a surgical
tool incorporating anatomical relief surfaces;
[0131] FIG. 52A depicts a cross-sectional cut of an end of a femur
with an osteophyte surface feature;
[0132] FIG. 52B illustrates the femur of FIG. 52A with the
cross-sectional view of an implant/tool incorporating an anatomical
relief designed to the shape of the femur with the osteophyte
intact;
[0133] FIG. 53A is a drawing of a cross-sectional view of an end of
a femur with a subchondral void in the bone;
[0134] FIG. 53B illustrates the femur of FIG. 53A with a
cross-sectional view of an implant designed to the shape of the
femur extending partially within the void;
[0135] FIGS. 54A through 54D and 55A through 55D illustrate models
for one particular patient receiving a single compartment knee
implant;
[0136] FIGS. 56A through 56D and 57A through 57D illustrate models
for one particular patient receiving a bicompartment knee
implant;
[0137] FIG. 58 displays an image of user interface for a computer
software program for generating models of patient-specific
renderings of implant assembly and surface features (e.g.,
osteophyte structures, voids, etc), together with bone models;
[0138] FIG. 59 shows an illustrative flow chart of the high level
processes of an exemplary computer software program for generating
models of patient-specific renderings of implant assembly and
surface features (e.g., osteophyte structures, voids, etc.),
together with bone models;
[0139] FIGS. 60A and 60B depict the posterior margin of an implant
component include one or more external anatomical relief surfaces
selected and/or designed using the imaging data or shapes derived
from the imaging data so that the implant component will not
interfere with and stay clear of the patient's PCL;
[0140] FIGS. 61A through 61D depict additional embodiments of
implant components selected and/or designed using the imaging data
or shapes derived from the imaging data so that the implant stays
clear of the cruciate ligament;
[0141] FIGS. 62A through 62C depict one alternative embodiment of a
surgical tool or jig that incorporates adjustable contact surfaces
that can be extended and/or retracted;
[0142] FIGS. 63A through 63C depict a humeral head and upper
humerus which forms part of a shoulder joint of a patient, with
various embodiments of associated patient-specific surgical
tools;
[0143] FIGS. 64A through 64C depict an upper humerus and humeral
head with osteophytes, with a more normalized surface that is
corrected with virtual removal of osteophytes;
[0144] FIGS. 65A through 65C depict an upper humerus and humeral
head with voids, fissures or cysts, with a more normalized surface
that is corrected with virtual removal of such structures;
[0145] FIGS. 66A through 66D depict a glenoid component of a
shoulder joint. FIG. 66A depicts a glenoid component with
osteophytes, and FIG. 66B depicts the glenoid component with a more
normalized surface that has been corrected by virtual removal of
the osteophytes. Two alternative embodiments of a glenoid jig are
shown in FIGS. 66C and 66D which incorporate different variants of
conforming and/or anatomical relief surfaces; and
[0146] FIGS. 67A through 67C depict a glenoid component of a
shoulder joint with voids, fissures or cysts. FIG. 67A depicts the
glenoid component, and FIG. 67B depicts the glenoid component with
a more normalized surface that has been corrected by virtual
"filling" of the voids, fissures or cysts. FIG. 67C shows a glenoid
jig that incorporates one embodiment of an anatomical relief
surface for engaging with the glenoid.
DETAILED DESCRIPTION OF THE INVENTION
[0147] The following description is presented to enable any person
skilled in the art to make and use the various embodiments of
devices, concepts and methods described herein. Various
modifications to the embodiments described will be readily apparent
to those skilled in the art, and the generic principles defined
herein can be applied to other embodiments and applications without
departing from the spirit and scope of the present systems and
methods as defined by the appended claims. Thus, the present
disclosure is not intended to be limited to the embodiments shown,
but is to be accorded the widest scope consistent with the
principles and features disclosed herein. To the extent necessary
to achieve a complete understanding of systems and methods
disclosed, the specification and drawings of all issued patents,
patent publications, and patent applications cited in this
application are incorporated herein by reference.
[0148] 3D guidance surgical tools, referred to herein as a 3D
guidance surgical templates, that may be used for surgical
assistance can include, without limitation, using templates, jigs
and/or molds, including 3D guidance molds. It is to be understood
that the terms "template," "jig," "mold," "3D guidance mold," and
"3D guidance template," shall be used interchangeably within the
detailed description and appended claims to describe the tool
unless the context indicates otherwise.
[0149] 3D guidance surgical tools that may be used may include
guide apertures. It is to be understood that the term guide
aperture shall be used interchangeably within the detailed
description and appended claims to describe both guide surface and
guide elements.
[0150] As will be appreciated by those of skill in the art, the
present disclosure contemplates and employs the use of, unless
otherwise indicated, conventional methods of x-ray imaging and
processing, x-ray tomosynthesis, ultrasound including A-scan,
B-scan and C-scan, computed tomography (CT scan), magnetic
resonance imaging (MRI), optical coherence tomography, single
photon emission tomography (SPECT) and positron emission tomography
(PET) within the skill of the art. Such techniques are explained
fully in the literature. See, e.g., X-Ray Structure Determination:
A Practical Guide, 2nd Edition, editors Stout and Jensen, 1989,
John Wiley & Sons, publisher; Body CT: A Practical Approach,
editor Slone, 1999, McGraw-Hill publisher; X-ray Diagnosis: A
Physician's Approach, editor Lam, 1998 Springer-Verlag, publisher;
and Dental Radiology: Understanding the X-Ray Image, editor
Laetitia Brocklebank 1997, Oxford University Press publisher. See
also, The Essential Physics of Medical Imaging (2.sup.nd Ed.),
Jerrold T. Bushberg, et al.
[0151] The present disclosure describes systems, methods and
compositions for repairing joints, particularly for repairing
articular cartilage and for facilitating the integration of a wide
variety of cartilage repair materials into a subject. Among other
things, the techniques described herein allow for the customization
of cartilage repair material to suit a particular subject, for
example in terms of size, cartilage thickness and/or curvature.
When the shape (e.g., size, thickness and/or curvature) of the
articular cartilage surface is an exact or near anatomic fit with
the non-damaged cartilage or with the subject's original cartilage,
the success of repair is enhanced. The repair material can be
shaped prior to implantation and such shaping can be based, for
example, on electronic images that provide information regarding
curvature or thickness of any "normal" cartilage surrounding the
defect and/or on curvature of the bone underlying the defect. Thus,
the current disclosure provides, among other things, for minimally
invasive methods for partial joint replacement. The methods can
facilitate only minimal or, in some instances, no loss, in bone
stock. Additionally, unlike with current techniques, the methods
described herein can help to restore the integrity of the articular
surface by achieving an exact or near anatomic match between the
implant and the surrounding or adjacent cartilage and/or
subchondral bone.
[0152] Advantages of the various embodiments can include, but are
not limited to, (i) customization of joint repair, thereby
enhancing the efficacy and comfort level for the patient following
the repair procedure; (ii) eliminating the need for a surgeon to
measure the defect to be repaired intraoperatively in some
embodiments; (iii) eliminating the need for a surgeon to shape the
material during the implantation procedure; (iv) providing methods
of evaluating curvature of the repair material based on bone or
tissue images or based on intraoperative probing techniques; (v)
providing methods of repairing joints with only minimal or, in some
instances, no loss in bone stock; and (vi) improving postoperative
joint congruity.
[0153] Thus, the methods described herein allow for the design and
use of joint repair material that more precisely fits the defect
(e.g., site of implantation) and, accordingly, provides improved
repair of the joint.
[0154] I. Assessment of Joints and Alignment
[0155] The methods and compositions described herein can be used to
treat defects resulting from disease of the cartilage (e.g.,
osteoarthritis), bone damage, cartilage damage, trauma, and/or
degeneration due to overuse or age. The various embodiments allow,
among other things, a health practitioner to evaluate and treat
such defects. The size, volume and shape of the area of interest
can include only the region of cartilage that has the defect, but
can also include contiguous parts of the cartilage surrounding the
cartilage defect.
[0156] As will be appreciated by those of skill in the art, size,
curvature and/or thickness measurements can be obtained using any
suitable technique. For example, one-dimensional, two-dimensional,
and/or three-dimensional measurements can be obtained using
suitable mechanical means, laser devices, electromagnetic or
optical tracking systems, molds, materials applied to the articular
surface that harden and "memorize the surface contour," and/or one
or more imaging techniques known in the art. Measurements can be
obtained non-invasively and/or intraoperatively (e.g., using a
probe or other surgical device). As will be appreciated by those of
skill in the art, the thickness of the repair device can vary at
any given point depending upon the depth of the damage to the
cartilage and/or bone to be corrected at any particular location on
an articular surface.
[0157] As illustrated in FIG. 1, typically the process begins by
first measuring the size of the area of diseased cartilage or
cartilage loss 10, as well the condition of the potential
underlying bony anatomical support structure. Thereafter the user
can optionally measure the thickness of adjacent cartilage 20. Once
these steps are performed, the curvature of the articular surface
is measured 30. Alternatively, the curvature of subchondral bone
can be measured.
[0158] Once the size of the defect is known, either an implant can
be selected from a library 32 or an implant can be generated based
on the patient specific parameters obtained in the measurements and
evaluation 34. Prior to installing the implant in the joint, the
implantation site is prepared 40 and then the implant is installed
42. One or more of these steps can be repeated as necessary or
desired as shown by the optional repeat steps 11, 21, 31, 33, 35,
and 41.
[0159] A. Imaging Techniques
[0160] I. Thickness and Curvature
[0161] As will be appreciated by those of skill in the art, imaging
techniques suitable for measuring thickness and/or curvature (e.g.,
of cartilage and/or bone) or size of areas of diseased cartilage or
cartilage loss include the use of x-rays, magnetic resonance
imaging (MRI), computed tomography scanning (CT, also known as
computerized axial tomography or CAT), optical coherence
tomography, ultrasound imaging techniques, and optical imaging
techniques. (See, also, International Patent Publication WO
02/22014 to Alexander, et al., published Mar. 21, 2002; U.S. Pat.
No. 6,373,250 to Tsoref et al., issued Apr. 16, 2002; and Vandeberg
et al. (2002) Radiology 222:430-436). Contrast or other enhancing
agents can be employed using any route of administration, e.g.
intravenous, intra-articular, etc.
[0162] Based on the imaging performed, the software may evaluate
the fit of different implants and/or surgical guide templates with
regard to dimensions, overall size and shape. The dimensions,
overall size and shape may be optimized with regard to cortical
bone shape and dimensions, cortical bone thickness, endosteal bone
shape, size of marrow cavity, articular surface shape and
dimensions, subchondral bone shape and dimensions, or subchondral
bone thickness. Thus, for example, an implant may either be custom
made or selected from a number of pre-manufactured implants that is
optimized with regard to any of the following or combinations
thereof: AP dimensions and shape, mediolateral dimensions and
shape, superoinferior dimensions and shape, shape of the
articulating surface, shape and dimensions of the interface in
contact with cortical bone, shape and dimensions of intramedullary
portions or components. These parameters may also be optimized for
implant function, e.g. for different degrees of joint flexion or
extension or abduction or adduction or internal or external
rotation.
[0163] In certain embodiments, CT or MRI is used to assess tissue,
bone, cartilage and any defects therein, for example cartilage
lesions or areas of diseased cartilage, to obtain information on
subchondral bone or cartilage degeneration and to provide
morphologic or biochemical or biomechanical information about the
area of damage. Specifically, changes such as fissuring, partial or
full thickness cartilage loss, and signal changes within residual
cartilage can be detected using one or more of these methods. For
discussions of the basic NMR principles and techniques, see MRI
Basic Principles and Applications, Second Edition, Mark A. Brown
and Richard C. Semelka, Wiley-Liss, Inc. (1999). For a discussion
of MRI including conventional T1 and T2-weighted spin-echo imaging,
gradient recalled echo (GRE) imaging, magnetization transfer
contrast (MTC) imaging, fast spin-echo (FSE) imaging, contrast
enhanced imaging, rapid acquisition relaxation enhancement (RARE)
imaging, gradient echo acquisition in the steady state (GRASS), and
driven equilibrium Fourier transform (DEFT) imaging, to obtain
information on cartilage, see Alexander, et al., WO 02/22014. Other
techniques include steady state free precision, flexible
equilibrium MRI and DESS. Thus, in various embodiments, the
measurements produced are based on three-dimensional images of the
joint obtained as described in Alexander, et al., WO 02/22014 or
sets of two-dimensional images ultimately yielding 3D information.
Two-dimensional, and three-dimensional images, or maps, of the
cartilage alone or in combination with a movement pattern of the
joint, e.g. flexion--extension, translation and/or rotation, can be
obtained. Three-dimensional images can include information on
movement patterns, contact points, contact zone of two or more
opposing articular surfaces, and movement of the contact point or
zone during joint motion. Two- and three-dimensional images can
include information on biochemical composition of the articular
cartilage. In addition, imaging techniques can be compared over
time, for example to provide up-to-date information on the shape
and type of repair material needed.
[0164] Traditional CT and MRI scans utilize two dimensional
cross-sectional images acquired in different imaging planes to
visualize complex three-dimensional articular anatomy. With
computed tomography, these slices are typically acquired in the
axial plane. The in-plane resolution is typically on the order of
0.25.times.0.25 millimeters. The slice thickness may vary from one
to five millimeters. Thus, the resolution obtained with these
imaging studies is not isotropic. Moreover, the CT slices and,
similarly with MRI, may be separated by one or more millimeters.
This means that the resolution of the images is excellent within
the imaging plane. However, two to ten-fold loss in image
resolution can be encountered in a plane perpendicular to the
slices acquired by the CT or MRI scanner. This limitation in
resolution perpendicular to the imaging plane can result in
inaccuracies in deriving the three-dimensional shape of, without
limitation, an implant and/or a 3-D guidance template, described in
more detail below.
[0165] In accordance with one embodiment, spiral CT imaging is
utilized to acquire the images rather than standard CT technology.
With recent CT technology, slip ring technology is incorporated in
the scanner. A slip ring is a circular contact with sliding brushes
that allows the gantry to rotate continuously, untethered by
electrical wires. The use of slip ring technology eliminates the
initial limitations at the end of each slice acquisition. Thus, the
rotating gantry is free to rotate continuously throughout the
examination of a joint. A slip ring CT scanner design allows
greater rotational velocities, thereby shortening scan times. With
a spiral CT scan data is acquired while the table is moving. As a
result, the x-ray source moves in a spiral or helical rather than a
circular pattern around the patient. The speed of the table motion
relative to the rotation of the CT gantry is often a consideration
for image quality in helical or spiral CT scanning. This parameter
is call pitch. In one embodiment, spiral CT scans will be acquired
through the joint wherein these spiral CT scans afford a resolution
that is isotropic, for example 1 millimeter by 1 millimeter by 1
millimeter in x, y and z direction, or 0.75.times.0.75.times.0.75
millimeters in x, y and z direction, or 0.5.times.0.5.times.0.5
millimeters in x, y and z direction, or 0.25.times.0.25.times.0.25
millimeters in x, y and z direction. Near isotropic data sets are
also acceptable particularly if the maximum resolution in any one
of the three special orientations does not exceed 1.5 millimeters,
or 1.0 millimeters, or 0.75 millimeters, or 0.5 millimeters. Thus,
the various embodiments recognize that the accuracy in placing a
3-D guidance template on an articular surface, or shaping an
implant, can be greatly improved with isotropic or near isotropic
data sets as compared to traditional 2-D slice based data sets
derived from either CT or MRI or other imaging technologies. For
example, a knee joint scan data acquired with near isotropic
resolution of 0.4.times.0.4.times.0.7 millimeters (e.g. a
resolution ratio of less than 2:1 between the different dimensions
and resolution in all three dimensions may be more desirable than 1
mm) will yield greater positional accuracy in placing a 3-D
guidance template on the articular surface than scan data acquired
using traditional CT scans, for example, with a scan resolution of
0.4.times.0.4.times.1.2 millimeters.
[0166] With MRI, standard acquisition call sequences also result in
two dimensional slices for displaying complex three dimensional
articular anatomy. The two dimensional slices can be acquired using
2-D or 3-D Fourier transformation. After the 2-D or 3-D transform,
2-D slices are available for image viewing and image processing. Of
note, typically the image resolution in the imaging plane will be
two or more fold greater than the image resolution perpendicular to
the primary imaging plane. Similar to CT, this limitation in
spatial resolution in the plane perpendicular to the imaging plane
can result in inaccuracies in deriving and subsequently placing 3-D
guidance molds. In one embodiment, MRI data is acquired or
processed so that the data used for generating the 3-D guidance
mold or implant has isotropic or near isotropic resolution. For
example, isotropic or near isotropic resolution may be achieved by
fusing two non-parallel imaging planes acquired using standard 2-D
or 3-D Fourier transform images, registering them relative to each
other and performing an image fusion (see U.S. patent application
Ser. No. 10/728,731, entitled "FUSION OF MULTIPLE IMAGING PLANES
FOR ISOTROPIC IMAGING IN MRI AND QUANTITATIVE IMAGE ANALYSIS USING
ISOTROPIC OR NEAR-ISOTROPIC IMAGING," hereby incorporated by
reference in its entirety). Alternatively, using latest generation
scan technology, for example, with 3-D FSE, 3-D DESS, 3-D MENSA,
3-D PAVA, 3-D LAVA, 3-D MERGE, 3-D MEDIC imaging sequences,
multi-channel coils, high field magnets, advanced gradient
technology, isotropic or near isotropic acquisition using 3-D
Fourier transform can be obtained. Using such advanced imaging
technology, image resolution of 0.5 by 0.5 by 0.8 millimeters or
greater may be obtained, achieving near isotropic and even
isotropic resolution, with resolution in all three dimensions of
less than 1 mm.
[0167] As will be appreciated by those of skill in the art, imaging
techniques can be combined, if desired. For example, C-arm imaging
or x-ray fluoroscopy can be used for motion imaging, while MRI can
yield high resolution cartilage information. C-arm imaging can be
combined with intra-articular contrast to visualize the
cartilage.
[0168] Any of the imaging devices described herein can also be used
intra-operatively (see, also below), for example using a hand-held
ultrasound and/or optical probe to image the articular surface
intra-operatively.
[0169] ii. Anatomical and Mechanical Axes, Virtual Ligament
Balancing
[0170] Imaging can be used to determine the anatomical and
biomechanical axes of an extremity associated with a joint, which
can then be used in creating an implant or surgical guide template
or mold. Suitable tests include, for example, an x-ray, or an x-ray
combined with an MRI. Typically, anatomical landmarks are
identified on the imaging test results (e.g., the x-ray film) and
those landmarks are then utilized to directly or indirectly
determine the desired axes. Thus, for example, if surgery is
contemplated in a hip joint, knee joint, or ankle joint, an x-ray
can be obtained. This x-ray can be a weight-bearing film of the
extremity, for example, a full-length leg film taken while the
patient is standing. This film can be used to determine the femoral
and tibial anatomical axes and to estimate the biomechanical axes.
As will be appreciated by those of skill in the art, these
processes for identifying, e.g., anatomical and biomechanical axis
of the joint can be applied to other joints without departing from
the scope of the invention.
[0171] Anatomical and biomechanical axes can also be determined
using other imaging modalities, including but not limited to,
computed tomography and MRI. For example, a CT scan can be obtained
through the hip joint, the knee joint, and the ankle joint.
Optionally, the scan can be reformatted in the sagittal, coronal,
or other planes. The CT images can then be utilized to identify
anatomical landmarks and to determine the anatomical and
biomechanical axes of the hip joint, knee joint, and/or ankle
joint.
[0172] Similarly, an MRI scan can be obtained for this purpose. For
example, an MRI scan of the thigh and pelvic region can be obtained
using a body coil or a torso phased array coil. A high resolution
scan of the knee joint can be obtained using a dedicated extremity
coil. A scan of the calf/tibia region and the ankle joint can be
obtained again using a body coil or a torso phased array coil.
Anatomical landmarks can be identified in each joint on these scans
and the anatomical and biomechanical axes can be estimated using
this information.
[0173] In various embodiments, the imaging scan can be extended for
5 cm, 10 cm or more, including 15 cm above and/or below the joint,
thereby deriving anatomic information that can be used to derive
the anatomic and biomechanical axis. For example, an MRI or CT scan
can be obtained through a knee joint. The scan can extend 15 cm
above and below the joint. The mid-femoral line and mid-tibial line
as well as other anatomic landmarks such as the femoral
transepicondylar line or Whiteside line or posterior condylar line
can be determined and can be used to estimate the anatomic and
biomechanical axes. Thus, in the example of a knee joint, no
additional scanning through the hip joint and ankle joints will be
absolutely required.
[0174] With, for example, MRI, even larger coverage may be
obtained, for example with a series of axial, sagittal or coronal
slices obtained with a large field of view, e.g. 20 cm or more, or
25 cm or more, or 30 cm or more, or 35 cm or more. These large
field of view scans can be utilized to estimate the anatomic and
biomechanical axes as described above. In various situations, they
can lack information on the surface detail of the joint due to
limitations in spatial resolution. A second or additional scan can
be performed with high resolution, e.g. with spatial resolution and
x and y axis of less than 1.0 mm, or less than 0.8 mm, or less than
0.6 mm. The additional high resolution scan may be utilized to
derive the articular surface detail adequate for a good and
accurate fit between the guidance template or implant, and the
articular surface or adjacent structures.
[0175] A biomechanical axis and, in some instances, an anatomical
axis may advantageously be defined by imaging the entire extremity
in question. Such imaging may include cross-sectional, spiral or
volumetric imaging via a CT or MRI scan or optical imaging through
the entire extremity, or acquisition of select images or slices or
volumes through an area of interest such as a hip joint, a knee
joint or ankle joint.
[0176] In an illustrative embodiment, scans through the entire or
portions of an entire extremity covering multiple joints may be
replaced with an extended scan through a single joint such as a
knee joint. For example, it may not be sufficient to estimate a
biomechanical axis or an anatomical access with a standard knee
scan such as a CT scan or MRI scan that includes, for example, only
ten centimeter of the area or volume of interest above, or ten
centimeters of area or volume of interest below the tibiofemoral
joints space. With an extended scan, a larger area adjacent to the
target joint can be included in the scan, e.g. fifteen centimeters
above and below the medial tibia femoral joint space, twenty
centimeters above and below the medial tibia femoral joint space,
fifteen centimeters above and twenty centimeters below the medial
tibiofemoral joint space, twenty centimeters above and twenty-five
centimeters below the medial tibiofemoral joint space. While the
extended scan is less involved on the operative side than the scan
involving the neighboring joints, it can, optionally be used to
provide an estimate of the anatomical axis, biomechanical axis,
and/or an implant axes or related planes. Thus, better ease of use
is provided at the expense of, possibly, more radiation and
possibly, less accuracy.
[0177] In another embodiment, cross-sectional or volumetric images
such as CT scans or MRI scans may be acquired through more than one
joint, typically one or more joints neighboring the one
contemplated for surgery. For example, CT or MRI slices, CT
spirals, CT or MRI volumes, MRI two plane acquisitions with
optional image fusion, or other tomographic acquisitions are
acquired through the hip joint, knee joint and ankle joint in a
patient scheduled for total knee replacement surgery. The 3D
surgical guidance templates may be optimized by using anatomic
and/or biomechanical information obtained in the adjacent
neighboring joints, for example, resulting in an improved anatomic
or functional result. By using cross-sectional or volumetric
imaging information, more accurate identification of anatomic
landmarks for identifying relevant anatomical and/or biomechanical
axis, relevant planes including surgical planes and implant planes,
as well as implant axes can be achieved when compared to x-rays or
CT scout scans, in particular when the cross-sectional or
volumetric data are acquired through neighboring joints. The
accuracy of the position, orientation, shape or combinations
thereof, of a 3D guide template can thus be improved with resulting
improvement in accuracy of the surgical correction of underlying
deformities such as varus, valgus, abduction, adduction, or
rotation deformities.
[0178] An imaging test obtained during weight-bearing conditions
has some inherent advantages, in that it demonstrates normal as
well as pathological loading and load distribution. A
cross-sectional imaging study such as a CT scan or MRI scan has
some advantages because it allows one to visualize and demonstrate
the anatomical landmarks in three, rather than two, dimensions,
thereby adding accuracy. Moreover, measurements can be performed in
other planes, such as the sagittal or oblique planes, that may not
be easily accessible in certain anatomical regions using
conventional radiography. In principle, any imaging test can be
utilized for this purpose.
[0179] The biomechanical axis can be defined as the axis going from
the center of the femoral head, between the condylar surfaces and
through the ankle joint
[0180] The software may automatically, semi-automatically or
manually assisted find or identify the relevant anatomic points to
calculate the anatomic and biomechanical axes, in accordance with
various embodiments. For example, the software or the user can find
the center of the femoral head. Optionally, this can be done in 3D
rather than only in 2D. Thus, for example, in the femoral head, the
software can find the center of the femoral head relative to its x,
y, and z-dimensions. Alternatively, the relevant anatomic points
can be selected manually and the axes can be calculated.
[0181] In another embodiment the software can compute methods of
adjusting varus or valgus or ante- or retroversion deformity or
rotational deformity based on such anatomic and biomechanical axis
measurements. For example, the surface of a surgical guide template
can be adapted so that surgical cuts performed for a total knee
implant can be placed to correct an underlying varus or valgus
deformity or, for example, ante- or retroversion. Alternatively,
the openings/cut planes of a surgical guide template used for
drilling, cutting and the like can be adjusted to achieve a varus
or valgus correction to a near anatomic or physiologic range. These
adjustments can be optimized for the implants of different
manufacturers, e.g. Johnson & Johnson, Stryker, Smith &
Nephew, Biomet and Zimmer.
[0182] In various embodiments, gait, loading and other physical
activities of a joint as well as static joint positions may be
simulated using a computer workstation. The template and its
apertures and the resultant surgical templates and/or procedures,
e.g. cuts, drilling, rasping, may be optimized using this
information to achieve an optimal functional result. For example,
the template and its apertures and the resultant implant position
may be optimized for different degrees of flexion and extension,
internal or external rotation, abduction or adduction, and ante or
retroversion. Thus, the templates may be used to achieve motion
that is optimized in one, two or more directions. Not only
anatomic, but also functional optimization is possible in this
manner.
[0183] The origin and insertion of ligaments, e.g. the anterior and
posterior cruciate ligaments and the medial and lateral collateral
ligaments in the case of a knee, can be visualized on the scan.
With MRI, the ligaments are directly visible. If the ligament is
torn, the location of the residual fibers at the origin or
attachment can be visualized. Different joint positions can then be
simulated and changes in ligament length can be determined for
different angles of flexion and extension, internal or external
rotation, abduction or adduction, and ante or retroversion. These
simulations can be performed without but also with the implant in
place. Thus, ligament length--and through this presumed
tension--can be estimated virtually with any given implant and
implant size. Different implants or component(s) can be tested
preoperatively on the computer workstation and the implant or
component(s) yielding the optimal ligament performance, e.g.
minimal change in ligament length, for different joint positions
can be determined pre-operatively. Thus, the various embodiments
provide, among others, for pre-operative ligament balancing,
including but not limited to by directly visualizing the ligaments
or fiber remnants.
[0184] For example, in one embodiment a loading apparatus may be
applied to the patient to simulate weight-bearing while acquiring
the CT scan. A non-limiting example of such a loading apparatus has
been described by Dynamed with the Dynawell device. Any loading
apparatus that can apply axial or other physiologic or near
physiologic loading forces on the hip, knee or ankle joints or two
or three of them may be used. Other more sophisticated scanning
procedures can be used to derive this information without departing
from the scope of the invention.
[0185] In one embodiment, when imaging a joint of the lower
extremity, a standing, weight-bearing x-ray can be obtained to
determine the biomechanical axis. In the case of a knee or hip
joint, for example, a standing, weight-bearing x-ray of the hip
joint or the knee joint can be obtained. Alternatively, standing,
weight-bearing x-rays can be obtained spanning the entire leg from
the hip to the foot. The x-ray can be obtained in the
antero-posterior or posterior-anterior projection but also in a
lateral projection or principally any other projection that is
desired. The user can measure the biomechanical axis, for example,
by finding the centroid of the femoral head and the centroid of the
ankle joint and by connecting these. This measurement can be
performed manually, for example, on a x-ray film or electronically,
for example, on a digitized or digital image, including with
software assistance. The axis measured on the standing,
weight-bearing x-ray can be cross referenced with another imaging
modality such a CT or MRI scan. For example, a biomechanical axis
can be determined on a standing x-ray of the leg. The result and
data can be cross referenced, for example, by identifying
corresponding bony anatomical landmarks to a CT scan or MRI scan.
The result and information can then be utilized to determine the
optimal shape of a 3-D guidance template. Specifically, the
orientation, position, or shape of the template can be influenced
based on the measurement of the biomechanical axis. Moreover, the
position or shape of any blocks attached to said templates or
linkages or the position or shape instruments attached to the mold,
block or linkages can be influenced by this measurement. Combining
the standing, weight-bearing imaging modality with CT scanning or
MRI scanning has the principle advantage that the joint is
evaluated during physiological loading. CT or MRI alone, typically
do not afford assessment in loaded, weight-bearing condition.
[0186] As described above, the biomechanical axis can be evaluated
in different planes or in three dimensions. For example, the actual
biomechanical axis can be assessed in the AP plane and a desired
biomechanical axis can be determined in this plane. In addition,
the actual biomechanical axis can be determined in the lateral
plane, for example, in the lateral projection radiograph, and the
desired biomechanical axis can be determined in the lateral plane.
By measuring the relevant biomechanical and anatomical axis in two
or more planes, the shape of a 3-D guidance template and/or implant
can be further refined and optimized with result in improvements in
clinical and patient function.
[0187] The biomechanical or anatomical axis may also be measured
using other approaches including a non-weight bearing position. For
example, anatomical landmarks can be identified on a CT scout scan
and cross referenced to a joint such as a knee joint or a hip joint
for which surgery is contemplated. Thus, for example, the user can
measure and determine the centroid of the ankle joint and the
centroid of the hip joint for knee surgery using the CT scout
scan.
[0188] In one embodiment, the anatomical landmarks are determined
using CT slices or MRI slices rather than a scout scan. A CT scout
scan or MRI scout scan can have inherent limitations in spatial
resolution. A CT scout scan is typically a single, 2-D radiographic
image of the extremity lacking 3-D anatomical information and
lacking high spatial resolution. An MRI scout scan is typically
composed of multiple 2-D MRI slices, possibly acquired in one, two,
or three planes. However, the resolution of the MRI scout scan is
typically also limited. By acquiring selective slices and even
isotropic or near isotropic data sets through neighboring joints,
anatomical landmarks can be identified in a more reliable manner
thereby improving the accuracy of anatomical and biomechanical axis
determination. This improvement in accuracy translates into an
improvement in accuracy in the resultant 3-D guidance mold, for
example, a knee or hip joint, including improved accuracy of its
shape, orientation, or position.
[0189] Computed Tomography imaging has been shown to be highly
accurate for the determination of the relative anatomical and
biomechanical axes of the leg (Testi Debora, Zannoni Cinzia,
Cappello Angelo and Viceconti Marco. "Border tracing algorithm
implementation for the femoral geometry reconstruction." Comp.
Meth. and Programs in Biomed., Feb. 14, 2000; Farrar M J, Newman R
J, Mawhinney R R, King R. "Computed tomography scan scout film for
measurement of femoral axis in knee arthroplasty." J. Arthroplasty.
1999 December; 14(8): 1030-1; Kim J S, Park T S, Park S B, Kim J S,
Kim I Y, Kim S I. "Measurement of femoral neck anteversion in 3D.
Part 1: 3D imaging method." Med. and Biol. Eng. and Computing.
38(6): 603-609, November 2000; Akagi M, Yamashita E, Nakagawa T,
Asano T, Nakamura T. "Relationship between frontal knee alignment
and reference axis in the distal femur." Clin. Ortho. and Related
Res. No. 388, 147-156, 2001; Mahaisavariya B, Sitthiseripratip K,
Tongdee T, Bohez E, Sloten J V, Oris P. "Morphological study of the
proximal femur: a new method of geometrical assessment using 3
dimensional reverse engineering." Med. Eng. and Phys. 24 (2002)
617-622; Lam Li On, Shakespeare D. "Varus/Valgus alignment of the
femoral component in total knee arthroplasty." The Knee, 10 (2003)
237-241).
[0190] The angles of the anatomical structures of the proximal and
distal femur also show a certain variability level (i.e. standard
deviation) comparable with the varus or valgus angle or the angle
between the anatomical femoral axis and the biomechanical axis
(Mahaisavariya B, Sitthiseripratip K, Tongdee T, Bohez E, Sloten J
V, Oris P. "Morphological study of the proximal femur: a new method
of geometrical assessment using 3 dimensional reverse engineering."
Med. Eng. and Phys. 24 (2002) 617-622). Thus, one approach for
assessing the axes can be based on CT scans of the hip, knee and
ankle joint or femur rather than only of the knee region.
[0191] CT has been shown to be efficient in terms of the contrast
of the bone tissue with respect to surrounding anatomical tissue so
the bone structures corresponding to the femur and tibia can be
extracted very accurately with semi automated computerized systems
(Mahaisavariya B, Sitthiseripratip K, Tongdee T, Bohez E, Sloten J
V, Oris P. "Morphological study of the proximal femur: a new method
of geometrical assessment using 3 dimensional reverse engineering."
Med. Eng. and Phys. 24 (2002) 617-622; Testi Debora, Zannoni
Cinzia, Cappello Angelo and Viceconti Marco. "Border tracing
algorithm implementation for the femoral geometry reconstruction."
Comp. Meth. and Programs in Biomed., Feb. 14, 2000).
[0192] While 2-D CT has been shown to be accurate in the estimation
of the biomechanical axis (Mahaisavariya B, Sitthiseripratip K,
Tongdee T, Bohez E, Sloten J V, Oris P. "Morphological study of the
proximal femur: a new method of geometrical assessment using 3
dimensional reverse engineering." Med. Eng. and Phys. 24 (2002)
617-622; Testi Debora, supra.; Lam Li On, Supra, 3-D CT has been
shown to be more accurate for the estimation of the femoral
anteversion angle (Kim J S, Park T S, Park S B, Kim J S, Kim I Y,
Kim S I. Measurement of femoral neck anteversion in 3D. Part 1: 3D
imaging method. Medical and Biological engineering and computing.
38(6): 603-609, November 2000; Kim J S, Park T S, Park S B, Kim J
S, Kim I Y, Kim S I. Measurement of femoral neck anteversion in 3D.
Part 1: 3D modeling method. Medical and Biological engineering and
computing. 38(6): 610-616, November 2000). Farrar used simple CT
2-D scout views to estimate the femoral axis (Farrar M J, Newman R
J, Mawhinney R R, King R. Computed tomography scan scout film for
measurement of femoral axis in knee arthroplasty. J. Arthroplasty.
1999 December; 14(8): 1030-1).
[0193] In one embodiment, 2-D sagittal and coronal reconstructions
of CT slice images are used to manually estimate the biomechanical
axis. One skilled in the art can easily recognize many different
ways to automate this process. For example, a CT scan covering at
least the hip, knee and ankle region is acquired. This results in
image slices (axial) which can be interpolated to generate the
sagittal and coronal views.
[0194] Preprocessing (filtering) of the slice images can be used to
improve the contrast of the bone regions so that they can be
extracted accurately using simple thresholding or a more involved
image segmentation tool like LiveWire or active contour models.
[0195] Identification of landmarks of interest like the centroid of
the tibial shaft, the ankle joint, the intercondylar notch and the
centroid of the femoral head can be performed. The biomechanical
axis can be defined as the line connecting the proximal and the
distal centroids, i.e. the femoral head centroid, the tibial or
ankle joint centroid. The position of the intercondylar notch can
be used for evaluation of possible deviations, errors or
deformations including varus and valgus deformity.
[0196] In one embodiment, multiple imaging tests can be combined.
For example, the anatomical and biomechanical axes can be estimated
using a weight-bearing x-ray of the extremity or portions of the
extremity. The anatomical information derived in this fashion can
then be combined with a CT or MRI scan of one or more joints, such
as a hip, knee, or ankle joint. Landmarks seen on radiography can
then, for example, be cross-referenced on the CT or MRI scan. Axis
measurements performed on radiography can be subsequently applied
to the CT or MRI scans or other imaging modalities. Similarly, the
information obtained from a CT scan can be compared with that
obtained with an MRI or ultrasound scan. In one embodiment, image
fusion of different imaging modalities can be performed. For
example, if surgery is contemplated in a knee joint, a full-length
weight-bearing x-ray of the lower extremity can be obtained. This
can be supplemented by a spiral CT scan, optionally with
intra-articular contrast of the knee joint providing high
resolution three-dimensional anatomical characterization of the
knee anatomy even including the menisci and cartilage. This
information, along with the axis information provided by the
radiograph can be utilized to select or derive therapies, such as
implants or surgical instruments.
[0197] In certain embodiments, it may be desirable to characterize
the shape and dimension of intra-articular structures, including
subchondral bone or the cartilage. This may be done, for example,
by using a CT scan or a spiral CT scan of one or more joints. The
spiral CT scan can optionally be performed using intra-articular
contrast. Alternatively, an MRI scan can be performed. If CT is
utilized, a full spiral scan, or a few selected slices, can be
obtained through neighboring joints. Typically, a full spiral scan
providing full three-dimensional characterization would be obtained
in the joint for which therapy is contemplated. If implants, or
templates, for surgical instruments are selected or shaped, using
this scan, the subchondral bone shape can be accurately determined
from the resultant image data. A standard cartilage thickness and,
similarly, a standard cartilage loss can be assumed in certain
regions of the articular surface. For example, a standard thickness
of 2 mm of the articular cartilage can be applied to the
subchondral bone in the anterior third of the medial and lateral
femoral condyles. Similarly, a standard thickness of 2 mm of the
articular cartilage can be applied to the subchondral bone in the
posterior third of the medial and lateral femoral condyles. A
standard thickness of 0 mm of the articular cartilage can be
applied in the central weight-bearing zone of the medial condyle,
and a different value can be applied to the lateral condyle. The
transition between these zones can be gradual, for example, from 2
mm to 0 mm. These standard values of estimated cartilage thickness
and cartilage loss in different regions of the joint can optionally
be derived from a reference database. The reference database can
include categories such as age, body mass index ("BMI"), severity
of disease, pain, severity of varus deformity, severity of valgus
deformity, Kellgren-Lawrence score, along with other parameters
that are determined to be relative and useful. Use of a standard
thickness for the articular cartilage can facilitate the imaging
protocols required for pre-operative planning.
[0198] Alternatively, however, the articular cartilage can be fully
characterized by performing a spiral CT scan of the joint in the
presence of intra-articular contrast or by performing an MRI scan
using cartilage sensitive pulse sequences.
[0199] The techniques described herein can be used to obtain an
image of a joint that is stationary, either weight bearing or not,
or in motion or combinations thereof. Imaging studies that are
obtained during joint motion can be useful for assessing the load
bearing surface. This can be advantageous for designing or
selecting implants, e.g. for selecting reinforcements in high load
areas, for surgical tools and for implant placement, e.g. for
optimizing implant alignment relative to high load areas.
[0200] iii. Joint Space
[0201] In accordance with another embodiment, a method and system
for determining joint space width is provided. Without limitation,
a CT scan, MRI scan, optical scan, and/or ultrasound imaging is
performed. The medial and lateral joint space width in a knee
joint, the joint space in a hip joint, ankle joint or other joint
is evaluated. This evaluation may be performed in two dimensions,
using a single scan plane orientation, such as sagittal or coronal
plane, or it may be performed in three dimensions. The evaluation
of joint space width may include measuring the distance from the
subchondral bone plate of one articular surface to the subchondral
bone plate of the opposing articular surface. Alternatively, the
cartilage thickness may be measured directly on one or more
articular surfaces. Joint space width or cartilage thickness may be
measured for different regions of the joint and joint space width
and cartilage loss can be evaluated in anterior, posterior, medial,
lateral, superior and/or inferior positions. The measurements may
be performed for different positions of the joint such as a neutral
position, 45 degrees of flexion, 90 degrees of flexion, 5 degrees
of abduction, 5 degrees of internal rotation and so forth. For
example, in a knee joint, the joint space width may be evaluated in
extension and at 25 degrees of knee flexion and 90 degrees of knee
flexion. The medial and lateral joint space width may be compared
and differences in medial and lateral joint space width can be
utilized to optimize the desired postoperative correction in
anatomical or biomechanical axis alignment based on this
information. The shape, orientation, or position of a 3D guided
template may be adjusted using this information, for example, in
knee or hip implant placement or other surgeries.
[0202] For example, the measurement may show reduced joint space
width or cartilage thickness in the medial compartment when
compared to a normal anatomic reference standard, e.g. from age or
sex or gender matched controls, and/or lateral compartment. This
can coincide with valgus alignment of the knee joint, measured, for
example, on the scout scan of an CT-scan or the localizer scan of
an MRI scan including multiple localizer scans through the hip,
knee and ankle joints.
[0203] If the biomechanical axis estimated on the comparison of the
medial and lateral joint space width coincides with the
biomechanical axis of the extremity measured on the scout scan, no
further adjustment may be necessary. If the biomechanical axis
estimated on the comparison of the medial and lateral joint space
width does not coincide with the biomechanical axis of the
extremity measured on the CT or MRI scout scan, additional
correction of the valgus deformity (or in other embodiments, varus
or other deformities) can be achieved.
[0204] This additional correction may be determined, for example,
by adding the difference in axis correction desired based on
biomechanical axis measured by comparison of the medial lateral
joint space width and axis correction desired based on measurement
of the biomechanical axis of the extremity measured on the scout or
localizer scan to axis correction desired based on measurement of
the biomechanical axis of the extremity measured on the scout or
localizer scan alone. By combining the information from both,
measurement of joint space width of the median and lateral
compartment and measurement of the biomechanical axis using the
scout scan or localizer scan or, for example, a weight bearing
x-ray, an improved assessment of axis alignment during load bearing
conditions can be obtained with resultant improvements in the
shape, orientation or position of the 3D guidance template and
related attachments or linkages.
[0205] Optionally, the extremity can be loaded while in the
scanner, for example, using a compression harness. Examples for
compression harnesses have been published, for example, by
Dynawell.
[0206] iv. Estimation of Cartilage Loss
[0207] In another embodiment, an imaging modality such as spiral
CT, spiral CT arthography, MRI, optical imaging, optical coherence
tomography, ultrasound and others may be used to estimate cartilage
loss in one, two or three dimensions. The information can be used
to determine a desired correction of a measured biomechanical or
anatomical axis. The correction can be in the anterior-posterior,
medio-lateral, and/or super-inferior direction, or any other
direction applicable or desirable, or combinations thereof. The
information can be combined with other data e.g., from a standing,
weight bearing x-ray or CT scout scan, or an MRI localizer scan or
a CT scan or MRI scan that includes axial/spiral or other images
through the hip, knee and ankle joints. The information can be used
to refine the axis correction desired based on, for example,
standing x-rays, non-weight bearing x-rays, CT scout scans, MRI
localizer scans and the like.
[0208] In another embodiment, any axis correction can be performed
in a single plane (e.g., the medial-lateral plane), in two planes
(e.g., the medial lateral and anterior-posterior planes), or
multiple planes, including oblique planes that are biomechanically
or anatomically relevant or desirable.
[0209] v. High Resolution Imaging
[0210] Additional improvements in accuracy of the 3D guide template
and/or implants surfaces may be obtained with use of imaging
technology that yields high spatial resolution, not only within the
imaging plane, but along all three planes, specifically the X, Y
and Z axis. With CT scanning, this can be achieved with the advent
of spiral CT Scanning techniques. With MRI, dual or more plane
scanning or volumetric acquisition can be performed. If dual or
more plane MRI scanning is performed, these multiple scan planes
can be fused, for example by cross-registration and resampling
along the X, Y and Z axis. The resultant effective resolution in X,
Y and Z direction is greatly improved as compared to standard CT
scanning or standard MRI scanning. Improvements in resolution have
the advantage that the resultant 3D guide templates can be
substantially more accurate, for example with regard to their
position, shape or orientation.
[0211] vi. Phantom Scans
[0212] Imaging modalities are subject to scan to scan variations,
for example, including spatial distortion. In one embodiment,
phantom scans may be performed in order to optimize the scan
quality, specifically spatial resolution and spatial distortion. A
phantom scan can be performed prior to a patient scan,
simultaneously with a patient scan or after a patient scan. Using
the phantom scan data, it is possible to make adjustments and
optimizations of the scanner and, moreover, to perform image post
processing to perform corrections, for example, correction of
geometric distortions. Thus, if a phantom scan detects certain
geometric distortion in the X, Y or Z axis and the amount of
distortion is measured on the phantom scan, a correction factor can
be included in the data prior to generating a 3D guide template.
The resulting 3D guide template is thus more accurate with
resulting improvement in intra-operative cross-reference to the
anatomic surface and resultant improved accuracy in any surgical
intervention such as drilling or cutting. In various embodiments,
the areas of distortion can be identified and/or indicated on any
relevant images, including where such distortions have been
"corrected" or otherwise altered from their original, initial or
raw data.
[0213] In another embodiment, a smoothing operation, e.g. using low
frequency filtering, can be performed in order to remove any image
related artifacts, such as stepping artifacts between adjacent CT
or MRI slices. In some applications, the smoothing operation can be
helpful in improving the fit between the joint and the template. In
various embodiments, the areas of smoothing or other image
alterations can be identified and/or indicated on any relevant
images, including where such alterations have "corrected" or
otherwise altered the image information from an original, initial,
raw or preprocessed data state.
[0214] B. Intraoperative Measurements
[0215] Alternatively, or in addition to, non-invasive imaging
techniques described above, measurements of the size of an area of
diseased cartilage or an area of cartilage loss, measurements of
cartilage thickness and/or curvature of cartilage or bone can be
obtained intraoperatively during arthroscopy or open arthrotomy.
Intraoperative measurements can, but need not, involve actual
contact with one or more areas of the articular surfaces.
[0216] Devices suitable for obtaining intraoperative measurements
of cartilage or bone or other articular structures, and to generate
a topographical map of the surface include but are not limited to,
Placido disks, optical measurements tools and device, optical
imaging tools and devices, and laser interferometers, and/or
deformable materials or devices. (See, for example, U.S. Pat. No.
6,382,028 to Wooh et al., issued May 7, 2002; U.S. Pat. No.
6,057,927 to Levesque et al., issued May 2, 2000; U.S. Pat. No.
5,523,843 to Yamane et al. issued Jun. 4, 1996; U.S. Pat. No.
5,847,804 to Sarver et al. issued Dec. 8, 1998; and U.S. Pat. No.
5,684,562 to Fujieda, issued Nov. 4, 1997).
[0217] In alternative embodiments, an optical imaging device or
measurement tool, e.g. a laser interferometer, can also be attached
to the end of an endoscopic device. Optionally, a small sensor can
be attached to the device in order to determine the cartilage
surface or bone curvature using phase shift interferometry,
producing a fringe pattern analysis phase map (wave front)
visualization of the cartilage surface. The curvature can then be
visualized on a monitor as a color coded, topographical map of the
cartilage surface. Additionally, a mathematical model of the
topographical map can be used to determine the ideal surface
topography to replace any cartilage or bone defects in the area
analyzed. This computed, ideal surface, or surfaces, can then be
visualized on the monitor, and can be used to select the curvature,
or curvatures, of the replacement cartilage or mold.
[0218] Optical imaging techniques can be utilized to generate a 3D
visualization or surface map of the cartilage or bone, which can be
used to generate an articular repair system or a mold. One skilled
in the art will readily recognize that other techniques for optical
measurements of the cartilage surface curvature can be employed
without departing from the scope of the invention. For example, a
2-dimensional or 3-dimensional map can be generated.
[0219] Other devices to measure cartilage and subchondral bone
intraoperatively include, for example, ultrasound probes. An
ultrasound probe, including a handheld probe, can be applied to the
cartilage and the curvature of the cartilage and/or the subchondral
bone can be measured. Moreover, the size of a cartilage defect can
be assessed and the thickness of the articular cartilage can be
determined. Such ultrasound measurements can be obtained in A-mode,
B-mode, or C-mode. If A-mode measurements are obtained, an operator
can typically repeat the measurements with several different probe
orientations, e.g. mediolateral and anteroposterior, in order to
derive a three-dimensional assessment of size, curvature and
thickness.
[0220] One skilled in the art will easily recognize that different
probe designs are possible using optical, laser interferometry,
mechanical and ultrasound probes. The probes may be handheld. In
certain embodiments, the probes or at least a portion of the probe,
typically the portion that is in contact with the tissue, can be
sterile. Sterility can be achieved with use of sterile covers, for
example similar to those disclosed in WO 99/08598A1 to Lang,
published Feb. 25, 1999.
[0221] Analysis on the curvature of the articular cartilage or
subchondral bone using imaging tests and/or intraoperative
measurements can be used to determine the size of an area of
diseased cartilage or cartilage loss. For example, the curvature
can change abruptly in areas of cartilage loss. Such abrupt or
sudden changes in curvature can be used to detect the boundaries of
diseased cartilage or cartilage defects.
[0222] As described above, measurements can be made while the joint
is stationary, either weight bearing or not, or in motion.
[0223] II. Repair Materials
[0224] A wide variety of materials find use in the practice of the
various embodiments disclosed and described herein, including, but
not limited to, plastics, metals, crystal free metals, ceramics,
biological materials (e.g., collagen or other extracellular matrix
materials), hydroxyapatite, cells (e.g., stem cells, chondrocyte
cells or the like), or combinations thereof. Based on the
information (e.g., measurements) obtained regarding the defect and
the articular surface and/or the subchondral bone, a repair
material can be formed or selected. Further, using one or more of
these techniques described herein, a cartilage replacement or
regenerating material having a curvature that will fit into a
particular cartilage defect, will follow the contour and shape of
the articular surface, and will match the thickness of the
surrounding cartilage. The repair material can include any
combination of materials, and typically include at least one
non-pliable material, for example materials that are not easily
bent or changed.
[0225] A. Metal and Polymeric Repair Materials
[0226] Currently, joint repair systems often employ metal and/or
polymeric materials including, for example, prostheses which are
anchored into the underlying bone (e.g., a femur in the case of a
knee prosthesis). See, e.g., U.S. Pat. No. 6,203,576 to Afriat, et
al. issued Mar. 20, 2001 and U.S. Pat. No. 6,322,588 to Ogle, et
al. issued Nov. 27, 2001, and references cited therein. A
wide-variety of metals are useful in the practice of the various
embodiments, and can be selected based on any criteria. For
example, material selection can be based on resiliency to impart a
desired degree of rigidity. Non-limiting examples of suitable
metals include silver, gold, platinum, palladium, iridium, copper,
tin, lead, antimony, bismuth, zinc, titanium, cobalt, stainless
steel, nickel, iron alloys, cobalt alloys, such as Elgiloy.RTM., a
cobalt-chromium-nickel alloy, and MP35N, a
nickel-cobalt-chromium-molybdenum alloy, and Nitinol.TM., a
nickel-titanium alloy, aluminum, manganese, iron, tantalum, crystal
free metals, such as Liquidmetal.RTM. alloys (available from
LiquidMetal Technologies, www.liquidmetal.com), other metals that
can slowly form polyvalent metal ions, for example to inhibit
calcification of implanted substrates in contact with a patient's
bodily fluids or tissues, and combinations thereof.
[0227] Suitable synthetic polymers include, without limitation,
polyamides (e.g., nylon), polyesters, polystyrenes, polyacrylates,
vinyl polymers (e.g., polyethylene, polytetrafluoroethylene,
polypropylene and polyvinyl chloride), polycarbonates,
polyurethanes, poly dimethyl siloxanes, cellulose acetates,
polymethyl methacrylates, polyether ether ketones, ethylene vinyl
acetates, polysulfones, nitrocelluloses, similar copolymers and
mixtures thereof. Bioresorbable synthetic polymers can also be used
such as dextran, hydroxyethyl starch, derivatives of gelatin,
polyvinylpyrrolidone, polyvinyl alcohol, poly[N-(2-hydroxypropyl)
methacrylamide], poly(hydroxy acids), poly(epsilon-caprolactone),
polylactic acid, polyglycolic acid, poly(dimethyl glycolic acid),
poly(hydroxy butyrate), and similar copolymers can also be
used.
[0228] Other materials would also be appropriate, for example, the
polyketone known as polyetheretherketone (PEEK.TM.). This includes
the material PEEK 450G, which is an unfilled PEEK approved for
medical implantation available from Victrex of Lancashire, Great
Britain. (Victrex is located at www.matweb.com or see Boedeker
www.boedeker.com). Other sources of this material include Gharda
located in Panoli, India (www.ghardapolymers.com).
[0229] It should be noted that the material selected can also be
filled. For example, other grades of PEEK are also available and
contemplated, such as 30% glass-filled or 30% carbon filled,
provided such materials are cleared for use in implantable devices
by the FDA, or other regulatory body. Glass filled PEEK reduces the
expansion rate and increases the flexural modulus of PEEK relative
to that portion which is unfilled. The resulting product is known
to be ideal for improved strength, stiffness, or stability. Carbon
filled PEEK is known to enhance the compressive strength and
stiffness of PEEK and lower its expansion rate. Carbon filled PEEK
offers wear resistance and load carrying capability.
[0230] As will be appreciated, other suitable similarly
biocompatible thermoplastic or thermoplastic polycondensate
materials that resist fatigue, have good memory, are flexible,
and/or deflectable have very low moisture absorption, and good wear
and/or abrasion resistance, can be used without departing from the
scope of the invention. The implant can also be comprised of
polyetherketoneketone (PEKK).
[0231] Other materials that can be used include polyetherketone
(PEK), polyetherketoneetherketoneketone (PEKEKK), and
polyetheretherketoneketone (PEEKK), and generally a
polyaryletheretherketone. Further other polyketones can be used as
well as other thermoplastics.
[0232] Reference to appropriate polymers that can be used for the
implant can be made to the following documents, all of which are
incorporated herein by reference. These documents include: PCT
Publication WO 02/02158 A1, dated Jan. 10, 2002 and entitled
Bio-Compatible Polymeric Materials; PCT Publication WO 02/00275 A1,
dated Jan. 3, 2002 and entitled Bio-Compatible Polymeric Materials;
and PCT Publication WO 02/00270 A1, dated Jan. 3, 2002 and entitled
Bio-Compatible Polymeric Materials.
[0233] The polymers can be prepared by any of a variety of
approaches including conventional polymer processing methods.
Various approaches include, for example, injection molding, which
is suitable for the production of polymer components with
significant structural features, and rapid prototyping approaches,
such as reaction injection molding and stereolithography. The
substrate can be textured or made porous by either physical
abrasion or chemical alteration to facilitate incorporation of the
metal coating. Other processes are also appropriate, such as
extrusion, injection, compression molding and/or machining
techniques. Typically, the polymer is chosen for its physical and
mechanical properties and is suitable for carrying and spreading
the physical load between the joint surfaces.
[0234] More than one metal and/or polymer can be used in
combination with each other. For example, one or more
metal-containing substrates can be coated with polymers in one or
more regions or, alternatively, one or more polymer-containing
substrate can be coated in one or more regions with one or more
metals.
[0235] The system or prosthesis can be porous or porous coated. The
porous surface components can be made of various materials
including metals, ceramics, and polymers. These surface components
can, in turn, be secured by various means to a multitude of
structural cores formed of various metals. Suitable porous coatings
include, but are not limited to, metal, ceramic, polymeric (e.g.,
biologically neutral elastomers such as silicone rubber,
polyethylene terephthalate and/or combinations thereof) or
combinations thereof. See, e.g., U.S. Pat. No. 3,605,123 to Hahn,
issued Sep. 20, 1971. U.S. Pat. No. 3,808,606 to Tronzo issued May
7, 1974 and U.S. Pat. No. 3,843,975 to Tronzo issued Oct. 29, 1974;
U.S. Pat. No. 3,314,420 to Smith issued Apr. 18, 1967; U.S. Pat.
No. 3,987,499 to Scharbach issued Oct. 26, 1976; and German
Offenlegungsschrift 2,306,552. There can be more than one coating
layer and the layers can have the same or different porosities.
See, e.g., U.S. Pat. No. 3,938,198 to Kahn, et al., issued Feb. 17,
1976.
[0236] The coating can be applied by surrounding a core with
powdered polymer and heating until cured to form a coating with an
internal network of interconnected pores. The tortuosity of the
pores (e.g., a measure of length to diameter of the paths through
the pores) can be used in evaluating the probable success of such a
coating in use on a prosthetic device. See, also, U.S. Pat. No.
4,213,816 to Morris issued Jul. 22, 1980. The porous coating can be
applied in the form of a powder and the article as a whole
subjected to an elevated temperature that bonds the powder to the
substrate. Selection of suitable polymers and/or powder coatings
can be determined in view of the teachings and references cited
herein, for example based on the melt index of each.
[0237] B. Biological Repair Material
[0238] Repair materials can also include one or more biological
material either alone or in combination with non-biological
materials. For example, any base material can be designed or shaped
and suitable cartilage replacement or regenerating material(s) such
as fetal cartilage cells can be applied to be the base. The cells
can be then be grown in conjunction with the base until the
thickness (and/or curvature) of the cartilage surrounding the
cartilage defect has been reached. Conditions for growing cells
(e.g., chondrocytes) on various substrates in culture, ex vivo and
in vivo are described, for example, in U.S. Pat. No. 5,478,739 to
Slivka et al. issued Dec. 26, 1995; U.S. Pat. No. 5,842,477 to
Naughton et al. issued Dec. 1, 1998; U.S. Pat. No. 6,283,980 to
Vibe-Hansen et al., issued Sep. 4, 2001, and U.S. Pat. No.
6,365,405 to Salzmann et al. issued Apr. 2, 2002. Non-limiting
examples of suitable substrates include plastic, tissue scaffold, a
bone replacement material (e.g., a hydroxyapatite, a bioresorbable
material), or any other material suitable for growing a cartilage
replacement or regenerating material on it.
[0239] Biological polymers can be naturally occurring or produced
in vitro by fermentation and the like. Suitable biological polymers
include, without limitation, collagen, elastin, silk, keratin,
gelatin, polyamino acids, cat gut sutures, polysaccharides (e.g.,
cellulose and starch) and mixtures thereof. Biological polymers can
be bioresorbable.
[0240] Biological materials used in the methods described herein
can be autografts (from the same subject); allografts (from another
individual of the same species) and/or xenografts (from another
species). See, also, International Patent Publications WO 02/22014
to Alexander et al. published Mar. 21, 2002 and WO 97/27885 to Lee
published Aug. 7, 1997. In certain embodiments autologous materials
may be used, as they can carry a reduced risk of immunological
complications to the host, including re-absorption of the
materials, inflammation and/or scarring of the tissues surrounding
the implant site.
[0241] In certain embodiments, the cartilage replacement material
has a particular biochemical composition. For instance, the
biochemical composition of the cartilage surrounding a defect can
be assessed by taking tissue samples and chemical analysis or by
imaging techniques. For example, WO 02/22014 to Alexander describes
the use of gadolinium for imaging of articular cartilage to monitor
glycosaminoglycan content within the cartilage. The cartilage
replacement or regenerating material can then be made or cultured
in a manner, to achieve a biochemical composition similar to that
of the cartilage surrounding the implantation site. The culture
conditions used to achieve the desired biochemical compositions can
include, for example, varying concentrations. Biochemical
composition of the cartilage replacement or regenerating material
can, for example, be influenced by controlling concentrations and
exposure times of certain nutrients and growth factors.
[0242] In various embodiments, a container or well can be formed to
the selected specifications, for example to match the material
needed for a particular subject or to create a stock of repair
materials in a variety of sizes. The size and shape of the
container can be designed using the thickness and curvature
information obtained from the joint and from the cartilage defect.
More specifically, the inside of the container can be shaped to
follow any selected measurements, for example as obtained from the
cartilage defect(s) of a particular subject. The container can be
filled with a cartilage replacement or regenerating material, for
example, collagen-containing materials, plastics, bioresorbable
materials and/or any suitable tissue scaffold. The cartilage
regenerating or replacement material can also consist of a
suspension of stem cells or fetal or immature or mature cartilage
cells that subsequently develop to more mature cartilage inside the
container. Further, development and/or differentiation can be
enhanced with use of certain tissue nutrients and growth
factors.
[0243] The material is allowed to harden and/or grow inside the
container until the material has the desired traits, for example,
thickness, elasticity, hardness, biochemical composition, etc.
Molds can be generated using any suitable technique, for example
computer devices and automation, e.g. computer assisted design
(CAD) and, for example, computer assisted modeling (CAM). Because
the resulting material generally follows the contour of the inside
of the container it will better fit the defect itself and
facilitate integration.
[0244] III. Devices Design
[0245] A. Cartilage Models
[0246] Using information on thickness and curvature of the
cartilage, a physical model of the surfaces of the articular
cartilage and of the underlying bone can be created. This physical
model can be representative of a limited area within the joint or
it can encompass the entire joint. For example, in the knee joint,
the physical model can encompass only the medial or lateral femoral
condyle, both femoral condyles and the notch region, the medial
tibial plateau, the lateral tibial plateau, the entire tibial
plateau, the medial patella, the lateral patella, the entire
patella or the entire joint. The location of a diseased area of
cartilage can be determined, for example using a 3D coordinate
system or a 3D Euclidian distance as described in WO 02/22014.
[0247] In this way, the size of the defect to be repaired can be
determined. As will be apparent, some, but not all, defects will
include less than the entire cartilage. Thus, in one embodiment,
the thickness of the normal or only mildly diseased cartilage
surrounding one or more cartilage defects is measured. This
thickness measurement can be obtained at a single point or at
multiple points, for example 2 point, 4-6 points, 7-10 points, more
than 10 points or over the length of the entire remaining
cartilage. Furthermore, once the size of the defect is determined,
an appropriate therapy (e.g., articular repair system) can be
selected such that as much as possible of the healthy, surrounding
tissue is preserved.
[0248] In other embodiments, the curvature of the articular surface
can be measured to design and/or shape the repair material.
Further, both the thickness of the remaining cartilage and the
curvature of the articular surface can be measured to design and/or
shape the repair material. Alternatively, the curvature of the
subchondral bone can be measured and the resultant measurement(s)
can be used to either select or shape a cartilage replacement
material. For example, the contour of the subchondral bone can be
used to re-create a virtual cartilage surface: the margins of an
area of diseased cartilage can be identified. The subchondral bone
shape in the diseased areas can be measured. A virtual contour can
then be created by copying the subchondral bone surface into the
cartilage surface, whereby the copy of the subchondral bone surface
connects the margins of the area of diseased cartilage.
[0249] Turning now to FIGS. 2A-H, various stages of knee
resurfacing steps are shown. FIG. 2A illustrates an example of
normal thickness cartilage 700 in the anterior, central and
posterior portion of a femoral condyle 702 with a cartilage defect
705 in the posterior portion of the femoral condyle. FIG. 2B shows
the detection of a sudden change in thickness indicating the
margins of a cartilage defect 710 that would be observed using the
imaging techniques or the mechanical, optical, laser or ultrasound
techniques described above. FIG. 2C shows the margins of a
weight-bearing surface 715 mapped onto the articular cartilage 700.
Cartilage defect 705 is located within the weight-bearing surface
715.
[0250] FIG. 2D shows an intended implantation site (stippled line)
720 and cartilage defect 705. In this depiction, the implantation
site 720 is slightly larger than the area of diseased cartilage
705. FIG. 2E depicts placement of a single component articular
surface repair system 725. The external surface of the articular
surface repair system 726 has a curvature that seamlessly extends
from the surrounding cartilage 700 resulting in good postoperative
alignment between the surrounding normal cartilage 700 and the
articular surface repair system 725.
[0251] FIG. 2F shows an exemplary multi-component articular surface
repair system 730. The distal surface 733 of the second component
732 has a curvature that extends from that of the adjacent
subchondral bone 735. The first component 736 has a thickness t and
surface curvature 738 that extends from the surrounding normal
cartilage 700. In this embodiment, the second component 732 could
be formed from a material with a Shore or Rockwell hardness that is
greater than the material forming the first component 736, if
desired. Thus it is contemplated that the second component 732
having at least portion of the component in communication with the
bone of the joint is harder than the first component 736 which
extends from the typically naturally softer cartilage material.
Other configurations, of course, are possible without departing
from the scope of the invention.
[0252] By providing a softer first component 736 and a firmer
second component 732, the overall implant can be configured so that
its relative hardness is analogous to that of the bone-cartilage or
bone-meniscus area that it abuts. Thus, the softer material first
component 736, being formed of a softer material, could perform the
cushioning function of the nearby meniscus or cartilage.
[0253] FIG. 2G shows another single component articular surface
repair system 740 with a peripheral margin 745 which is configured
so that it is substantially non-perpendicular to the surrounding or
adjacent normal cartilage 700. FIG. 2H shows a multi-component
articular surface repair system 750 with a first component 751 and
a second component 752 similar to that shown in FIG. 2G with a
peripheral margin 745 of the second component 745 substantially
non-perpendicular to the surrounding or adjacent normal cartilage
700.
[0254] Now turning to FIGS. 3A-E, these figures depict exemplary
knee imaging and resurfacing processes. FIG. 3A depicts a magnified
view of an area of diseased cartilage 805 demonstrating decreased
cartilage thickness when compared to the surrounding normal
cartilage 800. The margins 810 of the defect have been determined.
FIG. 3B depicts the measurement of cartilage thickness 815 adjacent
to the defect 805. FIG. 3C depicts the placement of a
multi-component mini-prosthesis 824 for articular resurfacing. The
thickness 820 of the first component 823 closely approximates that
of the adjacent normal cartilage 800. The thickness can vary in
different regions of the prosthesis. The curvature of the distal
portion 824 of the first component 823 closely approximates an
extension of the normal cartilage 800 surrounding the defect. The
curvature of the distal portion 826 of the second component 825 is
a projection of the surface 827 of the adjacent subchondral bone
830 and can have a curvature that is the same, or substantially
similar, to all or part of the surrounding subchondral bone.
[0255] FIG. 3D is a schematic depicting placement of a single
component mini-prosthesis 840 utilizing anchoring stems 845. As
will be appreciated by those of skill in the art, a variety of
configurations, including stems, posts, and nubs can be employed.
Additionally, the component is depicted such that its internal
surface 829 is located within the subchondral bone 830. In an
alternative construction, the interior surface 829 conforms to the
surface of the subchondral bone 831.
[0256] FIG. 3E depicts placement of a single component
mini-prosthesis 840 utilizing anchoring stems 845 and an opening at
the external surface 850 for injection of bone cement 855 or other
suitable material. The injection material 855 can freely
extravasate into the adjacent bone and marrow space from several
openings at the undersurface of the mini-prosthesis 860 thereby
anchoring the mini-prosthesis.
[0257] FIGS. 4A-C, depict an alternative knee resurfacing device.
FIG. 4A depicts a normal thickness cartilage in the anterior,
central and posterior portion of a femoral condyle 900 and a large
area of diseased cartilage 905 toward the posterior portion of the
femoral condyle. FIG. 4B depicts placement of a single component
articular surface repair system 910. Again, the implantation site
has been prepared with a single cut 921, as illustrated. However,
as will be appreciated by those of skill in the art, the repair
system can be perpendicular to the adjacent normal cartilage 900
without departing from the scope of the invention. The articular
surface repair system is not perpendicular to the adjacent normal
cartilage 900. FIG. 4C depicts a multi-component articular surface
repair system 920. Again, the implantation site has been prepared
with a single cut (cut line shown as 921). The second component 930
has a curvature similar to the extended surface 930 adjacent
subchondral bone 935. The first component 940 has a curvature that
extends from the adjacent cartilage 900.
[0258] B. Designs Encompassing Multiple Component Repair
Materials
[0259] The articular repair system or implants described herein can
include one or more components.
[0260] FIGS. 5A-B shows single and multiple component devices. FIG.
5A illustrates an example of a single component articular surface
repair system 1400 with varying curvature and radii that fits
within the subchondral bone 1420 such that the interior surface
1402 of the system 1400 does not form an extension of the surface
of the subchondral bone 1422. The articular surface repair system
is chosen to include convex 1402 and concave 1404 portions. Such
devices can be utilized in a lateral femoral condyle or small
joints such as the elbow joint. FIG. 5B depicts a multi-component
articular surface repair system with a second component 1410 with a
surface 1412 that forms an extension of the surface 1422 of the
subchondral bone 1420 and a first component 1405 with an interior
surface 1406 that forms an extension of the curvature and shape of
the surrounding normal cartilage 1415. The second component 1410
and the first component 1405 demonstrate varying curvatures and
radii with convex and concave portions that correspond to the
curvature of the subchondral bone 1420 and/or the normal cartilage
1415. As will be appreciated by those of skill in the art, these
two components can be formed such that the parts are integrally
formed with each other, or can be formed such that each part abuts
the other. Additionally, the relationship between the parts can be
by any suitable mechanism including adhesives and mechanical
means.
[0261] FIGS. 6A-B show articular repair systems 100 having an outer
contour 102 forming an extension of the surrounding normal
cartilage 200. The systems are implanted into the underlying bone
300 using one or more pegs 150, 175. The pegs, pins, or screws can
be porous-coated and can have flanges 125 as shown in FIG. 5B.
[0262] FIG. 7 shows an exemplary articular repair device 500
including a flat surface 510 to control depth and prevent toggle;
an exterior surface 515 having the contour of normal cartilage;
flanges 517 to prevent rotation and control toggle; a groove 520 to
facilitate tissue in-growth.
[0263] FIGS. 8A-D depict, in cross-section, another example of an
implant 640 with multiple anchoring pegs, stems, or screws 645.
FIG. 8B-D show various cross-sectional representations of various
possible embodiments of the pegs, or anchoring stems. FIG. 8B shows
a peg 645 having a notch 646 or groove around its circumference;
FIG. 18C shows a peg 645 with radially-extending arms 647 that help
anchor the device in the underlying bone; and FIG. 8D shows a peg
645 with multiple grooves or flanges 648.
[0264] FIGS. 9A-B depict an external view of an exemplary implant
650 with multiple anchoring pegs 655 which illustrates that the
pegs are not necessarily linearly aligned along the longitudinal
axis of the device.
[0265] FIG. 10A depicts an implant 660 with a peg 661 having
radially extending arms 665. FIGS. 10B-E are top views of the
implant pegs illustrating a variety of suitable alternative
shapes.
[0266] Examples of one-component systems include, but are not
limited to, a plastic, a polymer, a metal, a metal alloy, crystal
free metals, a biologic material or combinations thereof. In
certain embodiments, the surface of the repair system facing the
underlying bone can be smooth. In other embodiments, the surface of
the repair system facing the underlying bone can be porous or
porous-coated. In another aspect, the surface of the repair system
facing the underlying bone is designed with one or more grooves,
for example to facilitate the in-growth of the surrounding tissue.
The external surface of the device can have a step-like design,
which can be advantageous for altering biomechanical stresses.
Optionally, flanges can also be added at one or more positions on
the device (e.g., to prevent the repair system from rotating, to
control toggle and/or prevent settling into the marrow cavity). The
flanges can be part of a conical or a cylindrical design. A portion
or all of the repair system facing the underlying bone can also be
flat which can help to control depth of the implant and to prevent
toggle.
[0267] Non-limiting examples of multiple-component systems include
combinations of metal, plastic, metal alloys, crystal free metals,
and one or more biological materials. One or more components of the
articular surface repair system can be composed of a biologic
material (e.g. a tissue scaffold with cells such as cartilage cells
or stem cells alone or seeded within a substrate such as a
bioresorbable material or a tissue scaffold, allograft, autograft
or combinations thereof) and/or a non-biological material (e.g.,
polyethylene or a chromium alloy such as chromium cobalt).
[0268] Thus, the repair system can include one or more areas of a
single material or a combination of materials, for example, the
articular surface repair system can have a first and a second
component. The first component is typically designed to have size,
thickness and curvature similar to that of the cartilage tissue
lost while the second component is typically designed to have a
curvature similar to the subchondral bone. In addition, the first
component can have biomechanical properties similar to articular
cartilage, including but not limited to similar elasticity and
resistance to axial loading or shear forces. The first and the
second component can consist of two different metals or metal
alloys. One or more components of the system (e.g., the second
portion) can be composed of a biologic material including, but not
limited to bone, or a non-biologic material including, but not
limited to hydroxyapatite, tantalum, a chromium alloy, chromium
cobalt or other metal alloys.
[0269] One or more regions of the articular surface repair system
(e.g., the outer margin of the first portion and/or the second
portion) can be bioresorbable, for example to allow the interface
between the articular surface repair system and the patient's
normal cartilage, over time, to be filled in with hyaline or
fibrocartilage. Similarly, one or more regions (e.g., the outer
margin of the first portion of the articular surface repair system
and/or the second portion) can be porous. The degree of porosity
can change throughout the porous region, linearly or non-linearly,
for where the degree of porosity will typically decrease towards
the center of the articular surface repair system. The pores can be
designed for in-growth of cartilage cells, cartilage matrix, and
connective tissue thereby achieving a smooth interface between the
articular surface repair system and the surrounding cartilage.
[0270] The repair system (e.g., the second component in multiple
component systems) can be attached to the patient's bone with use
of a cement-like material such as methylmethacrylate, injectable
hydroxy- or calcium-apatite materials and the like.
[0271] In certain embodiments, one or more portions of the
articular surface repair system can be pliable or liquid or
deformable at the time of implantation and can harden later.
Hardening can occur, for example, within 1 second to 2 hours (or
any time period therebetween), within 1 second to 30 minutes (or
any time period therebetween), or between 1 second and 10 minutes
(or any time period therebetween).
[0272] One or more components of the articular surface repair
system can be adapted to receive injections. For example, the
external surface of the articular surface repair system can have
one or more openings therein. The openings can be sized to receive
screws, tubing, needles or other devices which can be inserted and
advanced to the desired depth, for example, through the articular
surface repair system into the marrow space. Injectables such as
methylmethacrylate and injectable hydroxy- or calcium-apatite
materials can then be introduced through the opening (or tubing
inserted therethrough) into the marrow space thereby bonding the
articular surface repair system with the marrow space. Similarly,
screws or pins, or other anchoring mechanisms. can be inserted into
the openings and advanced to the underlying subchondral bone and
the bone marrow or epiphysis to achieve fixation of the articular
surface repair system to the bone. Portions or all components of
the screw or pin can be bioresorbable, for example, the distal
portion of a screw that protrudes into the marrow space can be
bioresorbable. During the initial period after the surgery, the
screw can provide the primary fixation of the articular surface
repair system. Subsequently, ingrowth of bone into a porous coated
area along the undersurface of the articular cartilage repair
system can take over as the primary stabilizer of the articular
surface repair system against the bone.
[0273] The articular surface repair system can be anchored to the
patient's bone with use of a pin or screw or other attachment
mechanism. The attachment mechanism can be bioresorbable. The screw
or pin or attachment mechanism can be inserted and advanced towards
the articular surface repair system from a non-cartilage covered
portion of the bone or from a non-weight-bearing surface of the
joint.
[0274] The interface between the articular surface repair system
and the surrounding normal cartilage can be at an angle, for
example oriented at an angle of 90 degrees relative to the
underlying subchondral bone. Suitable angles can be determined in
view of the teachings herein, and in certain cases, non-90 degree
angles can have advantages with regard to load distribution along
the interface between the articular surface repair system and the
surrounding normal cartilage.
[0275] The interface between the articular surface repair system
and the surrounding normal cartilage and/or bone can be covered
with a pharmaceutical or bioactive agent, for example a material
that stimulates the biological integration of the repair system
into the normal cartilage and/or bone. The surface area of the
interface can be irregular, for example, to increase exposure of
the interface to pharmaceutical or bioactive agents.
[0276] C. Pre-Existing Repair Systems
[0277] As described herein, repair systems, including surgical
instruments, templates, guides and/or molds, of various sizes,
curvatures and thicknesses can be obtained. These repair systems,
including surgical instruments, guides, templates and/or molds, can
be catalogued and stored to create a library of systems from which
an appropriate system for an individual patient can then be
selected. In other words, a defect, or an articular surface, is
assessed in a particular subject and a pre-existing repair system,
including surgical instruments, templates, guides and/or molds,
having a suitable shape and size is selected from the library for
further manipulation (e.g., shaping) and implantation.
[0278] D. Mini-Prosthesis
[0279] As noted above, the methods and compositions described
herein can be used to replace only a portion of the articular
surface, for example, an area of diseased cartilage or lost
cartilage on the articular surface. In these systems, the articular
surface repair system can be designed to replace only the area of
diseased or lost cartilage or it can extend beyond the area of
diseased or lost cartilage, e.g., 3 or 5 mm into normal adjacent
cartilage. In certain embodiments, the prosthesis replaces less
than about 70% to 80% (or any value therebetween) of the articular
surface (e.g., any given articular surface such as a single femoral
condyle, etc.), less than about 50% to 70% (or any value
therebetween), less than about 30% to 50% (or any value
therebetween), less than about 20% to 30% (or any value
therebetween), or less than about 20% of the articular surface.
[0280] The prosthesis can include multiple components, for example
a component that is implanted into the bone (e.g., a metallic
device) attached to a component that is shaped to cover the defect
of the cartilage overlaying the bone. Additional components, for
example intermediate plates, meniscal repair systems and the like
can also be included. It is contemplated that each component
replaces less than all of the corresponding articular surface.
However, each component need not replace the same portion of the
articular surface. In other words, the prosthesis can have a
bone-implanted component that replaces less than 30% of the bone
and a cartilage component that replaces 60% of the cartilage. The
prosthesis can include any combination, provided each component
replaces less than the entire articular surface.
[0281] The articular surface repair system can be formed or
selected so that it will achieve a near anatomic fit or match with
the surrounding or adjacent cartilage. Typically, the articular
surface repair system is formed and/or selected so that its outer
margin located at the external surface will be aligned with the
surrounding or adjacent cartilage.
[0282] Thus, the articular repair system can be designed to replace
the weight-bearing portion (or more or less than the weight bearing
portion) of an articular surface, for example in a femoral condyle.
The weight-bearing surface refers to the contact area between two
opposing articular surfaces during activities of normal daily
living (e.g., normal gait). At least one or more weight-bearing
portions can be replaced in this manner, e.g., on a femoral condyle
and on a tibia.
[0283] In other embodiments, an area of diseased cartilage or
cartilage loss can be identified in a weight-bearing area and only
a portion of the weight-bearing area, specifically the portion
containing the diseased cartilage or area of cartilage loss, can be
replaced with an articular surface repair system.
[0284] In another embodiment, the articular repair system can be
designed or selected to replace substantially all of the articular
surface, e.g. a condyle.
[0285] In another embodiment, for example, in patients with diffuse
cartilage loss, the articular repair system can be designed to
replace an area slightly larger than the weight-bearing
surface.
[0286] In certain aspects, the defect to be repaired is located
only on one articular surface, typically the most diseased surface.
For example, in a patient with severe cartilage loss in the medial
femoral condyle but less severe disease in the tibia, the articular
surface repair system can only be applied to the medial femoral
condyle. In the various methods described herein, the articular
surface repair system can be designed to achieve an exact or a near
anatomic fit with the adjacent normal cartilage.
[0287] In other embodiments, more than one articular surface can be
repaired. The area(s) of repair will be typically limited to areas
of diseased cartilage or cartilage loss or areas slightly greater
than the area of diseased cartilage or cartilage loss within the
weight-bearing surface(s).
[0288] The implant and/or the implant site can be sculpted to
achieve a near anatomic alignment between the implant and the
implant site. In another embodiment, an electronic image is used to
measure the thickness, curvature, or shape of the articular
cartilage or the subchondral bone, and/or the size of a defect, and
an articular surface repair system is selected using this
information. The articular surface repair system can be inserted
arthroscopically. The articular surface repair system can have a
single radius. More typically, however, as shown in FIG. 5A,
discussed above, the articular surface repair system 1400 has
varying curvatures and radii within the same plane, e.g.
anteroposterior or mediolateral or superoinferior or oblique
planes, or within multiple planes. In this manner, the articular
surface repair system can be shaped to achieve a near anatomic
alignment between the implant and the implant site. This design
allows not only allows for different degrees of convexity or
concavity, but also for concave portions within a predominantly
convex shape or vice versa 1400.
[0289] In another embodiment the articular surface repair system
has an anchoring stem, used to anchor the device, for example, as
described in U.S. Pat. No. 6,224,632 to Pappas et al issued May 1,
2001. The stem, or peg, can have different shapes including
conical, rectangular, fin among others. The mating bone cavity is
typically similarly shaped as the corresponding stem.
[0290] As shown in FIG. 6, discussed above, the articular surface
repair system 100 can be affixed to the subchondral bone 300, with
one or more stems, or pegs, 150 extending through the subchondral
plate into the marrow space. In certain instances, this design can
reduce the likelihood that the implant will settle deeper into the
joint over time by resting portions of the implant against the
subchondral bone. The stems, or pegs, can be of any shape suitable
to perform the function of anchoring the device to the bone. For
example, the pegs can be cylindrical or conical. Optionally, the
stems, or pegs, can further include notches or openings to allow
bone in-growth. In addition, the stems can be porous coated for
bone in-growth. The anchoring stems or pegs can be affixed to the
bone using bone cement. An additional anchoring device can also be
affixed to the stem or peg. The anchoring device can have an
umbrella shape (e.g., radially expanding elements) with the wider
portion pointing towards the subchondral bone and away from the
peg. The anchoring device can be advantageous for providing
immediate fixation of the implant. The undersurface of the
articular repair system facing the subchondral bone can be textured
or rough thereby increasing the contact surface between the
articular repair system and the subchondral bone. Alternatively,
the undersurface of the articular repair system can be porous
coated thereby allowing in-growth. The surgeon can support the
in-growth of bone by treating the subchondral bone with a rasp,
typically to create a larger surface area and/or until bleeding
from the subchondral bone occurs.
[0291] In another embodiment, the articular surface repair system
can be attached to the underlying bone or bone marrow using bone
cement. Bone cement is typically made from an acrylic polymeric
material. Typically, the bone cement is comprised of two
components: a dry powder component and a liquid component, which
are subsequently mixed together. The dry component generally
includes an acrylic polymer, such as polymethylmethacrylate (PMMA).
The dry component can also contain a polymerization initiator such
as benzoylperoxide, which initiates the free-radical polymerization
process that occurs when the bone cement is formed. The liquid
component, on the other hand, generally contains a liquid monomer
such as methyl methacrylate (MMA). The liquid component can also
contain an accelerator such as an amine (e.g.,
N,N-dimethyl-p-toluidine). A stabilizer, such as hydroquinone, can
also be added to the liquid component to prevent premature
polymerization of the liquid monomer. When the liquid component is
mixed with the dry component, the dry component begins to dissolve
or swell in the liquid monomer. The amine accelerator reacts with
the initiator to form free radicals that begin to link monomer
units to form polymer chains. In the next two to four minutes, the
polymerization process proceeds changing the viscosity of the
mixture from a syrup-like consistency (low viscosity) into a
dough-like consistency (high viscosity). Ultimately, further
polymerization and curing occur, causing the cement to harden and
affix a prosthesis to a bone.
[0292] In certain aspects of the embodiments disclosed herein, bone
cement or another liquid attachment material such as injectable
calciumhydroxyapatite can be injected into the marrow cavity
through one or more openings in the prosthesis. These openings in
the prosthesis could extend from the articular surface to the
undersurface of the prosthesis. After injection, the openings could
be closed with a polymer, silicon, metal, metal alloy or
bioresorbable plug.
[0293] In another embodiment, one or more components of the
articular surface repair (e.g., the surface of the system that is
pointing towards the underlying bone or bone marrow) can be porous
or porous coated. A variety of different porous metal coatings have
been proposed for enhancing fixation of a metallic prosthesis by
bone tissue in-growth. Thus, for example, U.S. Pat. No. 3,855,638
to Pilliar issued Dec. 24, 2974, discloses a surgical prosthetic
device, which can be used as a bone prosthesis, comprising a
composite structure consisting of a solid metallic material
substrate and a porous coating of the same solid metallic material
adhered to and extending over at least a portion of the surface of
the substrate. The porous coating consists of a plurality of small
discrete particles of metallic material bonded together at their
points of contact with each other to define a plurality of
connected interstitial pores in the coating. The size and spacing
of the particles, which can be distributed in a plurality of
monolayers, can be such that the average interstitial pore size is
not more than about 200 microns. Additionally, the pore size
distribution can be substantially uniform from the
substrate-coating interface to the surface of the coating. In
another embodiment, the articular surface repair system can contain
one or more polymeric materials that can be loaded with and release
therapeutic agents including drugs or other pharmacological
treatments that can be used for drug delivery. The polymeric
materials can, for example, be placed inside areas of porous
coating. The polymeric materials can be used to release therapeutic
drugs, e.g. bone or cartilage growth stimulating drugs. This
embodiment can be combined with other embodiments, wherein portions
of the articular surface repair system can be bioresorbable. For
example, the first layer of an articular surface repair system or
portions of its first layer can be bioresorbable. As the first
layer gets increasingly resorbed, local release of a cartilage
growth-stimulating drug can facilitate in-growth of cartilage cells
and matrix formation.
[0294] In any of the methods or compositions described herein, the
articular surface repair system can be pre-manufactured with a
range of sizes, curvatures and thicknesses. Alternatively, the
articular surface repair system can be custom-made for an
individual patient. In addition, the repair system can incorporate
various anatomical relief features, as described below, to
accommodate various anatomical features of the patient.
[0295] IV. Manufacturing
[0296] A. Shaping
[0297] In certain instances shaping of the repair material will be
required before or after formation (e.g., growth to desired
thickness or after selection of a pre-manufactured implant and/or
blank), for example where the thickness of the required cartilage
material is not uniform (e.g., where different sections of the
cartilage replacement or regenerating material require different
thicknesses). Shaping can include the removal of material as well
as the addition of material, as well as combinations thereof for
differing areas of a single implant.
[0298] The replacement material can be shaped by any suitable
technique including, but not limited to, mechanical abrasion, laser
abrasion or ablation, radiofrequency treatment, cryoablation, metal
additive technologies, variations in exposure time and
concentration of nutrients, enzymes or growth factors and any other
means suitable for influencing or changing cartilage thickness.
See, e.g., WO 00/15153 to Mansmann published Mar. 23, 2000; If
enzymatic digestion is used, certain sections of the cartilage
replacement or regenerating material can be exposed to higher doses
of the enzyme or can be exposed longer as a means of achieving
different thicknesses and curvatures of the cartilage replacement
or regenerating material in different sections of said
material.
[0299] The material can be shaped manually and/or automatically,
for example using a device into which a pre-selected thickness
and/or curvature has been input and then programming the device
using the input information to achieve the desired shape.
[0300] In addition to, or instead of, shaping the cartilage repair
material, the site of implantation (e.g., bone surface, any
cartilage material remaining, etc.) can also be shaped by any
suitable technique in order to enhance integration of the repair
material.
[0301] B. Sizing
[0302] The articular repair system can be formed or selected so
that it will achieve a near anatomic fit or match with the
surrounding or adjacent cartilage or subchondral bone or menisci
and other tissue. The shape of the repair system can be based on
the analysis of an electronic image (e.g. MRI, CT, digital
tomosynthesis, optical coherence tomography or the like). If the
articular repair system is intended to replace an area of diseased
cartilage or lost cartilage, the near anatomic fit can be achieved
using a method that provides a virtual reconstruction of the shape
of healthy cartilage in an electronic image.
[0303] In one embodiment, a near normal cartilage surface at the
position of the cartilage defect can be reconstructed by
interpolating the healthy cartilage surface across the cartilage
defect or area of diseased cartilage. This can, for example, be
achieved by describing the healthy cartilage by means of a
parametric surface (e.g. a B-spline surface), for which the control
points are placed such that the parametric surface follows the
contour of the healthy cartilage and bridges the cartilage defect
or area of diseased cartilage. The continuity properties of the
parametric surface will provide a smooth integration of the part
that bridges the cartilage defect or area of diseased cartilage
with the contour of the surrounding healthy cartilage. The part of
the parametric surface over the area of the cartilage defect or
area of diseased cartilage can be used to determine the shape or
part of the shape of the articular repair system to match with the
surrounding cartilage.
[0304] In another embodiment, a near normal cartilage surface at
the position of the cartilage defect or area of diseased cartilage
can be reconstructed using morphological image processing. In a
first step, the cartilage can be extracted from the electronic
image using manual, semi-automated and/or automated segmentation
techniques (e.g., manual tracing, region growing, live wire,
model-based segmentation), resulting in a binary image. Defects in
the cartilage appear as indentations that can be filled with a
morphological closing operation performed in 2-D or 3-D with an
appropriately selected structuring element. The closing operation
is typically defined as a dilation followed by an erosion. A
dilation operator sets the current pixel in the output image to 1
if at least one pixel of the structuring element lies inside a
region in the source image. An erosion operator sets the current
pixel in the output image to 1 if the whole structuring element
lies inside a region in the source image. The filling of the
cartilage defect or area of diseased cartilage creates a new
surface over the area of the cartilage defect or area of diseased
cartilage that can be used to determine the shape or part of the
shape of the articular repair system to match with the surrounding
cartilage or subchondral bone.
[0305] As described above, the articular repair system, including
surgical tools and instruments, molds, in situ repair systems, etc.
can be formed or selected from a library or database of systems of
various sizes, curvatures and thicknesses so that it will achieve a
near anatomic fit or match with the surrounding or adjacent
cartilage and/or subchondral bone. These systems can be pre-made or
made to order for an individual patient. In order to control the
fit or match of the articular repair system with the surrounding or
adjacent cartilage or subchondral bone or menisci and other tissues
preoperatively, a software program can be used that projects the
articular repair system over the anatomic position where it will be
implanted. Suitable software is commercially available and/or
readily modified or designed by a skilled programmer.
[0306] In yet another embodiment, the articular repair system
including unicompartmental and total knee implants as well as hip
devices can be projected over the implantation site using one or
more 2-D or 3-D images. The cartilage and/or subchondral bone and
other anatomic structures can be optionally extracted from a 2-D or
3-D electronic image such as an MRI or a CT using manual,
semi-automated and/or automated segmentation techniques. A 2-D or
3-D representation of the cartilage and/or bone and other anatomic
structures as well as the articular repair system can be generated,
for example using a polygon or NURBS surface or other parametric
surface representation. Ligaments, menisci and other articular
structures can be displayed in 2-D and 3-D. For a description of
various parametric surface representations see, for example Foley,
J. D. et al., Computer Graphics: Principles and Practice in C;
Addison-Wesley, 2.sup.nd edition, 1995).
[0307] The 2-D or 3-D representations of the cartilage and/or
subchondral bone and other anatomic structures and the articular
repair system can be merged into a common coordinate system. The
articular repair system, including surgical tools and instruments,
molds, in situ repair systems, etc. can then be placed at the
desired implantation site. The representations of the cartilage,
subchondral bone, ligaments, menisci and other anatomic structures
and the articular repair system are rendered into a 2-D or 3-D
image, for example application programming interfaces (APIs)
OpenGL.RTM. (standard library of advanced 3-D graphics functions
developed by SGI, Inc.; available as part of the drivers for
PC-based video cards, for example from www.nvidia.com for NVIDIA
video cards or www.3dlabs.com for 3Dlabs products, or as part of
the system software for Unix workstations) or DirectX.RTM.
(multimedia API for Microsoft Windows.RTM. based PC systems;
available from www.microsoft.com). The 2-D or 3-D image can be
rendered or displayed showing the cartilage, subchondral bone,
ligaments, menisci or other anatomic objects, and the articular
repair system from varying angles, e.g. by rotating or moving them
interactively or non-interactively, in real-time or
non-real-time.
[0308] In another embodiment, the implantation site may be
visualized using one or more cross-sectional 2-D images, as
described in U.S. Ser. No. 10/305,652, entitled "Methods and
Compositions for Articular Repair," filed Nov. 27, 2002, which is
hereby incorporated by reference in its entirety. Typically, a
series of 2-D cross-sectional images will be used. The 2-D images
can be generated with imaging tests such as CT, MRI, digital
tomosynthesis, ultrasound, optical imaging, optical coherence
tomography, other imaging modalities using methods and tools known
to those of skill in the art. The articular repair system or
implant can then be superimposed onto one or more of these 2-D
images. The 2-D cross-sectional images may be reconstructed in
other planes, e.g. from sagittal to coronal, etc. Isotropic data
sets (e.g., data sets where the slice thickness is the same or
nearly the same as the in-plane resolution) or near isotropic data
sets can also be used. Multiple planes may be displayed
simultaneously, for example using a split screen display. The
operator may also scroll through the 2-D images in any desired
orientation in real time or near real time; the operator can rotate
the imaged tissue volume while doing this. The articular repair
system or implant may be displayed in cross-section utilizing
different display planes, e.g. sagittal, coronal or axial,
typically matching those of the 2-D images demonstrating the
cartilage, subchondral bone, ligaments, menisci or other tissue.
Alternatively, a three-dimensional display may be used for the
articular repair system. The 2-D electronic image and the 2-D or
3-D representation of the articular repair system or implant may be
merged into a common coordinate system. The cartilage repair system
or implant can then be placed at the desired implantation site. The
series of 2-D cross-sections of the anatomic structures, the
implantation site and the articular repair system or implant may be
displayed interactively (e.g. the operator can scroll through a
series of slices) or non-interactively (e.g. as an animation that
moves through the series of slices), in real-time or
non-real-time.
[0309] The software can be designed so that the articular repair
system, including surgical tools and instruments, molds, in situ
repair systems, etc. with the best fit relative to the cartilage
and/or subchondral bone is automatically selected, for example
using one or more of the techniques described above. Alternatively,
the operator can select an articular repair system, including
surgical tools and instruments, molds, in situ repair systems, etc.
and project it or drag it onto the implantation site displayed on
the cross-sectional 2-D or the 3-D images. The operator can then
move and rotate the articular repair system relative to the
implantation site and scroll through a cross-sectional 2-D or 3-D
display of the articular repair system and of the anatomic
structures. The operator can perform a visual and/or
computer-assisted inspection of the fit between the articular
repair system and the implantation site. This can be performed for
different positions of the joint, e.g. extension, 45, 90 degrees of
flexion, adduction, abduction, internal or external rotation. The
procedure can be repeated until a satisfactory fit has been
achieved. The procedure can be entirely manual by the operator; it
can, however, also be computer-assisted. For example, the software
can select a first trial implant that the operator can test (e.g.,
evaluate the fit). Software that highlights areas of poor alignment
between the implant and the surrounding cartilage or subchondral
bone or menisci or other tissues can also be designed and used.
Based on this information, the software or the operator can select
another implant and test its alignment.
[0310] In all of the above embodiments, the biomechanical axis and
relevant anatomical axes or planes can be displayed simultaneous
with the joint and/or articular repair device in the 2-D or 3-D
display. Simultaneous display of at least one or more biomechanical
axes or anatomical axes or planes can help improve the assessment
of fit of the articular repair system. Biomechanical axis or
relevant anatomical axes or planes can also be displayed for
different positions of the joint.
[0311] C. Rapid Prototyping, Other Manufacturing Techniques
[0312] Rapid prototyping is a technique for fabricating a
three-dimensional object from a computer model of the object. A
special printer is used to fabricate the prototype from a plurality
of two-dimensional layers. Computer software sections the
representations of the object into a plurality of distinct
two-dimensional layers and then a three-dimensional printer
fabricates a layer of material for each layer sectioned by the
software. Together the various fabricated layers form the desired
prototype. More information about rapid prototyping techniques is
available in US Patent Publication No 2002/0079601A1 to Russell et
al., published Jun. 27, 2002. An advantage to using rapid
prototyping is that it enables the use of free form fabrication
techniques that use toxic or potent compounds safely. These
compounds can be safely incorporated in an excipient envelope,
which reduces worker exposure
[0313] A powder piston and build bed can be provided. Powder
includes any material (metal, plastic, etc.) that can be made into
a powder or bonded with a liquid. The power is rolled from a feeder
source with a spreader onto a surface of a bed. The thickness of
the layer is controlled by the computer. The print head then
deposits a binder fluid onto the powder layer at a location where
it is desired that the powder bind. Powder is again rolled into the
build bed and the process is repeated, with the binding fluid
deposition being controlled at each layer to correspond to the
three-dimensional location of the device formation. For a further
discussion of this process see, for example, US Patent Publication
No 2003/017365A1 to Monkhouse et al. published Sep. 18, 2003.
[0314] The rapid prototyping can use the two dimensional images
obtained to determine each of the two-dimensional shapes for each
of the layers of the prototyping machine. In this scenario, each
two dimensional image slice would correspond to a two dimensional
prototype slide. Alternatively, the three-dimensional shape of the
defect can be determined, as described above, and then broken down
into two dimensional slices for the rapid prototyping process. The
advantage of using the three-dimensional model is that the
two-dimensional slices used for the rapid prototyping machine can
be along the same plane as the two-dimensional images taken or
along a different plane altogether.
[0315] Rapid prototyping can be combined or used in conjunction
with casting techniques. For example, a shell or container with
inner dimensions corresponding to an articular repair system
including surgical instruments, molds, alignment guides or surgical
guides, can be made using rapid prototyping. Plastic or wax-like
materials are typically used for this purpose. The inside of the
container can subsequently be coated, for example with a ceramic,
for subsequent casting. Using this process, personalized casts can
be generated.
[0316] Rapid prototyping can be used for producing articular repair
systems including surgical tools, molds, alignment guides, cut
guides etc. Rapid prototyping can be performed at a manufacturing
facility. Alternatively, it may be performed in the operating room
after an intraoperative measurement has been performed.
[0317] Alternatively, milling techniques can be utilized for
producing articular repair systems including surgical tools, molds,
alignment guides, cut guides etc.
[0318] Alternatively, laser based techniques can be utilized for
producing articular repair systems including surgical tools, molds,
alignment guides, cut guides etc.
[0319] V. Implantation
[0320] Following one or more manipulations (e.g., shaping, growth,
development, etc), the cartilage replacement or regenerating
material can then be implanted into the area of the defect.
Implantation can be performed with the cartilage replacement or
regenerating material still attached to the base material or
removed from the base material. Any suitable methods and devices
can be used for implantation, for example, devices as described in
U.S. Pat. No. 6,375,658 to Hangody et al. issued Apr. 23, 2002;
U.S. Pat. No. 6,358,253 to Torrie et al. issued Mar. 19, 2002; U.S.
Pat. No. 6,328,765 to Hardwick et al. issued Dec. 11, 2001; and
International Publication WO 01/19254 to Cummings et al. published
Mar. 22, 2001.
[0321] In selected cartilage defects, the implantation site can be
prepared with a single cut across the articular surface, for
example, as shown in FIG. 8. In this case, single 810 and
multi-component 820 prostheses can be utilized.
[0322] A. The Joint Replacement Procedure
[0323] i. Knee Joint
[0324] Performing a total knee arthroplasty is a complicated
procedure. In replacing the knee with an artificial knee, it is
often desirable to get the anatomical and mechanical axes of the
lower extremity aligned correctly to ensure optimal functioning of
the implanted knee.
[0325] As shown in FIG. 11A, the center of the hip 1902 (located at
the head 1930 of the femur 1932), the center of the knee 1904
(located at the notch where the intercondylar tubercle 1934 of the
tibia 1936 meet the femur) and ankle 1906 lie approximately in a
straight line 1910 which defines the mechanical axis of the lower
extremity. The anatomic axis 1920 aligns 5-7.degree. offset .theta.
from the mechanical axis in the valgus, or outward, direction.
[0326] The long axis of the tibia 1936 is collinear with the
mechanical axis of the lower extremity 1910. From a
three-dimensional perspective, the lower extremity of the body
ideally functions within a single plane known as the median
anterior-posterior plane (MAP-plane) throughout the
flexion-extension arc. In order to accomplish this, the femoral
head 1930, the mechanical axis of the femur, the patellar groove,
the intercondylar notch, the patellar articular crest, the tibia
and the ankle remain within the MAP-plane during the
flexion-extension movement. During movement, the tibia rotates as
the knee flexes and extends in the epicondylar axis which is
perpendicular to the MAP-plane.
[0327] A variety of image slices can be taken at each individual
joint, e.g., the knee joint 1950-1950.sub.n, and the hip joint
1952-1950.sub.n. These image slices can be used as described above
in Section I along with an image of the full leg to ascertain the
axis.
[0328] With disease and malfunction of the knee, alignment of the
anatomic axis is altered. Performing a total knee arthroplasty is
one solution for correcting a diseased knee. Implanting a total
knee joint, such as the PFC Sigma RP Knee System by Johnson &
Johnson, requires that a series of resections be made to the
surfaces forming the knee joint in order to facilitate installation
of the artificial knee. The resections should be made to enable the
installed artificial knee to achieve flexion-extension movement
within the MAP-plane and to optimize the patient's anatomical and
mechanical axis of the lower extremity.
[0329] First, the tibia 1930 is resected to create a flat surface
to accept the tibial component of the implant. In most cases, the
tibial surface is resected perpendicular to the long axis of the
tibia in the coronal plane, but is typically sloped 4-7.degree.
posteriorly in the sagittal plane to match the normal slope of the
tibia. As will be appreciated by those of skill in the art, the
sagittal slope can be 0.degree. where the device to be implanted
does not require a sloped tibial cut. The resection line 1958 is
perpendicular to the mechanical axis 1910, but the angle between
the resection line and the surface plane of the plateau 1960 varies
depending on the amount of damage to the knee.
[0330] FIGS. 11B-D illustrate an anterior view of a resection of an
anatomically normal tibial component, a tibial component in a varus
knee, and a tibial component in a valgus knee, respectively. In
each figure, the mechanical axis 1910 extends vertically through
the bone and the resection line 1958 is perpendicular to the
mechanical axis 1910 in the coronal plane, varying from the surface
line formed by the joint depending on the amount of damage to the
joint. FIG. 11B illustrates a normal knee wherein the line
corresponding to the surface of the joint 1960 is parallel to the
resection line 1958. FIG. 11C illustrates a varus knee wherein the
line corresponding to the surface of the joint 1960 is not parallel
to the resection line 1958. FIG. 11D illustrates a valgus knee
wherein the line corresponding to the surface of the joint 1960 is
not parallel to the resection line 1958.
[0331] Once the tibial surface has been prepared, the surgeon turns
to preparing the femoral condyle.
[0332] The plateau of the femur 1970 is resected to provide flat
surfaces that communicate with the interior of the femoral
prosthesis. The cuts made to the femur are based on the overall
height of the gap to be created between the tibia and the femur.
Typically, a 20 mm gap is desirable to provide the implanted
prosthesis adequate room to achieve full range of motion. The bone
is resected at a 5-7.degree. angle valgus to the mechanical axis of
the femur. Resected surface 1972 forms a flat plane with an angular
relationship to adjoining surfaces 1974, 1976. The angle .theta.',
.theta.'' between the surfaces 1972-1974, and 1972-1976 varies
according to the design of the implant.
[0333] ii. Hip Joint
[0334] As illustrated in FIG. 11F, the external geometry of the
proximal femur includes the head 1980, the neck 1982, the lesser
trochanter 1984, the greater trochanter 1986 and the proximal
femoral diaphysis. The relative positions of the trochanters 1984,
1986, the femoral head center 1902 and the femoral shaft 1988 are
correlated with the inclination of the neck-shaft angle. The
mechanical axis 1910 and anatomic axis 1920 are also shown.
Assessment of these relationships can change the reaming direction
to achieve neutral alignment of the prosthesis with the femoral
canal.
[0335] Using anteroposterior and lateral radiographs, measurements
are made of the proximal and distal geometry to determine the size
and optimal design of the implant.
[0336] Typically, after obtaining surgical access to the hip joint,
the femoral neck 1982 is resected, e.g. along the line 1990. Once
the neck is resected, the medullary canal is reamed. Reaming can be
accomplished, for example, with a conical or straight reamer, or a
flexible reamer. The depth of reaming is dictated by the specific
design of the implant. Once the canal has been reamed, the proximal
reamer is prepared by serial rasping, with the rasp directed down
into the canal.
[0337] B. Surgical Tools
[0338] Further, surgical assistance can be provided by using a
device applied to the outer surface of the articular cartilage or
the bone, including the subchondral bone, in order to match the
alignment of the articular repair system and the recipient site or
the joint. The device can be round, circular, oval, ellipsoid,
curved or irregular in shape. The shape can be selected or adjusted
to match or enclose an area of diseased cartilage or an area
slightly larger than the area of diseased cartilage or
substantially larger than the diseased cartilage. The area can
encompass the entire articular surface or the weight bearing
surface. Such devices can be used when replacement of a majority or
an entire articular surface is contemplated.
[0339] Mechanical devices can be used for surgical assistance
(e.g., surgical tools), for example using gels, molds, plastics or
metal. One or more electronic images or intraoperative measurements
can be obtained providing object coordinates that define the
articular and/or bone surface and shape. These objects' coordinates
can be utilized to either shape the device, e.g. using a CAD/CAM
technique, to be adapted to a patient's articular anatomy or,
alternatively, to select a typically pre-made device that has a
good fit with a patient's articular anatomy. The device can have a
surface and shape that will match all or portions of the articular
cartilage, subchondral bone and/or other bone surface and shape,
e.g. similar to a "mirror image." The device can include, without
limitation, one or more cut planes, apertures, slots and/or holes
to accommodate surgical instruments such as drills, reamers,
curettes, k-wires, screws and saws.
[0340] The device may have a single component or multiple
components. The components may be attached to the unoperated and
operated portions of the intra- or extra-articular anatomy. For
example, one component may be attached to the femoral neck, while
another component may be in contact with the greater or lesser
trochanter. Typically, the different components can be used to
assist with different parts of the surgical procedure. When
multiple components are used, one or more components may also be
attached to a different component rather than the articular
cartilage, subchondral bone or other areas of osseous or
non-osseous anatomy. For example, a tibial mold may be attached to
a femoral mold and tibial cuts can be performed in reference to
femoral cuts.
[0341] Components may also be designed to fit to the joint after an
operative step has been performed. For example, in a knee, one
component may be designed to fit all or portions of a distal femur
before any cuts have been made, while another component may be
designed to fit on a cut that has been made with the previously
used mold or component. In a hip, one component may be used to
perform an initial cut, for example through the femoral neck, while
another subsequently used component may be designed to fit on the
femoral neck after the cut, for example covering the area of the
cut with a central opening for insertion of a reamer. Using this
approach, subsequent surgical steps may also be performed with high
accuracy, e.g. reaming of the marrow cavity.
[0342] In another embodiment, a guide may be attached to a mold to
control the direction and orientation of surgical instruments. For
example, after the femoral neck has been cut, a mold may be
attached to the area of the cut, whereby it fits portions or all of
the exposed bone surface. The mold may have an opening adapted for
a reamer. Before the reamer is introduced a femoral reamer guide
may be inserted into the mold and advanced into the marrow cavity.
The position and orientation of the reamer guide may be determined
by the femoral mold. The reamer can then be advanced over the
reamer guide and the marrow cavity can be reamed with improved
accuracy. Similar approaches are feasible in the knee and other
joints.
[0343] All mold components may be disposable. Alternatively, some
molds components may be re-usable. Typically, mold components
applied after a surgical step such as a cut as been performed can
be reusable, since a reproducible anatomic interface will have been
established.
[0344] Interconnecting or bridging components may be used. For
example, such interconnecting or bridging components may couple the
mold attached to the joint with a standard, unmodified or only
minimally modified cut block used during knee or hip surgery.
Interconnecting or bridging components may be made of plastic or
metal. When made of metal or other hard material, they can help
protect the joint from plastic debris, for example when a reamer or
saw would otherwise get into contact with the mold.
[0345] The accuracy of the attachment between the component or mold
and the cartilage or subchondral bone or other osseous structures
can be better than 2 mm, better than 1 mm, better than 0.7 mm,
better than 0.5 mm, or better than 0.5 mm. The accuracy of the
attachment between different components or between one or more
molds and one or more surgical instruments can be better than 2 mm,
better than 1 mm, better than 0.7 mm, better than 0.5 mm, or better
than 0.5 mm.
[0346] The angular error of any attachments or between any
components or between components, molds, instruments and/or the
anatomic or biomechanical axes is less than 2 degrees, less than
1.5 degrees, less than 1 degree, and/or less than 0.5 degrees. The
total angular error can be less than 2 degrees, less than 1.5
degrees, less than 1 degree, and/or less than 0.5 degrees.
[0347] In various embodiments, a position will be chosen that will
result in an anatomically desirable cut plane, drill hole, or
general instrument orientation for subsequent placement of an
articular repair system or for facilitating placement of the
articular repair system. Moreover, the device can be designed so
that the depth of the drill, reamer or other surgical instrument
can be controlled, e.g., the drill cannot go any deeper into the
tissue than defined by the device, and the size of the hole in the
block can be designed to essentially match the size of the implant.
Information about other joints or axis and alignment information of
a joint or extremity can be included when selecting the position of
these slots or holes. Alternatively, the openings in the device can
be made larger than needed to accommodate these instruments. The
device can also be configured to conform to the articular shape.
The apertures, or openings, provided can be wide enough to allow
for varying the position or angle of the surgical instrument, e.g.,
reamers, saws, drills, curettes and other surgical instruments. An
instrument guide, typically comprised of a relatively hard
material, can then be applied to the device. The device helps
orient the instrument guide relative to the three-dimensional
anatomy of the joint.
[0348] The mold may contact the entire articular surface. In
various embodiments, the mold can be in contact with only a portion
of the articular surface. Thus, the mold can be in contact, without
limitation, with: 100% of the articular surface; 80% of the
articular surface; 50% of the articular surface; 30% of the
articular surface; 30% of the articular surface; 20% of the
articular surface; or 10% or less of the articular surface. An
advantage of a smaller surface contact area is a reduction in size
of the mold thereby enabling cost efficient manufacturing as well
as predisposing the implant for implantation using minimally
invasive surgical techniques. The size of the mold and its surface
contact areas should be sufficient, however, to ensure accurate
placement so that subsequent drilling and cutting can be performed
with sufficient accuracy.
[0349] In various embodiments, the maximum diameter of the mold is
less than 10 cm. In other embodiments, the maximum diameter of the
mold may be less than: 8 cm; 5 cm; 4 cm; 3 cm; or even less than 2
cm.
[0350] The mold may be in contact with three or more surface points
rather than an entire surface. These surface points may be on the
articular surface or external to the articular surface. By using
contact points rather than an entire surface or portions of the
surface, the size of the mold may be reduced.
[0351] Reductions in the size of the mold can be used to enable
minimally invasive surgery (MIS) in the hip, the knee, the shoulder
and other joints. MIS technique with small molds will help to
reduce intraoperative blood loss, preserve tissue including
possibly bone, enable muscle sparing techniques and reduce
postoperative pain and enable faster recovery. Thus, in one
embodiment, the mold is used in conjunction with a muscle sparing
technique. In another embodiment, the mold may be used with a bone
sparing technique. In another embodiment, the mold is shaped to
enable MIS technique with an incision size of less than 15 cm, or
less than 13 cm, or less than 10 cm, or less than 8 cm, or less
than 6 cm.
[0352] The mold may be placed in contact with points or surfaces
outside of the articular surface. For example, the mold can rest on
bone in the intercondylar notch or the anterior or other aspects of
the tibia or the acetabular rim or the lesser or greater
trochanter. Optionally, the mold may only rest on points or
surfaces that are external to the articular surface. Furthermore,
the mold may rest on points or surfaces within the weight-bearing
surface, or on points or surfaces external to the weight-bearing
surface.
[0353] The mold may be designed to rest on bone or cartilage
outside the area to be worked on, e.g. cut, drilled etc. In this
manner, multiple surgical steps can be performed using the same
mold. For example, in the knee, the mold may be stabilized against
portions of the intercondylar notch, which can be selected external
to areas to be removed for total knee arthroplasty or other
procedures. In the hip, the mold may be attached external to the
acetabular fossa, providing a reproducible reference that is
maintained during a procedure, for example total hip arthroplasty.
The mold may be affixed to the underlying bone, for example with
pins or drills etc.
[0354] In additional embodiments, the mold may rest on the
articular cartilage. The mold may rest on the subchondral bone or
on structures external to the articular surface that are within the
joint space or on structures external to the joint space. If the
mold is designed to rest on the cartilage, an imaging test
demonstrating the articular cartilage can be used in one
embodiment. This can, for example, include ultrasound, spiral CT
arthrography, MRI using, for example, cartilage displaying pulse
sequences, or MRI arthrography. In another embodiment, an imaging
test demonstrating the subchondral bone, e.g. CT or spiral CT, can
be used and a standard cartilage thickness can be added to the
scan. The standard cartilage thickness can be derived, for example,
using an anatomic reference database, age, gender, and race
matching, age adjustments and any method known in the art or
developed in the future for deriving estimates of cartilage
thickness. The standard cartilage thickness may, in some
embodiments, be uniform across one or more articular surfaces or it
can change across the articular surface.
[0355] The mold may be adapted to rest substantially on subchondral
bone. In this case, residual cartilage can create some offset and
inaccurate result with resultant inaccuracy in surgical cuts,
drilling and the like. In various embodiments, portions of the
residual cartilage can be removed in a first step in areas where
the mold is designed to contact the bone and the subchondral bone
is exposed. In a second step, the mold is then placed on the
subchondral bone.
[0356] With advanced osteoarthritis, significant articular
deformity can result. The articular surface(s) can become
flattened. There can be cyst formation or osteophyte formation.
"Tram track" like structures can form on the articular surface. In
one embodiment, osteophytes or other deformities may be removed by
the computer software prior to generation of the mold. The software
can automatically, semi-automatically or manually with input from
the user simulate surgical removal of the osteophytes or other
deformities, and predict the resulting shape of the joint and the
associated surfaces. The mold can then be designed based on the
predicted shape. Intraoperatively, these osteophytes or other
deformities can then also optionally be removed prior to placing
the mold and performing the procedure. Alternatively, the mold can
be designed to avoid such deformities, such as by incorporating one
or more anatomical relief surfaces. For example, the mold may only
be in contact with points on the articular surface or external to
the articular surface that are not affected or involved by
osteophytes. The mold can rest on the articular surface or external
to the articular surface on three or more points or small surfaces
with the body of the mold elevated or detached from the articular
surface so that the accuracy of its position cannot be affected by
osteophytes or other articular deformities. The mold can rest on
one or more tibial spines or portions of the tibial spines.
Alternatively, all or portions of the mold may be designed to rest
on osteophytes or other excrescences or pathological changes.
[0357] The surgeon can, optionally, make fine adjustments between
the alignment device and the instrument guide. In this manner, an
optimal compromise can be found, for example, between biomechanical
alignment and joint laxity or biomechanical alignment and joint
function, e.g. in a knee joint flexion gap and extension gap. By
oversizing the openings in the alignment guide, the surgeon can
utilize the instruments and insert them in the instrument guide
without damaging the alignment guide. Thus, in particular if the
alignment guide is made of plastic, debris will not be introduced
into the joint. The position and orientation between the alignment
guide and the instrument guide can be also be optimized with the
use of, for example, interposed spacers, wedges, screws and other
mechanical or electrical methods known in the art.
[0358] A surgeon may desire to influence joint laxity as well as
joint alignment. This can be optimized for different flexion and
extension, abduction, or adduction, internal and external rotation
angles. For this purpose, for example, spacers can be introduced
that are attached or that are in contact with one or more molds.
The surgeon can intraoperatively evaluate the laxity or tightness
of a joint using spacers with different thickness or one or more
spacers with the same thickness. For example, spacers can be
applied in a knee joint in the presence of one or more molds and
the flexion gap can be evaluated with the knee joint in flexion.
The knee joint can then be extended and the extension gap can be
evaluated. Ultimately, the surgeon will select an optimal
combination of spacers for a given joint and mold. A surgical cut
guide can be applied to the mold with the spacers optionally
interposed between the mold and the cut guide. In this manner, the
exact position of the surgical cuts can be influenced and can be
adjusted to achieve an optimal result. Thus, the position of a mold
can be optimized relative to the joint, bone or cartilage for
soft-tissue tension, ligament balancing or for flexion, extension,
rotation, abduction, adduction, anteversion, retroversion and other
joint or bone positions and motion. The position of a cut block or
other surgical instrument may be optimized relative to the mold for
soft-tissue tension or for ligament balancing or for flexion,
extension, rotation, abduction, adduction, anteversion,
retroversion and other joint or bone positions and motion. Both the
position of the mold and the position of other components including
cut blocks and surgical instruments may be optimized for
soft-tissue tension or for ligament balancing or for flexion,
extension, rotation, abduction, adduction, anteversion,
retroversion and other joint or bone positions and motion.
[0359] Someone skilled in the art will recognize other means for
optimizing the position of the surgical cuts or other
interventions. As stated above, expandable or ratchet-like devices
may be utilized that can be inserted into the joint or that can be
attached or that can touch the mold (see also FIG. 27D). Such
devices can extend from a cutting block or other devices attached
to the mold, optimizing the position of drill holes or cuts for
different joint positions or they can be integrated inside the
mold. Integration in the cutting block or other devices attached to
the mold is contemplated, since the expandable or ratchet-like
mechanisms can be sterilized and re-used during other surgeries,
for example in other patients. Optionally, the expandable or
ratchet-like devices may be disposable. The expandable or ratchet
like devices may extend to the joint without engaging or contacting
the mold; alternatively, these devices may engage or contact the
mold. Hinge-like mechanisms are applicable. Similarly, jack-like
mechanisms are useful. In principal, any mechanical or electrical
device useful for fine-tuning the position of the cut guide
relative to the molds may be used. These embodiments are helpful
for soft-tissue tension optimization and ligament balancing in
different joints for different static positions and during joint
motion.
[0360] A surgeon may desire to influence joint laxity as well as
joint alignment. This can be optimized for different flexion and
extension, abduction, or adduction, internal and external rotation
angles. For this purpose, for example, spacers or expandable or
ratchet-like can be utilized that can be attached or that can be in
contact with one or more molds. The surgeon can intraoperatively
evaluate the laxity or tightness of a joint using spacers with
different thickness or one or more spacers with the same thickness
or using such expandable or ratchet like devices. For example,
spacers or a ratchet like device can be applied in a knee joint in
the presence of one or more molds and the flexion gap can be
evaluated with the knee joint in flexion. The knee joint can then
be extended and the extension gap can be evaluated. Ultimately, the
surgeon will select an optimal combination of spacers or an optimal
position for an expandable or ratchet-like device for a given joint
and mold. A surgical cut guide can be applied to the mold with the
spacers or the expandable or ratchet-like device optionally
interposed between the mold and the cut guide or, in select
embodiments, between the mold and the joint or the mold and an
opposite articular surface. In this manner, the exact position of
the surgical cuts can be influenced and can be adjusted to achieve
an optimal result. Someone skilled in the art will recognize other
means for optimizing the position of the surgical cuts or drill
holes. For example, expandable or ratchet-like devices can be
utilized that can be inserted into the joint or that can be
attached or that can touch the mold. Hinge-like mechanisms are
applicable. Similarly, jack-like mechanisms are useful. In
principal, any mechanical or electrical device useful for
fine-tuning the position of the cut guide relative to the molds can
be used.
[0361] The template and any related instrumentation such as spacers
or ratchets can be combined with a tensiometer to provide a better
intraoperative assessment of the joint. The tensiometer can be
utilized to further optimize the anatomic alignment and tightness
of the joint and to improve post-operative function and outcomes.
Optionally, local contact pressures may be evaluated
intraoperatively, for example using a sensor like the ones
manufactured by Tekscan, South Boston, Mass. The contact pressures
can be measured between the mold and the joint or between the mold
and any attached devices such as a surgical cut block.
[0362] The template may be a mold that can be made of a plastic or
polymer. The mold may be produced by rapid prototyping technology,
in which successive layers of plastic are laid down, as know in the
art. In other embodiments, the template or portions of the template
can be made of metal. The mold can be milled or made using laser
based manufacturing techniques.
[0363] The template may be casted using rapid prototyping and, for
example, lost wax technique. It may also be milled. For example, a
preformed mold with a generic shape can be used at the outset,
which can then be milled to the patient specific dimensions. The
milling may only occur on one surface of the mold, such as the
surface that faces the articular surface. Milling and rapid
prototyping techniques may be combined.
[0364] Curable materials may be used which can be poured into forms
that are, for example, generated using rapid prototyping. For
example, liquid metal may be used. Cured materials may optionally
be milled or the surface can be further refined using other
techniques.
[0365] Metal inserts may be applied to plastic components. For
example, a plastic mold may have at least one guide aperture to
accept a reaming device or a saw. A metal insert may be used to
provide a hard wall to accept the reamer or saw. Using this or
similar designs can be useful to avoid the accumulation of plastic
or other debris in the joint when the saw or other surgical
instruments may get in contact with the mold. Other hard materials
can be used to serve as inserts. These can also include, for
example, hard plastics or ceramics.
[0366] In another embodiment, the mold does not have metallic
inserts to accept a reaming device or saw. The metal inserts or
guides may be part of an attached device that is typically in
contact with the mold. A metallic drill guide or a metallic saw
guide may thus, for example, have metallic or hard extenders that
reach through the mold thereby, for example, also stabilizing any
devices applied to the mold against the physical body of the
mold.
[0367] The template may not only be used for assisting the surgical
technique and guiding the placement and direction of surgical
instruments. In addition, the templates can be utilized for guiding
the placement of the implant or implant components. For example, in
the hip joint, tilting of the acetabular component is a frequent
problem with total hip arthroplasty. A template can be applied to
the acetabular wall with an opening in the center large enough to
accommodate the acetabular component that the surgeon intends to
place. The template can have receptacles or notches that match the
shape of small extensions that can be part of the implant or that
can be applied to the implant. For example, the implant can have
small members or extensions applied to the twelve o'clock and six
o'clock positions. By aligning these members with notches or
receptacles in the mold, the surgeon can ensure that the implant is
inserted without tilting or rotation. These notches or receptacles
can also be helpful to hold the implant in place while bone cement
is hardening in cemented designs.
[0368] One or more templates can be used during the surgery. For
example, in the hip, a template can be initially applied to the
proximal femur that closely approximates the 3D anatomy prior to
the resection of the femoral head. The template can include an
opening to accommodate a saw. The opening is positioned to achieve
an optimally placed surgical cut for subsequent reaming and
placement of the prosthesis. A second template can then be applied
to the proximal femur after the surgical cut has been made. The
second template can be useful for guiding the direction of a reamer
prior to placement of the prosthesis. As can be seen in this, as
well as in other examples, templates can be made for joints prior
to any surgical intervention. However, it is also possible to make
templates that are designed to fit to a bone or portions of a joint
after the surgeon has already performed selected surgical
procedures, such as cutting, reaming, drilling, etc. The template
can account for the shape of the bone or the joint resulting from
these procedures.
[0369] In certain embodiments, the surgical assistance device
comprises an array of adjustable, closely spaced pins (e.g.,
plurality of individually moveable mechanical elements). One or
more electronic images or intraoperative measurements can be
obtained providing object coordinates that define the articular
and/or bone surface and shape. These objects' coordinates can be
entered or transferred into the device, for example manually or
electronically, and the information can be used to create a surface
and shape that will match all or portions of the articular and/or
bone surface and shape by moving one or more of the elements, e.g.
similar to an "image." The device can include slots and holes to
accommodate surgical instruments such as drills, curettes, k-wires,
screws and saws. The position of these slots and holes may be
adjusted by moving one or more of the mechanical elements.
Typically, a position will be chosen that will result in an
anatomically desirable cut plane, reaming direction, or drill hole
or instrument orientation for subsequent placement of an articular
repair system or for facilitating the placement of an articular
repair system.
[0370] Information about other joints or axis and alignment
information of a joint or extremity can be included when selecting
the position of the, without limitation, cut planes, apertures,
slots or holes on the template. The biomechanical and/or anatomic
axes may be derived using above-described imaging techniques
including, without limitation, a standard radiograph, including a
load bearing radiograph, for example an upright knee x-ray or a
whole leg length film (e.g., hip to foot). These radiographs may be
acquired in different projections, for example anteroposterior,
posteroanterior, lateral, oblique etc. The biomechanical and
anatomic axes may also be derived using other imaging modalities
such as CT scan or MRI scan, a CT scout scan or MRI localized scans
through portions or all of the extremity, either alone or in
combination, as described in above embodiments. For example, when
total or partial knee arthroplasty is contemplated, a spiral CT
scan may be obtained through the knee joint. The spiral CT scan
through the knee joint serves as the basis for generating the
negative contour template(s)/mold(s) that will be affixed to
portions or all of the knee joint. Additional CT or MRI scans may
be obtained through the hip and ankle joint. These may be used to
define the centroids or centerpoints in each joint or other
anatomic landmarks, for example, and then to derive the
biomechanical and other axes.
[0371] In another embodiment, the biomechanical axis may be
established using non-image based approaches including traditional
surgical instruments and measurement tools such as intramedullary
rods, alignment guides and also surgical navigation. For example,
in a knee joint, optical or radiofrequency markers can be attached
to the extremity. The lower limb may then be rotated around the hip
joint and the position of the markers can be recorded for different
limb positions. The center of the rotation will determine the
center of the femoral head. Similar reference points may be
determined in the ankle joint etc. The position of the templates
or, more typically, the position of surgical instruments relative
to the templates may then be optimized for a given biomechanical
load pattern, for example in varus or valgus alignment. Thus, by
performing these measurements pre- or intraoperatively, the
position of the surgical instruments may be optimized relative to
the molds and the cuts can be placed to correct underlying axis
errors such as varus or valgus malalignment or ante- or
retroversion.
[0372] In various embodiments, upon imaging, a physical template of
a joint, such as a knee joint, or hip joint, or ankle joint or
shoulder joint can be generated. The template can be used to
perform image guided surgical procedures such as partial or
complete joint replacement, articular resurfacing, or ligament
repair. The template may include reference points or opening or
apertures for surgical instruments such as drills, saws, burrs and
the like.
[0373] In order to derive an optimal orientation of drill holes,
cut planes, saw planes and the like, openings or receptacles in
said template or attachments can be adjusted to account for at
least one axis. The axis can be anatomic or biomechanical, for
example, for a knee joint, a hip joint, an ankle joint, a shoulder
joint or an elbow joint.
[0374] In one embodiment, only a single axis is used for placing
and optimizing such drill holes, saw planes, cut planes, and or
other surgical interventions. This axis may be, for example, an
anatomical or biomechanical axis. In one embodiment, a combination
of axis and/or planes can be used for optimizing the placement of
the drill holes, saw planes, cut planes or other surgical
interventions. For example, two axes (e.g., one anatomical and one
biomechanical) can be factored into the position, shape or
orientation of the 3D guided template and related attachments or
linkages. For example, two axes, (e.g., one anatomical and
biomechanical) and one plane (e.g., the top plane defined by the
tibial plateau), can be used. Alternatively, two or more planes can
be used (e.g., a coronal and a sagittal plane), as defined by the
image or by the patients anatomy.
[0375] Angle and distance measurements and surface topography
measurements may be performed in these one or more, two or more, or
three or more multiple planes, as contemplated and/or necessary.
These angle measurements can, for example, yield information on
varus or valgus deformity, flexion or extension deficit, hyper or
hypo-flexion or hyper- or hypo-extension, abduction, adduction,
internal or external rotation deficit, or hyper- or hypo-abduction,
hyper- or hypo-adduction, hyper- or hypo-internal or external
rotation.
[0376] Single or multi-axis line or plane measurements can then be
utilized to determine various angles of correction, e.g., by
adjusting surgical cut or saw planes or other surgical
interventions. Typically, two axis corrections will be desirable
over a single axis correction, a two plane correction will be
desirable over a single plane correction, and so forth.
[0377] In accordance with another embodiment, more than one
drilling, cut, boring and/or reaming or other surgical intervention
is performed for a particular treatment such as the placement of a
joint resurfacing or replacing implant, or components thereof.
These two or more surgical interventions (e.g., drilling, cutting,
reaming, sawing) are made in relationship to a biomechanical axis,
and/or an anatomical axis and/or an implant axis. The 3D guidance
template or attachments or linkages thereto include two or more
openings, guides, apertures or reference planes to make at least
two or more drillings, reamings, borings, sawings or cuts in
relationship to a biomechanical axis, an anatomical axis, an
implant axis or other axis derived therefrom or related
thereto.
[0378] While in simple embodiments it is possible that only a
single cut or drilling will be made in relationship to a
biomechanical axis, an anatomical axis, an implant axis and/or an
axis related thereto, in most meaningful implementations, two or
more drillings, borings, reamings, cutting and/or sawings will be
performed or combinations thereof in relationship to a
biomechanical, anatomical and/or implant axis.
[0379] For example, an initial cut may be placed in relationship to
a biomechanical axis of particular joint. A subsequent drilling,
cut or other intervention can be performed in relation to an
anatomical axis. Both can be designed to achieve a correction in a
biomechanical axis and/or anatomical axis. In another example, an
initial cut can be performed in relationship to a biomechanical
axis, while a subsequent cut is performed in relationship to an
implant axis or an implant plane. Any combination in surgical
interventions and in relating them to any combination of
biomechanical, anatomical, implant axis or planes related thereto
is possible. In various embodiments, it is desirable that a single
cut or drilling be made in relationship to a biomechanical or
anatomical axis. Subsequent cuts or drillings or other surgical
interventions can then be made in reference to said first
intervention. These subsequent interventions can be performed
directly off the same 3D guidance template or they can be performed
by attaching surgical instruments or linkages or reference frames
or secondary or other templates to the first template or the cut
plane or hole and the like created with the first template.
[0380] FIG. 12 shows an example of a surgical tool 410 having one
surface 400 matching the geometry of an articular surface of the
joint. Also shown is an aperture 415 in the tool 410 capable of
controlling drill depth and width of the hole and allowing
implantation or insertion of implant 420 having a press-fit
design.
[0381] In another embodiment, a frame can be applied to the bone or
the cartilage in areas other than the diseased bone or cartilage.
The frame can include holders and guides for surgical instruments.
The frame can be attached to one or more previously defined
anatomic reference points. Alternatively, the position of the frame
can be cross-registered relative to one, or more, anatomic
landmarks, using an imaging test or intraoperative measurement, for
example one or more fluoroscopic images acquired intraoperatively.
One or more electronic images or intraoperative measurements
including using mechanical devices can be obtained providing object
coordinates that define the articular and/or bone surface and
shape. These objects' coordinates can be entered or transferred
into the device, for example manually or electronically, and the
information can be used to move one or more of the holders or
guides for surgical instruments. Typically, a position will be
chosen that will result in a surgically or anatomically desirable
cut plane or drill hole orientation for subsequent placement of an
articular repair system. Information about other joints or axis and
alignment information of a joint or extremity can be included when
selecting the position of these slots or holes.
[0382] In various embodiments, the template may include a reference
element, such as a pin, that upon positioning of the template on
the articular surface, establishes a reference plane relative to a
biomechanical axis or an anatomical axis or plane of a limb. For
example, in a knee surgery the reference element may establish a
reference plane from the center of the hip to the center of the
ankle. In other embodiments, the reference element may establish an
axis that subsequently be used a surgical tool to correct an axis
deformity.
[0383] In these embodiments, the template can be created directly
from the joint during surgery or, alternatively, created from an
image of the joint, for example, using one or more computer
programs to determine object coordinates defining the surface
contour of the joint and transferring (e.g., dialing-in) these
co-ordinates to the tool. Subsequently, the tool can be aligned
accurately over the joint and, accordingly, the surgical instrument
guide or the implant will be more accurately placed in or over the
articular surface.
[0384] In both single-use and re-useable embodiments, the tool can
be designed so that the instrument controls the depth and/or
direction of the drill, i.e., the drill cannot go any deeper into
the tissue than the instrument allows, and the size of the hole or
aperture in the instrument can be designed to essentially match the
size of the implant. The tool can be used for general prosthesis
implantation, including, but not limited to, the articular repair
implants described herein and for reaming the marrow in the case of
a total arthroplasty.
[0385] Identification and preparation of the implant site and
insertion of the implant can be supported by a surgical navigation
system. In such a system, the position or orientation of a surgical
instrument with respect to the patient's anatomy can be tracked in
real-time in one or more 2D or 3D images. These 2D or 3D images can
be calculated from images that were acquired preoperatively, such
as MR or CT images. Non-image based surgical navigation systems
that find axes or anatomical structures, for example with use of
joint motion, can also be used. The position and orientation of the
surgical instrument as well as the mold including alignment guides,
surgical instrument guides, reaming guides, drill guides, saw
guides, etc. can be determined from markers attached to these
devices. These markers can be located by a detector using, for
example, optical, acoustical or electromagnetic signals.
[0386] Identification and preparation of the implant site and
insertion of the implant can also be supported with use of a C-arm
system. The C-arm system can afford imaging of the joint in one or
multiple planes. The multiplanar imaging capability can aid in
defining the shape of an articular surface. This information can be
used to selected an implant with a good fit to the articular
surface. Currently available C-arm systems also afford
cross-sectional imaging capability, for example for identification
and preparation of the implant site and insertion of the implant.
C-arm imaging can be combined with administration of radiographic
contrast.
[0387] In various embodiments, the surgical devices described
herein can include one or more materials that harden to form a mold
of the articular surface. In various embodiments, the materials
used are biocompatible, such as, without limitation, acylonitrile
butadiene styrene, polyphenylsulfone and polycarbonate. As used
herein "biocompatible" shall mean any material that is not toxic to
the body (e.g., produces a negative reaction under ISO 10993
standards, incorporated herein by reference). In various
embodiments, these biocompatible materials may be compatible with
rapid prototyping techniques.
[0388] In further embodiments, the mold material is capable of heat
sterilization without deformation. An exemplary mold material is
polyphenylsulfone, which does not deform up to a temperature of
207.degree. C. Alternatively, the mold may be capable of
sterilization using gases, e.g. ethyleneoxide. The mold may be
capable of sterilization using radiation, e.g. .gamma.-radiation.
The mold may be capable of sterilization using hydrogen peroxide or
other chemical means. The mold may be capable of sterilization
using any one or more methods of sterilization known in the art or
developed in the future.
[0389] A wide-variety of materials capable of hardening in situ
include polymers that can be triggered to undergo a phase change,
for example polymers that are liquid or semi-liquid and harden to
solids or gels upon exposure to air, application of ultraviolet
light, visible light, exposure to blood, water or other ionic
changes. (See, also, U.S. Pat. No. 6,443,988 to Felt et al. issued
Sep. 3, 2002 and documents cited therein). Non-limiting examples of
suitable curable and hardening materials include polyurethane
materials (e.g., U.S. Pat. No. 6,443,988 to Felt et al., U.S. Pat.
No. 5,288,797 to Khalil issued Feb. 22, 1994, U.S. Pat. No.
4,098,626 to Graham et al. issued Jul. 4, 1978 and U.S. Pat. No.
4,594,380 to Chapin et al. issued Jun. 10, 1986; and Lu et al.
(2000) BioMaterials 21(15):1595-1605 describing porous
poly(L-lactide acid foams); hydrophilic polymers as disclosed, for
example, in U.S. Pat. No. 5,162,430; hydrogel materials such as
those described in Wake et al. (1995) Cell Transplantation
4(3):275-279, Wiese et al. (2001) J. Biomedical Materials Research
54(2):179-188 and Marler et al. (2000) Plastic Reconstruct. Surgery
105(6):2049-2058; hyaluronic acid materials (e.g., Duranti et al.
(1998) Dermatologic Surgery 24(12):1317-1325); expanding beads such
as chitin beads (e.g., Yusof et al. (2001) J. Biomedical Materials
Research 54(1):59-68); crystal free metals such as
Liquidmetals,.RTM., and/or materials used in dental applications
(See, e.g., Brauer and Antonucci, "Dental Applications" pp. 257-258
in "Concise Encyclopedia of Polymer Science and Engineering" and
U.S. Pat. No. 4,368,040 to Weissman issued Jan. 11, 1983). Any
biocompatible material that is sufficiently flowable to permit it
to be delivered to the joint and there undergo complete cure in
situ under physiologically acceptable conditions can be used. The
material can also be biodegradable.
[0390] The curable materials can be used in conjunction with a
surgical tool as described herein. For example, the surgical tool
can be a template that includes one or more apertures therein
adapted to receive injections and the curable materials can be
injected through the apertures. Prior to solidifying in situ the
materials will conform to the articular surface (subchondral bone
and/or articular cartilage) facing the surgical tool and,
accordingly, will form a mirror and/or negative image impression of
the surface upon hardening, thereby recreating a normal or near
normal articular surface.
[0391] In addition, curable materials or surgical tools can also be
used in conjunction with any of the imaging tests and analysis
described herein, for example by molding these materials or
surgical tools based on an image of a joint. For example, rapid
prototyping may be used to perform automated construction of the
template. The rapid prototyping may include the use of, without
limitation, 3D printers, stereolithography machines or selective
laser sintering systems. Rapid prototyping is a typically based on
computer-aided manufacturing (CAM). Although rapid prototyping
traditionally has been used to produce prototypes, they are now
increasingly being employed to produce tools or even to manufacture
production quality parts. In an exemplary rapid prototyping method,
a machine reads in data from a CAD drawing, and lays down
successive millimeter-thick layers of plastic or other engineering
material, and in this way the template can be built from a long
series of cross sections. These layers are glued together or fused
(often using a laser) to create the cross section described in the
CAD drawing.
[0392] FIG. 13 is a flow chart illustrating the steps involved in
designing a mold for use in preparing a joint surface. Optionally,
the first step can be to measure the size of the area of the
diseased cartilage or cartilage loss 2100, Once the size of the
cartilage loss has been measured, the user can measure the
thickness of the adjacent cartilage 2120, prior to measuring the
curvature of the articular surface and/or the subchondral bone
2130. Alternatively, the user can skip the step of measuring the
thickness of the adjacent cartilage 2102. Once an understanding and
determination of the shape of the subchondral bone is determined,
either a mold can be selected from a library of molds 3132 or a
patient specific mold can be generated 2134. In either event, the
implantation site is then prepared 2140 and implantation is
performed 2142. Any of these steps can be repeated by the optional
repeat steps 2101, 2121, 2131, 2133, 2135, 2141.
[0393] A variety of techniques can be used to derive the shape of
the template, as described above. For example, a few selected CT
slices through the hip joint, along with a full spiral CT through
the knee joint and a few selected slices through the ankle joint
can be used to help define the axes if surgery is contemplated of
the knee joint. Once the axes are defined, the shape of the
subchondral bone can be derived, followed by applying standardized
cartilage loss.
[0394] Methodologies for stabilizing the 3D guidance templates will
now be described. The 3D guide template may be stabilized using
multiple surgical tools such as, without limitation: K-wires; a
drill bit anchored into the bone and left within the template to
stabilize it against the bone; one or more convexities or cavities
on the surface facing the cartilage; bone stabilization against
intra/extra articular surfaces, optionally with extenders, for
example, from an articular surface onto an extra-articular surface;
and/or stabilization against newly placed cuts or other surgical
interventions.
[0395] Specific anatomic landmarks may be selected in the design
and make of the 3D guide template in order to further optimize the
anatomic stabilization. For example, a 3D guidance template may be
designed to with an anatomical relief or other such structure (or
absence of structure) to cover portions or all off an osteophyte or
bone spur in order to enhance anchoring of the 3D guide template
against the underlying articular anatomy. The 3D guidance template
may be designed to the shape of a trochlear or intercondylar notch
and can encompass multiple anatomic areas such as a trochlea, a
medial and a lateral femoral condyle at the same time. In the
tibia, a 3D guide template may be designed to encompass a medial
and lateral tibial plateau at the same time and it can optionally
include the tibial spine for optimized stabilization and
cross-referencing. In a hip, the fovea capitis may be utilized in
order to stabilize a 3D guide template. Optionally, the surgeon may
elect to resect the ligamentum capitis femoris in order to improve
the stabilization. Also in the hip, an acetabular mold can be
designed to extend into the region of the tri-radiate cartilage,
the medial, lateral, superior, inferior, anterior and posterior
acetabular wall or ring. By having these extensions and additional
features for stabilization, a more reproducible position of the 3D
template can be achieved with resulted improvement in accuracy of
the surgical procedure. Typically, a template with more than one
convexity or concavity or multiple convexities or concavities
(including relevant anatomical relief surfaces) will provide better
cross-referencing in the anatomic surface and higher accuracy and
higher stabilization than compared to a mold that has only few
surface features such as a singular convexity. Thus, in order to
improve the implementation and intraoperative accuracy, careful
surgical planning and preoperative planning is desired, that
encompasses more than one convexity, more than two convexities
and/or more than three convexities, or that encompasses more than
one concavity, more than two concavities or more than three
concavities on an articular surface or adjoined surface, including
bone and cartilage outside the weight-bearing surface.
[0396] In another embodiment, more than one convexity and
concavity, more than two convexities and concavities and/or more
then three convexities and concavities are included in the surface
of the mold in order to optimize the interoperative
cross-referencing and in order to stabilize the mold prior to any
surgical intervention.
[0397] Turning now to particular 3D surgical template
configurations and to templates for specific joint applications
which are intended to teach the concept of the design as it would
then apply to other joints in the body.
[0398] i. 3D Guidance Template Configurations/Positioning
[0399] In various embodiments, the 3D guidance template may include
a surface that duplicates the inner surface of an implant or an
implant component, and/or that conforms to an articular surface, at
least partially. More than one of the surfaces of the template may
match or conform to one or more of the surfaces or portions of one
or more of these surfaces of an implant, implant component, and/or
articular surface.
[0400] FIG. 20 shows an example of a 3D guidance template 3000 in a
hip joint, in accordance with one embodiment, wherein the template
has extenders 3010 extending beyond the margin of the joint to
provide for additional stability and to fix the template in place.
The surface of the template facing the joint 3020 is a mirror
and/or negative image of a portion of the joint that is not
affected by the arthritic process 3030. By designing the template
to be a mirror and/or negative image of at least a portion of the
joint that is not affected by the arthritic process, greater
reproducibility in placing the template can be achieved. In this
design, the template spares the arthritic portions 3040 of the
joint and does not include them in its joint facing surface. The
template can optionally have metal sleeves 3050 to accommodate a
reamer or other surgical instruments, to protect a plastic. The
metal sleeves or, optionally, the template can also include stops
3060 to limit the advancement of a surgical instrument once a
predefined depth has been reached.
[0401] FIG. 21 shows another embodiment of a 3D guidance template
3100 for an acetabulum. The articular surface is roughened 3110 in
some sections by the arthritic process. At least a portion of the
template 3120 is made to be a mirror and/or negative image of the
articular surface altered by the arthritic process 3110. By
matching the template to the joint in areas where it is altered by
the arthritic process improved intraoperative localization and
improved fixation can be achieved. In other section, the template
can be matched to portions of the joint that are not altered by the
arthritic process 3130.
[0402] FIG. 22 shows another embodiment of a 3D guidance template
3200 designed to guide a posterior cut 3210 using a posterior
reference plane 3220. The joint facing surface of the template 3230
is, at least in part, a mirror and/or negative image of portions of
the joint that are not altered by the arthritic process. The
arthritic process includes an osteophyte 3240. The template
includes a recess or anatomical relief 3250 that helps avoid the
osteophyte 3240. The template is at least in part substantially
matched to portions of the joint that are not involved by the
arthritic process.
[0403] FIG. 23 shows another embodiment of a 3D guidance template
3300 designed to guide an anterior cut 3310 using an anterior
reference plane 3320. The joint facing surface of the template 3230
is, at least in part, a mirror and/or negative image of portions of
the joint that are altered by the arthritic process. The arthritic
process includes an osteophyte 3240. The joint facing surface of
the template 3230 is a mirror and/or negative image of the
arthritic process, at least in part, including an alternative
embodiment of an anatomical relief surface to accommodate the
osteophyte 3240. The template in this embodiment is at least in
part matched to portions of the joint that are involved by the
arthritic process as well as the adjacent uninvolved joint surface
structure.
[0404] FIG. 24 shows another embodiment of a 3D guidance template
3400 for guiding a tibial cut (not shown), wherein the tibia 3410
includes an arthritic portion 3420, in this example a subchondral
cyst 3430. The template is designed to avoid contacting the
entirety of the arthritic process by including an anatomic relief
surface 3440 spanning across the defect or cyst. If desired, the
surface 3440 could include another embodiment of an anatomical
relief that desirably avoids substantially contact with and/or more
closely follows and/or fills the positive and/or negative surface
features of the tibia.
[0405] FIG. 25 shows another embodiment of a 3D guidance template
3500 for guiding a tibial cut (not shown), wherein the tibia 3510
includes an arthritic portion 3520, in this example a subchondral
cyst 3530. The template is designed to include the arthritic
process 3520 by extending one embodiment of an anatomic relief
surface 3540 into the defect or cyst 3530. The surface of the
template facing the joint 3550 is a mirror and/or negative image of
portions of normal joint 3560 and portions of the joint that are
altered by the arthritic process 3530. The interface between normal
and arthritic tissue is included in the shape of the template
3520.
[0406] FIGS. 26A-D show a knee joint with a femoral condyle 3600
including a normal 3610 and arthritic 3620 region, in accordance
with various embodiments. The interface 3630 between normal 3610
and arthritic 3620 tissue is shown. The template is designed to
guide a posterior cut 3640 using a guide plane 3650 or guide
aperture 3660.
[0407] In one embodiment shown in FIG. 26A the surface of the
template facing the joint 3670 is a mirror and/or negative image of
at least portions of the surface of the joint that is healthy or
substantially unaffected by the arthritic process. A recessed area
or anatomical relief 3670 can be present to avoid contact with the
diseased joint region. This design can be favorable when an imaging
test is used that does not provide sufficient detail about the
diseased region of the joint to accurately generate a template.
[0408] In a similar embodiment shown in FIG. 26B the surface of the
template facing the joint 3670 is a mirror and/or negative image of
at least portions of the surface of the joint that is healthy or
substantially unaffected by the arthritic process. The diseased
area 3620 is covered by the template, but the template includes an
anatomical relief portion that is not substantially in contact with
the diseased area.
[0409] In another embodiment shown in FIG. 26C the surface of the
template facing the joint 3670 is a mirror and/or negative image of
at least portions of the surface of the joint that are arthritic.
The diseased area 3620 is covered by the template, and the template
is in close contact with it. This design can be advantageous to
obtain greater accuracy in positioning the template if the
arthritic area is well defined on the imaging test, e.g. with high
resolution spiral CT or near isotropic MRI acquisitions or MRI with
image fusion. This design can also provide enhanced stability
during surgical interventions by more firmly fixing the template
against the irregular underlying surface.
[0410] In another embodiment shown in FIG. 26D the surface of the
template facing the joint 3670 is a mirror and/or negative image of
at least portions of the surface of the joint that are arthritic.
The diseased area 3620 is covered by the template, and the template
is in close contact with it. Moreover, healthy or substantially
normal regions 3610 are covered by the template and the template is
in close contact with them. The template is also closely mirroring
the shape of the interface between substantially normal or near
normal and diseased joint tissue 3630. This design can be
advantageous to obtain even greater accuracy in positioning the
template due to the change in surface profile or contour at the
interface and resultant improved placement of the template on the
joint surface. This design can also provide enhanced stability
during surgical interventions by more firmly fixing and anchoring
the template against the underlying surface and the interface
3630.
[0411] In various embodiments, the template may include guide
apertures or reference points for two or more planes, or at least
one of a cut plane and one of a drill hole or reaming opening for a
peg or implant stem.
[0412] The distance between two opposing, articulating implant
components may be optimized intraoperatively for different pose
angles of the joint or joint positions, such as different degrees
of section, extension, abduction, adduction, internal and external
rotation. For example, spacers, typically at least partially
conforming to the template, may be placed between the template of
the opposite surface, where the opposite surface can be the native,
uncut joint, the cut joint, the surgically prepared joint, the
trial implant, or the definitive implant component for that
articular surface. Alternatively, spacers may be placed between the
template and the articular surface for which it will enable
subsequent surgical interventions. For example, by placing spacers
between a tibial template and the tibia, the tibial cut height can
be optimized. The thicker the spacer, or the more spacers
interposed between the tibial template and the tibial plateau the
less deep the cut will be, i.e. the less bone will be removed from
the top of the tibia.
[0413] The spacers may be non-conforming to the template, e.g. they
may be of a flat nature. The spacers may be convex or concave or
include multiple convexities or concavities. The spacers may be
partially conforming to the template. For example, in one
embodiment, the surface of the spacer optionally facing the
articular surface can be molded and individualized to the articular
surface, thereby forming a template/mold, while the opposite
surface of the spacer can be flat or curved or have any other
non-patient specific design. The opposite surface may allow for
placement of blocks or other surgical instruments or for linkages
to other surgical instruments and measurement devices.
[0414] In another embodiment, the template may include multiple
slots spaced at equal distance or at variable distances wherein
these slots allow to perform cuts at multiple cut heights or cut
depths that can be decided on intraoperatively. In another
embodiment, the template may include a ratchet-like mechanism
wherein the ratchet can be placed between the articular surface and
the template or between the template and the opposite surface
wherein the opposite surface may include the native, uncut opposite
surface, the cut opposite surface, an opposite surface template, a
trial implant or the implant component designed for the opposite
surface. By using a ratchet-like device, soft tissue tension can be
optimized, for example, for different pose angles of the joint or
joint positions such as flexion, extension, abduction, adduction,
internal rotation and external rotation at one or more degrees for
each direction.
[0415] Optimizing soft tissue tension will improve joint function
that advantageously enhances postoperative performance. Soft tissue
tension may, for example, be optimized with regard to ligament
tension or muscle tension but also capsular tension. In the knee
joint, soft tissue tension optimization includes typically ligament
balancing, e.g. the cruciate ligaments and/or the collateral
ligaments, for different degrees of knee flexion and knee
extension.
[0416] In one disclosed embodiment, a 3D guidance template may
attach to two or more points on the joint. In other embodiments, a
template may attach to three or more points on the joint, four or
more points on the joint, five or more points on the joint, six or
more points on the joint, seven or more points on the joint, ten or
more points on the joint, or more portions for the entire surface
to be replaced.
[0417] In another embodiment, the template may include one or more
linkages for surgical instruments. The linkages may also be
utilized for attaching other measurement devices such as alignment
guides, intramedullary guides, laser pointing devices, laser
measurement devices, optical measurement devices, radio frequency
measurement devices, surgical navigation and the like. Someone
skilled in the art will recognize many surgical instruments and
measurement in alignment devices may be attached to the template.
Alternatively, these surgical instruments or alignment devices may
be included within the template.
[0418] In another embodiment, a link or a linkage may be attached
or may be incorporated or may be part of a template that rests on a
first articular surface. Said link or linkage may further extend to
a second articular surface which is typically an opposing articular
surface. Said link or linkage can thus help cross-reference the
first articular surface with the second articular surface,
ultimately assisting the performance of surgical interventions on
the second articular surface using the cross reference to the first
articular surface. The second articular surface may optionally be
cut with a second template. Alternatively, the second articular
surface may be cut using a standard surgical instrument,
non-individualized, that is cross referenced via the link to the
surgical mold placed on the first articular surface. The link or
linkage may include adjustment means, such as ratchets, telescoping
devices and the like to optimize the spatial relationship between
the first articular surface and the second, opposing articular
surface. This optimization may be performed for different degrees
of joint flexion, extension, abduction, adduction and rotation.
[0419] In another embodiment, the linkage may be made to the cut
articular surface or, more general, an articular surface that has
been altered using a template and related surgical intervention.
Thus, cross reference can be made from the first articular surface
from a mold attached to said first articular surface, the mold
attached to a surgically altered, for example, cut articular
surface, the surgical instrument attached to said articular surface
altered using the mold, e.g. cut or drilled, and the like. Someone
skilled in the art will easily recognize multiple different
variations of this approach. Irrespective of the various
variations, in a first step the articular surface is surgically
altered, for example, via cutting, drilling or reaming using a mold
while in the second step cross reference is established with a
second articular surface.
[0420] By establishing cross reference between said first and said
second articular surface either via the template and/or prior to or
after a surgical intervention, the surgical intervention performed
on the second articular surface can be performed using greater
accuracy and improved usability in relation to said articulating,
opposing first articular surface.
[0421] FIGS. 27A-D show multiple templates with linkages on the
same articular surface (A-C) and to an opposing articular surface
(D), in accordance with various embodiments. The biomechanical axis
is denoted as 3700. A horizontal femoral cut 3701, an anterior
femoral cut 3702, a posterior femoral cut 3703, an anterior chamfer
cut 3704 and a posterior chamfer cut 3705 are planned in this
example. A first template 3705 is applied in order to determine the
horizontal cut plane and to perform the cut. The cut is
perpendicular to the biomechanical axis 3700. The first template
3705 has linkages or extenders 3710 for connecting a second
template 3715 for the anterior cut 3702 and for connecting a third
template 3720 for the posterior cut 3703. The linkages 3710
connecting the first template 3705 with the second 3715 and third
template 3720 help in achieving a reproducible position of the
templates relative to each other. At least one of the templates,
such as the first template 3705, will have a surface 3706 that is a
mirror and/or negative image of the articular surface 3708. In this
example, all three templates have surface facing the joint that is
a mirror and/or negative image of the joint, although one template
having a surface conforming to the joint suffices in many
applications and embodiments.
[0422] A fourth template 3725 may optionally be used in order to
perform an anterior chamfer cut 3704. The fourth template may have
a guide aperture or reference plane 3730 that can determine the
anterior chamfer cut 3704. The fourth template can, but need not
always have, at least one surface 3735 matching one or more cut
articular surfaces 3740. The fourth template may have one or more
outriggers or extenders 3745 stabilizing the template against the
cut or uncut articular surface.
[0423] A fifth template 3750 may optionally be used to perform a
anterior chamfer cut 3705. The fifth template may have a guide
aperture or reference plane 3755 that can determine the posterior
chamfer cut 3705. The fifth template may have at least one surface
3735 matching one or more cut articular surfaces 3740. Oblique
planes 3760 may help to further stabilize the template during the
procedure. The fifth template may have one or more outriggers or
extenders 3745 stabilizing the template against the cut or uncut
articular surface.
[0424] In another embodiment, an opposite articular side 3765 may
be cut in reference to a first articular side 3766. Any order or
sequence of cutting is possible: femur first then tibia, tibia
first then femur, patella first, and so forth. A template 3770 may
be shaped to the uncut or, in this example, cut first articular
side. The template may have stabilizers against the first articular
surface, for example with extenders 3772 into a previously created
peg hole 3773 for an implant. The template may have a linkage or an
extender 3775 to a second articular surface 3765. Surgical
instruments may be attached to the linkage or extender 3775. In
this example, a tibial cut guide 3778 with multiple apertures or
reference planes 3779 for a horizontal tibial cut is attached. The
tibial cut guide may but may not have a surface matching the tibial
surface.
[0425] By referencing a first, e.g. femoral, to a second, e.g.
tibial cut greater accuracy can be achieved in the alignment of
these cuts, which will result in improved implant component
alignment and less wear. Ratchet like devices 3785 or hinge like
devices or spacers may be inserted into the space between the first
and the second articular surface and soft-tissue tension and
ligament balancing can be evaluated for different distances
achieved between the first 3766 and second 3765 articular surface,
with one or more of them being cut or uncut. In this manner,
soft-tissue tension and ligament balancing can be tested during
different pose angles, e.g. degrees of flexion or extension.
Optionally, tensiometers can be used. Once an ideal soft-tissue
tension and/or ligament balancing has been achieved, the tibial cut
may be performed through one of the guide apertures 3779 in
reference to the femoral cut.
[0426] FIG. 28 is an example demonstrating a deviation in the AP
plane of the femoral 3801 and tibial 3803 axes in a patient. Axis
deviations can be determined in any desired plane including the AP
plane, not only the ML plane. The axis deviation can be measured.
The desired correction can be determined and the position,
orientation and shape of a 3D guidance template can be adjusted in
order to achieve the necessary correction. The correction may, for
example, be designed to achieve a result wherein the femoral 3801
and tibial 3803 axes will coincide with the biomechanical axis
3805.
[0427] The various embodiments described herein optionally provide
for trial implants and trial devices that help test
intraoperatively the result of the surgical intervention achieved
using the 3D guidance mold. Trial implants or devices can be
particularly useful for subsequent adjustments and fine-tuning of
the surgical intervention, for example, optimizing soft tissue
tension in different articular pose angles.
[0428] In another embodiment, the templates may also allow for
intraoperative adjustments. For example, the template may include
an opening for a pin. The pin can be placed in the bone and the
template can be rotated around the pin thereby optimizing, for
example, medial and lateral ligament tension in a knee joint or
thereby optimizing the cut orientation and resultant rotation and
alignment of an implant relative to the anatomic or biomechanical
axis.
[0429] In another embodiment, standard tools including alignment
guides may be attached to the mold, via linkages for example, and
the attachment can allow for additional adjustments in mold and
subsequently implant alignment and rotation.
[0430] The above-described embodiments can be particularly useful
for optimization of soft tissue tension including ligament
balancing, for example, in a knee joint. Optimization of soft
tissue tension can advantageously improve post-operative function
and range of motion.
[0431] Linkages may also be utilized to stabilize and fix
additional molds or surgical instruments on the articular
surface.
[0432] Moreover, linkages can allow separation of one large mold
into multiple smaller molds. The use of multiple smaller, linked
molds advantageously enable smaller surgical axis with the
potential to enhance muscle sparing and to reduce the size of the
skin cut.
[0433] In another embodiment, all or portions of the template may
be made of metal, metal-alloys, teflon, ceramics. In various other
embodiments, metal, metal-alloys, teflon, ceramics and other hard
materials, typically materials that offer a hardness of, without
limitation, greater than shore 60D, is placed in areas where the
surgical instruments will be in contact with the template.
[0434] ii. 3D Guidance Molds for Ligament Repair and
Replacement
[0435] In various embodiments, 3D guidance molds may also be
utilized for planning the approach and preparing the surgical
intervention and conducting the surgical intervention for ligament
repair and replacement.
[0436] In one example, the anterior cruciate ligament is replaced
using a 3D guidance mold. The anterior cruciate ligament is a
collagenous structure located in the center of the knee joint, and
is covered by the synovial sheath. The ligament has an average
length of thirty (30) to thirty-eight (38) millimeters and an
average width of ten (10) to eleven (11) millimeters. The ligament
is proximally attached to the posterior aspect of the lateral
femoral condyle's medial surface. The ligament passes anteriorly,
medially and distally within the joint to its attachment at the
anteromedial region of the tibial plateau, between the tibial
eminences. The distal portion of the ligament fans out to create a
large tibial attachment known as the footprint of the ligament. The
ligament has two functional subdivisions which include the
anteromedial band and the posterolateral band. The posterolateral
band is taut when the knee is extended and the anteromedial band
becomes taut when the knee is flexed. Because of its internal
architecture and attachments sides on femur and tibia, the ACL
provides restraint to anterior translation and internal rotation of
the tibia in angulation and hyperextension of the knee. The
prevalence of ACL injuries are about 1 in 3,000 subjects in the
United States and approximately 250,000 new injuries each year.
[0437] Other tendon and ligament injuries, for example, including
the rotator cuff, the ankle tendons and ligaments, or the posterior
cruciate ligament can also be highly prevalent and frequent.
[0438] Selecting the ideal osseous tunnel sights is a crucial step
in ligament reconstruction, for example, the anterior and posterior
cruciate ligament.
[0439] In the following paragraphs, embodiments will be described
in detail as they can be applied to the anterior cruciate ligament.
However, the various embodiments mentioned below and modifications
thereof may often be applicable to other ligaments, including the
posterior cruciate ligament and also tendons such as tendons around
the ankle joint or rotator cuff and shoulder joint.
Anterior Cruciate Ligament
[0440] The normal anterior cruciate ligament is composed of a large
number of fibers. Each fiber can have a different length, a
different origin and a different insertion and is frequently under
different tension during the range of motion of the knee joint. One
of the limitations of today's ACL graft is that they have parallel
fibers. Thus, even with ideal selection of the placement of the
osseous tunnels, fibers of an ACL graft will undergo length and
tension changes with range of motion. Therefore, today's ACL
replacement cannot duplicate the original ligament. However,
placing the center of the osseous tunnels at the most isometric
points, maximizes the stability that can be obtained during motion
and minimizes later on graft wear and ultimately resultant
failure.
[0441] In illustrative embodiments, 3D guidance templates may be
selected and designed to enable highly accurate, reproducible and
minimally invasive graft tunnels in the femur and the tibia.
[0442] In one embodiment, imaging such as MRI is performed
pre-operatively. The images can be utilized to identify the origin
of the ligament and its insertion onto the opposing articular
surface, in the case of an anterior cruciate ligament, the tibia.
Once the estimated location of the origin and the footprint, i.e.
the insertion of the ligament has been identified, 3D guidance
templates may be made to be applied to these areas or their
vicinity.
[0443] The 3D guidance templates may be made and shaped to the
articular surface, for example, adjacent to the intended tunnel
location or they may be shaped to bone or cartilage outside the
weight bearing zone, for example, in the intercondylar notch. A 3D
guidance template for femoral or tibial tunnel placement for ACL
repair may include blocks, attachments or linkages for reference
points or guide aperture to guide and direct the direction and
orientation of a drill, and optionally, also the drill depth.
Optionally, the 3D guidance templates may be hollow. The 3D
guidance templates may be circular, semi-circular or ellipsoid. The
3D guidance templates may have a central opening to accommodate a
drill.
[0444] In one embodiment, the 3D guidance template is placed on,
over or near the intended femoral or tibial entry point and
subsequently the drill hole. Once proper anatomic positioning has
been achieved, the ligament tunnel can be created. The 3D guidance
template, its shape, position, and orientation, may be optimized to
reflect the desired tunnel location in the femur and the tibia,
wherein the tunnel location, position, orientation and angulation
is selected to achieve the best possible functional results.
Additional considerations in placing the femoral or tibial tunnel
includes a sufficient distance to the cortical bone in order to
avoid failure or fracture of the tunnel.
[0445] Thus, optionally, the distance of the tunnel to the adjacent
cortical bone and also other articular structures may optionally be
factored into the position, shape and orientation of the femoral or
tibial 3D guidance templates in order to achieve the optimal
compromise between optimal ligament function and possible
post-operative complications such as failure of the tunnel.
[0446] In another embodiment, the imaging test may be utilized to
determine the origin and insertion of the ligament. This
determination can be performed on the basis of bony landmarks
identified on the scan, e.g. a CT scan or MRI scan. Alternatively,
this determination can be performed by identifying ligament
remnants, for example, in the area of the ligament origin and
ligament attachment. By determining the origin and the insertion of
the ligament the intended graft length may be estimated and
measured. This measurement may be performed for different pose
angles of the joint such as different degrees of flexion,
extension, abduction, adduction, internal and external
rotation.
[0447] In another embodiment, the imaging test may be utilized to
identify the ideal graft harvest site wherein the graft harvest
site can optionally be chosen to include sufficiently long ligament
portion and underlying bone block proximally and distally in order
to fulfill the requirement for graft length as measured earlier in
the imaging test. An additional 3D guidance template for the same
3D guidance templates, possibly with linkages, may be utilized to
harvest the ligament and bone from the donor site in the case of an
autograft. Optionally, 3D guidance templates may also be utilized
or designed or shaped or selected to guide the extent of an
optional notchplasty. This can include, for example, the removal of
osteophytes.
[0448] In the case of an ACL replacement, the 3D guidance templates
may in this manner optimize selection of femoral and tibial tunnel
sites. Tunnel sites may even be optimized for different knee pose
angles, i.e. joint positions, and different range of motion.
Selecting the properly positioned femoral tunnel site ensures
maximum post operative knee stability.
[0449] The intra-articular site of the tibial tunnel has less
effect on changes in graft length but its position can be optimized
using proper placement, position, and shape of 3D guidance
templates to prevent intercondular notch impingement.
[0450] Moreover, the 3D guidance templates may include an optional
stop for the drill, for example, to avoid damage to adjacent
neurovascular bundles or adjacent articular structures, including
the articular cartilage or other ligaments.
[0451] Optionally, the 3D guidance templates may also include a
stop, for example, for a drill in order to include the drill
depth.
[0452] The direction and orientation of the tibial tunnel and also
the femoral tunnel may be determined with use of the 3D guidance
template, whereby it will also include selection of an optimal
tunnel orientation in order to match graft length as measured
pre-operatively with the tunnel length and the intra-articular
length of the graft ligament.
[0453] In one embodiment, a tibial 3D guidance template is, for
example, selected so that its opening is located immediately
posterior to the anatomic center of the ACL tibial footprint.
Anatomic landmarks may be factored into the design, shape,
orientation, and position of the tibial guidance template,
optionally. These include, without limitation, the anterior horn of
the lateral meniscus, the medial tibial spine, the posterior
cruciate ligament, and the anterior cruciate ligament stump.
[0454] The tunnel site may be located utilizing the 3D guidance
template in the anterior posterior plane by extending a line in
continuation with the inner edge of the anterior horn of the
lateral meniscus. This plane will typically be located six (6) to
seven (7) millimeters anterior to the interior border of the PCL.
The position, shape and orientation of the 3D guidance template
will be typically so that the resultant tibial tunnel and the
resultant location and orientation of the ACL graft, once in place,
may touch the lateral aspect of the PCL, but will not significantly
deflect it. Similarly, the location of the tibial guidance template
and the resultant ligament tunnel and the resultant location of the
ACL graft, once in place, may be chosen so that the graft will
neither abrade nor impinge against the medial aspect of the lateral
femoral condyle or the roof of the intercondylar notch when the
knee is, for example, in full extension. In this manner, highly
accurate graft placement is possible thereby avoiding the problems
of impingement and subsequent graft failure.
[0455] In another embodiment, the pre-operative scan can be
evaluated to determine the maximal possible graft length, for
example, patella tendon graft. If there is concern that the maximal
graft length is not sufficient for the intended ACL replacement,
the tunnel location and orientation, specifically the exits from
the femur or the tibia can be altered and optimized in order to
match the graft length with the tunnel length and intra-articular
length.
[0456] In one embodiment, the graft length is measured or simulated
pre-operatively, for example, by measuring the optimal graft length
for different flexion and extension angles. Using this approach, an
optimal position, shape, orientation and design of the 3D guidance
template may be derived at an optimal compromise between isometric
graft placement, avoidance of impingement onto the PCL, and/or
avoidance of impingement onto the femoral condyle, maximizing
achievable graft lengths.
[0457] Intraoperatively, the femoral and/or tibial 3D guidance
templates may include adjustment means. These adjustment means can,
for example, allow movement of the template by one or two or more
millimeters intervals in posterior or medial or lateral
orientation, with resultant movement of the femoral or tibial
tunnel. Additionally, intraoperative adjustment may also allow for
rotation of the template, with resultant rotation of the resultant
femoral or tibial tunnels.
[0458] A single template may be utilized to derive the femoral
tunnel. A single template may also be utilized to derive the tibial
tunnel. More than one template may be used on either side.
[0459] Optionally, the templates may include linkages, for example,
for attaching additional measurement devices, guide wires, or other
surgical instruments. Alignment guides including mechanical,
electrical or optical devices may be attached or incorporated in
this manner.
[0460] In another embodiment, the opposite articular surface may be
cross referenced against a first articular surface. For example, in
the case of an ACL repair, the femoral tunnel may be prepared first
using a 3D guidance template, whereby the 3D guidance template
helps determine the optimal femoral tunnel position, location,
orientation, diameter, and shape. The femoral guidance template may
include a link inferiorly to the tibia or an attachable linkage,
wherein said link or said attachable linkage may be utilized to
determine the ideal articular entry point for the tibial tunnel. In
this manner, the tibial tunnel can be created in an anatomic
environment and in mechanical cross reference with the femoral
tunnel. The reverse approach is possible, whereby the tibial tunnel
is created first using the 3D guidance template with a link or
linkage to a subsequently created femoral tunnel. Creating the
femoral or tibial tunnel in reference to each other advantageously
helps reduce the difficulty in performing the ligament repair and
also can improve the accuracy of the surgery in select clinical
situations.
[0461] In another embodiment, the template for ligament repair may
include exterior anatomical reliefs such as optional flanges or
extenders. These flanges or extenders may have the function of
tissue retractors. By having tissue retractor function, the
intra-articular template for ligament repair can provide the
surgeon with a clearer entry to the intended site of surgical
intervention and improve visualization. Moreover, flanges or
extenders originating from or attached to the 3D guidance templates
may also serve as tissue protectors, for example, protecting the
posterior cruciate ligament, the articular cartilage, or other
articular structures as well as extra-articular structures.
[0462] In another embodiment, an additional 3D guidance template or
linkages to a first or second articular 3D guidance templates can
be utilized to place ligament attachment means, for example,
interference screws.
[0463] If an allograft is chosen and the allograft length and
optionally, dimensions are known pre-operatively, additional
adjustments may be made to the position, shape and orientation of
the 3D guidance templates and additional tunnels in order to match
graft dimensions with tunnel dimensions and graft length with
intra-femoral tunnel length, intra-articular length and
intra-tibial tunnel length. Optionally, this adjustment and
optimization can be performed for different pose angles of the
joint, e.g. different degrees of flexion or extension.
[0464] FIGS. 30A-C illustrate an exemplary use of 3D guidance
templates for performing ligament repair; in this case repair of
the anterior cruciate ligament (ACL). A 3D guidance template 4000
is placed in the intercondylar notch region 4005. At least one
surface 4010 of the template 4000 is a mirror and/or negative image
of at least portions of the notch 4005 or the femur. The template
4000 may be optionally placed against the trochlea and/or the
femoral condyle (not shown). The mold 4000 includes an opening 4020
and, optionally, metal sleeves 4030, wherein the position, location
and orientation of the opening 4020 and/or the metal sleeves 4030
determine the position and orientation of the femoral graft tunnel
4040.
[0465] A tibial template 4050 may be used to determine the location
and orientation of the tibial tunnel 4060. Specifically, an opening
4065 within the tibial mold 4050 will determine the position, angle
and orientation of the tibial tunnel 4060. The opening may include
optional metal sleeves 4068. At least one surface 4070 of the
tibial template 4050 will substantially match the surface of the
tibia 4075. The template may be matched to a tibial spine 4080
wherein the tibial spine can help identify the correct position of
the mold and help fix the template in place during the surgical
intervention. Of note, the sleeves 4030 and 4068 may be made of
other hard materials, e.g. ceramics. The femoral and/or tibial
template may be optionally attached to the femoral or tibial
articular surface during the procedure, for example using K-wires
or screws.
[0466] FIG. 30C shows a top view of the tibial plateau 4085. The
PCL 4086 is seen as are the menisci 4087. The original site of ACL
attachment 4090 is shown. The intended tunnel site 4092 may be
slightly posterior to the original ACL attachment 4090. The
template 4095 may placed over the intended graft tunnel 4092. The
template will typically have a perimeter slightly greater than the
intended tunnel site. The templates may allow for attachments,
linkages or handles.
PCL Repair
[0467] All of the embodiments described above may also be applied
to PCL repair as well as the repair of other ligaments or
tendons.
[0468] For PCL repair, 3D guidance templates may be designed for
single, as well as double bundle surgical technique. With single
bundle surgical technique, a 3D guidance template may be created
with a position, orientation and shape of the template or
associated reference points or guide apertures for surgical
instruments that will help create a femoral tunnel in the location
of the anatomic origin of the ligament. Alternatively, the template
and any related reference points or guide apertures or linkages may
be designed and placed so that an anterior placement of the femoral
tunnel in the anatomic footprint is performed. A more anterior
placement of the femoral tunnel can restore normal knee laxity
better than isometric graft placement. The 3D guidance templates
may be designed so that optimal tension is achieved not only in
knee extension but also in knee flexion, particularly ninety
degrees of knee flexion. Thus, the origin and the insertion of the
PCL may be identified pre-operatively on the scan, either by
identifying residual fiber bundles or by identifying the underlying
anatomic landmarks. The distance between the origin and the
insertion may thus be determined in the extension and can be
simulated for different flexion degrees or other articular
positions. Femoral and tibial tunnel placement and orientation may
then be optimized in order to achieve an isometric or near
isometric ligament placement. Intraoperative adjustments are
feasible as described in the foregoing embodiments.
[0469] A 3D guidance template may also be designed both on the
femoral as well as on the tibial side using double bundle
reconstruction techniques. With double bundle reconstruction
techniques, the femoral or tibial template can include or
incorporate links or can have attachable linkages so that a femoral
tunnel can be created and cross referenced with a tibial tunnel, or
a tibial tunnel can be created and cross referenced to a femoral
tunnel.
[0470] As described for the ACL, the templates may include stops
for drills and reaming devices or other surgical instruments, for
example, to protect popliteal neurovascular structures. The
templates may include extenders or flanges to serve as tissue
retractors as well as tissue protectors.
[0471] In principle, templates may be designed to be compatible
with any desired surgical technique. In the case of PCL repair,
templates may be designed to be compatible with single bundle, or a
double bundle reconstruction, tibial inlay techniques as well as
other approaches.
[0472] As previously stated, 3D guidance templates are applicable
to any type of ligament or tendon repair and can provide
reproducible, simple intraoperative location of intended attachment
sites or tunnels. The shape, orientation and position of the 3D
guidance templates may be individualized and optimized for
articular anatomy, as well as the biomechanical situation, and may
incorporate not only the articular shape but also anatomic lines,
anatomic planes, biomechanical lines or biomechanical planes, as
well as portions or all of the shape of devices or anchors or
instruments to be implanted or to be used during implantation or to
be used during surgical repair of a ligament or tendon tear.
[0473] iii. Impingement Syndromes, Removal of Exophytic Bone Growth
Including Osteophytes
[0474] 3D guidance templates may also be utilized to treat
impingement syndromes, for example, by template guided removal of
osteophytes or exophytic bone growth. In one embodiment, an imaging
test such as a CT scan or an MRI scan is obtained through the area
of concern. If a joint is imaged, the images can demonstrate an
osteophyte or, more generally, exophytic bone growth in intra and
extra-articular locations. The scan data may then be utilized to
design a template having one or more anatomical relief surfaces
that match, substantially match, overlay and/or are recessed from
the surface adjacent to the exophytic bone growth or osteophyte,
the surface overlying the exophytic bone growth or osteophyte or
both or portions of one or both. The template may have openings or
apertures or linkages that allow placement of surgical tools for
removal of the exophytic bone growth or the osteophyte, such as
reamers, drills, rotating blades and the like. Someone skilled in
the art will recognize many different surgical instruments that can
be utilized in this manner.
[0475] Two representative examples where a 3D guidance template can
be applied to treat local impingement syndromes are the pincer and
Cam impingement syndromes in the hip joint. Pincer and Cam
impingement represent femoro-acetabular impingement syndromes
caused by an abutment between the proximal femur and the acetabular
rim during the end range of motion. Untreated femoral-acetabular
impingement can cause osteoarthritis of the hip.
[0476] In Cam impingement, a non-spherical portion of the femoral
head, typically located near the head-neck junction, is jammed into
the acetabulum during hip joint motion. The Cam impingement can
lead to considerable shear forces and subsequently chondral
erosion.
[0477] In one embodiment, an imaging test, such as a CT scan or MRI
scan may be performed pre-operatively. The imaging test may be used
to identify the non-spherical portion of the femoral head at the
head-neck junction that is responsible for the impingement. A 3D
guidance template may be designed that can be applied
intraoperatively to this region. The template is designed to
fulfill three principle functions:
[0478] 1. Intraoperative highly accurate identification of the
non-spherical portion of the femoral head by placement of the
individualized portion of the 3D template onto the area or
immediately adjacent to the area.
[0479] 2. Guidance of surgical instrumentation to remove the
non-spherical portion and to re-establish a spherical or
essentially spherical shape.
[0480] 3. Control of the depth of the bone removal and the shape of
the bone removal. For this purpose, a stop may be incorporated into
the design of the 3D guidance template. Of note, the stop may be
asymmetrical and can even be designed to be a mirror and/or
negative image of the desired articular contour.
[0481] FIG. 31 shows an example of treatment of CAM impingement
using a 3D guidance template 4100. The impinging area 4105 may be
removed with a saw (not shown) inserted into the guide aperture
4110. The guide aperture may be designed and placed so that only
the impinging portion of the joint is removed.
[0482] In Pincer impingement, linear bony contact occurs between
the normal femoral head-neck junction and enlarged or hypertrophied
portion of the acetabulum. Pre-operatively an imaging test may be
performed in order to identify the abnormal, over covered or
enlarged area of the acetabulum. The amount of bone removal may be
determined on the imaging study, e.g. a CT scan or MRI scan. A 3D
guidance template may then be designed that will achieve the
identical three functions described above in Cam impingement.
[0483] FIG. 32 shows an example of treatment of Pincer impingement
using a 3D guidance template 4200. The impinging area 4205 may be
removed with a saw (not shown) inserted into the guide aperture
4210. The guide aperture may be designed and placed so that only
the impinging portion of the joint is removed.
[0484] Accurate and reproducible identification of the abnormal
bony surface causing the impingement is critical in any form of
musculoskeletal impingement syndrome. 3D guidance template systems
are ideally suited to achieve this purpose and to guide the
surgical instrumentation for removal of the source of impingement.
Moreover, since the localization of the impinging area is performed
pre-operatively during the imaging test, and intra-operatively
using the 3D guidance template, this approach allows for minimally
invasive, tissue, specifically muscle sparing approaches.
[0485] iv. Surgical Navigation and 3D Guidance Templates
[0486] 3D guidance template technology as described herein may be
combined with surgical navigation techniques. Surgical navigation
techniques may be image guided or non-image guided for this
purpose. Passive or active surgical navigation systems may be
employed. Surgical navigation systems that use optical or
radiofrequency transmission or registration may be used. A
representative example is the Vector Vision navigation system
manufactured by Brain Lab, Germany. This is a passive infrared
navigation system. Once the patient is positioned appropriately in
the operating room, retro-reflective markers can be applied to the
extremity near the area of intended surgery. With image guided
navigation, an imaging study such as a CT scan or MRI scan, can be
transferred into the workstation of the navigation system. For
registration purposes, the surgeon can, for example, utilize a
pointer navigation tool to touch four or more reference points that
are simultaneously co-identified and cross registered on the CT or
MRI scan on the workstation. In the knee joint, reference points
may include the trochlear groove, the most lateral point of the
lateral condyle, the most medial femoral condyle, the tip of the
tibial spines and so forth. Using image guided navigation,
anatomical and biomechanical axis of the joint can be determined
reliably.
[0487] Alternatively, non-image guided navigation may be utilized.
In this case, retro-reflective markers or small radio frequency
transmitters are positioned on the extremity. Movement of the
extremity and of the joints is utilized, for example, to identify
the center of rotation. If surgery of the knee joint is
contemplated, the knee joint may be rotated around the femur. The
marker or radiofrequency transmitter motion may be utilized to
identify the center of the rotation, which will coincide with the
center of the femoral head. In this manner, the biomechanical axis
may be determined non-invasively.
[0488] The information resulting in imaging guided navigation,
pertaining to either anatomical or biomechanical axis can be may be
utilized to optimize the position of any molds, blocks, linkages or
surgical instruments attached to or guided through the 3D guidance
molds.
[0489] In one embodiment, the joint or more specifically the
articular surface, may be scanned intra-operatively, for example,
using ultrasound or optical imaging methods. The optical imaging
methods may include stereographic or stereographic like imaging
approaches, for example, multiple light path stereographic imaging
of the joint and the articular surface or even single light path 3D
optical imaging. Other scan technologies that are applicable are,
for example, C-arm mounted fluoroscopic imaging systems that can
optionally also be utilized to generate cross-sectional images such
as a CT scan. Intraoperative CT scanners are also applicable.
Utilizing the intraoperative scan, a point cloud of the joint or
the articular surface or a 3D reconstruction or a 3D visualization
and other 3D representations may be generated that can be utilized
to generate an individualized template wherein at least a portion
of said template includes a surface that is a mirror and/or
negative image of the joint or the articular surface. A rapid
prototyping or a milling or other manufacturing machine can be
available in or near the operating room and the 3D guidance
template may be generated intraoperatively.
[0490] The intraoperative scan in conjunction with the rapid
production of an individualized 3D guidance template matching the
joint or the articular surface, in whole or at least in part, has
the advantage to generate rapidly a tool for rapid intraoperative
localization of anatomical landmarks, including articular
landmarks. A 3D guidance template may then optionally be
cross-registered, for example, using optical markers or
radiofrequency transmitters attached to the template with the
surgical navigation system. By cross-referencing the 3D guidance
template with the surgical navigation system, surgical instruments
can now be reproducibly positioned in relationship to the 3D
guidance template to perform subsequent procedures in alignment
with or in a defined relationship to at least one or more
anatomical axis and/or at least one or more biomechanical axis or
planes.
[0491] v. Stereoscopy, Stereoscopic Imaging:
[0492] In addition to cross-sectional or volumetric imaging
technologies including CT, spiral CT, and MRI, stereoscopic imaging
modalities may be utilized. Stereoscopic imaging is any technique
capable of recording three-dimensional information from two
two-dimensional, projectional imaging. Traditional stereoscopic
imaging includes creating a 3D visualization or representation
starting from a pair of 2D images. The projection path of the 2D
images is offset. The offset is, for example, designed to create an
impression of object depth for the eyes of the viewer. The offset
or minor deviation between the two images is similar to the
prospectors that both eyes naturally receive inbinocular vision.
Using two or more images with an offset or minor deviation in
perspective, it is possible to generate a point cloud or 3D surface
or 3D visualization of a joint or an articular surface, which can
then be input into a manufacturing system such as a rapid
prototyping or milling machine. Dual or more light path, as well as
single light path, systems can be employed
[0493] vi. Knee Joint
[0494] When a total knee arthroplasty is contemplated, the patient
can undergo an imaging test, as discussed in more detail above,
that will demonstrate the articular anatomy of a knee joint, e.g.
width of the femoral condyles, the tibial plateau etc.
Additionally, other joints can be included in the imaging test
thereby yielding information on femoral and tibial axes,
deformities such as varus and valgus and other articular alignment.
The imaging test can be an x-ray image, including in a standing,
load-bearing position, a CT or spiral CT scan or an MRI scan or
combinations thereof. A spiral CT scan may be advantageous over a
standard CT scan due to its improved spatial resolution in
z-direction in addition to x and y resolution. The articular
surface and shape as well as alignment information generated with
the imaging test can be used to shape the surgical assistance
device, to select the surgical assistance device from a library of
different devices with pre-made shapes and sizes, or can be entered
into the surgical assistance device and can be used to define an
optimal location and orientation of saw guides or drill holes or
guides for reaming devices or other surgical instruments.
Intraoperatively, the surgical assistance device is applied to the
tibial plateau and subsequently the femoral condyle(s) by matching
its surface with the articular surface or by attaching it to
anatomic reference points on the bone or cartilage. The surgeon can
then introduce a reamer or saw through the guides and prepare the
joint for the implantation. By cutting the cartilage and bone along
anatomically defined planes, a more reproducible placement of the
implant can be achieved. This can ultimately result in improved
postoperative results by optimizing biomechanical stresses applied
to the implant and surrounding bone for the patient's anatomy and
by minimizing axis malalignment of the implant. In addition, the
surgical assistance device can greatly reduce the number of
surgical instruments needed for total or unicompartmental knee
arthroplasty. Thus, the use of one or more surgical assistance
devices can help make joint arthroplasty more accurate, improve
postoperative results, improve long-term implant survival, reduce
cost by reducing the number of surgical instruments used. Moreover,
the use of one or more surgical assistance device can help lower
the technical difficulty of the procedure and can help decrease
operating room ("OR") times.
[0495] Thus, surgical tools described herein can also be designed
and used to control drill alignment, depth and width, for example
when preparing a site to receive an implant. For example, the tools
described herein, which typically conform to the joint surface, can
provide for improved drill alignment and more accurate placement of
any implant. An anatomically correct tool can be constructed by a
number of methods and can be made of any material, including a
substantially translucent and/or transparent material such as
plastic, Lucite, silastic, SLA or the like, and typically is a
block-like shape prior to molding.
[0496] FIG. 14A depicts, in cross-section, an example of a mold 600
for use on the tibial surface having an upper surface 620. The mold
600 contains an aperture 625 through which a surgical drill or saw
can fit. The aperture guides the drill or saw to make the proper
hole or cut in the underlying bone 610 as illustrated in FIGS.
11B-D. Dotted lines 632 illustrate where the cut corresponding to
the aperture will be made in bone.
[0497] FIG. 14B depicts, a mold 608 suitable for use on the femur.
As can be appreciated from this perspective, additional apertures
are provided to enable additional cuts to the bone surface. The
apertures 605 enable cuts 606 to the surface of the femur. The
resulting shape of the femur corresponds to the shape of the
interior surface of the femoral implant, typically as shown in FIG.
11E. Additional shapes can be achieved, if desired, by changing the
size, orientation and placement of the apertures. Such changes
would be desired where, for example, the interior shape of the
femoral component of the implant requires a different shape of the
prepared femur surface.
[0498] Turning now to FIG. 15, a variety of illustrations are
provided showing a tibial cutting block and mold system. FIG. 15A
illustrates the tibial cutting block 2300 in conjunction with a
tibia 2302 that has not been resected. In this depiction, the
cutting block 2300 consists of at least two pieces. The first piece
is a patient specific interior piece 2310 or mold that is designed
on its inferior surface 2312 to mate, or substantially mate, with
the existing geography of the patient's tibia 2302. The superior
surface 2314 and side surfaces 2316 of the first piece 2310 are
configured to mate within the interior of an exterior piece 2320.
The reusable exterior piece 2320 fits over the interior piece 2310.
The system can be configured to hold the mold onto the bone.
[0499] The reusable exterior piece has a superior surface 2322 and
an inferior surface 2324 that mates with the first piece 2310. The
reusable exterior piece 2320 includes cutting guides 2328, to
assist the surgeon in performing the tibial surface cut described
above. As shown herein a plurality of cutting guides can be
provided to provide the surgeon a variety of locations to choose
from in making the tibial cut. If necessary, additional spacers can
be provided that fit between the first patient configured, or
molded, piece 2310 and the second reusable exterior piece, or
cutting block, 2320.
[0500] If desired, the mold may be a single component or multiple
components. In one embodiment, one or more components are patient
specific while other components such as spacers or connectors to
surgical instruments are generic. In one embodiment, the mold can
rest on portions of the joint on the articular surface or external
to the articular surface. Other surgical tools then may connect to
the mold. For example, a standard surgical cut block as described
for standard implants, for example in the knee the J&J PFC
Sigma system, the Zimmer Nexgen system or the Stryker Duracon
system, can be connected or placed on the mold. In this manner, the
patient specific component can be minimized and can be made
compatible with standard surgical instruments.
[0501] The mold may include receptacles for standard surgical
instruments including alignment tools or guides. For example, a
tibial mold for use in knee surgery may have an extender or a
receptacle or an opening to receive a tibial alignment rod. In this
manner, the position of the mold can be checked against the
standard alignment tools and methods. Moreover, the combined use of
molds and standard alignment tools including also surgical
navigation techniques can help improve the accuracy of or optimize
component placement in joint arthroplasty, such as hip or knee
arthroplasty. For example, the mold can help define the depth of a
horizontal tibial cut for placement of a tibial component. A tibial
alignment guide, for example an extramedullary or intramedullary
alignment guide, used in conjunction with a tibial mold can help
find the optimal anteroposterior angulation, posterior slope,
tibial slant, or varus-valgus angle of the tibial cut. The mold may
be designed to work in conjunction with traditional alignment tools
known in the art.
[0502] The mold may include markers, e.g. optoelectronic or
radiofrequency, for surgical navigation. The mold may have
receptacles to which such markers can be attached, either directly
or via a linking member.
[0503] The molds can be used in combination with a surgical
navigation system. They can be used to register the bones
associated with a joint into the coordinate system of the surgical
navigation system. For example, if a mold for a joint surface
includes tracking markers for surgical navigation, the exact
position and orientation of the bone can be detected by the
surgical navigation system after placement of the mold in its
unique position. This helps to avoid the time-consuming process to
acquire the coordinates of tens to hundreds of points on the joint
surface for registration.
[0504] Referring back to FIG. 15A, the variable nature of the
interior piece facilitates obtaining the most accurate cut despite
the level of disease of the joint because it positions the exterior
piece 2320 such that it can achieve a cut that is perpendicular to
the mechanical axis. Either the interior piece 2310 or the exterior
piece 2320 can be formed out of any suitable material.
Additionally, it should be understood that the various embodiments
described herein may be of a single piece configuration as the two
or more piece configuration described herein. The reusable exterior
piece 2320 and the patient specific interior piece 2310 can be a
single piece that is either patient specific (where manufacturing
costs of materials support such a product) or is reusable based on
a library of substantially defect conforming shapes developed in
response to known or common tibial surface sizes and defects.
[0505] The interior piece 2310 is typically molded to the tibia
including the subchondral bone and/or the cartilage, as well as
including one or more anatomical relief surfaces (not shown), if
desired. The surgeon will typically remove any residual meniscal
tissue prior to applying the mold. Optionally, the interior surface
2312 of the mold can include shape information of portions or all
of the menisci.
[0506] Turning now to FIG. 15B-D, a variety of views of the
removable exterior piece 2320. The top surface 2322 of the exterior
piece can be relatively flat. The lower surface 2324 which abuts
the interior piece conforms to the shape of the upper surface of
the interior piece. In this illustration the upper surface of the
interior piece is flat, therefore the lower surface 2324 of the
reusable exterior surface is also flat to provide an optimal mating
surface.
[0507] A guide plate 2326 is provided that extends along the side
of at least a portion of the exterior piece 2320. The guide plate
2326 provides one or more slots or guides 2328 through which a saw
blade can be inserted to achieve the cut desired of the tibial
surface. Additionally, the slot, or guide, can be configured so
that the saw blade cuts at a line perpendicular to the mechanical
axis, or so that it cuts at a line that is perpendicular to the
mechanical axis, but has a 4-7.degree. slope in the sagittal plane
to match the normal slope of the tibia.
[0508] Optionally, a central bore 2330 can be provided that, for
example, enables a drill to ream a hole into the bone for the stem
of the tibial component of the knee implant.
[0509] FIGS. 15E-H illustrate the interior, patient specific, piece
2310 from a variety of perspectives. FIG. 15E shows a side view of
the piece showing the uniform superior surface 2314 and the uniform
side surfaces 2316 along with the irregular inferior surface 2316.
The inferior surface mates with the irregular surface of the tibia
2302. FIG. 15F illustrates a superior view of the interior,
patient, specific piece of the mold 2310. Optionally having an
aperture 2330. FIG. 15G illustrates an inferior view of the
interior patient specific mold piece 2310 further illustrating the
irregular surface which includes convex and concave portions to the
surface, as necessary to achieve optimal mating with the surface of
the tibia. FIG. 15H illustrates cross-sectional views of the
interior patient specific mold piece 2310. As can be seen in the
cross-sections, the surface of the interior surface changes along
its length.
[0510] As is evident from the views shown in FIGS. 15B and 15D, the
length of the guide plate 2326 can be such that it extends along
all or part of the tibial plateau, e.g. where the guide plate 2326
is asymmetrically positioned as shown in FIG. 15B or symmetrically
as in FIG. 15D. If total knee arthroplasty is contemplated, the
length of the guide plate 2326 typically extends along all of the
tibial plateau. If unicompartmental arthroplasty is contemplated,
the length of the guide plate typically extends along the length of
the compartment that the surgeon will operate on. Similarly, if
total knee arthroplasty is contemplated, the length of the molded,
interior piece 2310 typically extends along all of the tibial
plateau; it can include one or both tibial spines. If
unicompartmental arthroplasty is contemplated, the length of the
molded interior piece typically extends along the length of the
compartment that the surgeon will operate on; it can optionally
include a tibial spine.
[0511] Turning now to FIG. 15I, an alternative embodiment is
depicted of the aperture 2330. In this embodiment, the aperture
features lateral protrusions to accommodate using a reamer or punch
to create an opening in the bone that accepts a stem having
flanges.
[0512] FIGS. 15J and 15M depict alternative embodiments designed to
control the movement and rotation of the cutting block 2320
relative to the mold 2310. As shown in FIG. 15J a series of
protrusions, illustrated as pegs 2340, are provided that extend
from the superior surface of the mold. As will be appreciated by
those of skill in the art, one or more pegs or protrusions can be
used without departing from the scope of the invention. For
purposes of illustration, two pegs have been shown in FIG. 15J.
Depending on the control desired, the pegs 2340 are configured to
fit within, for example, a curved slot 2342 that enables rotational
adjustment as illustrated in FIG. 15K or within a recess 2344 that
conforms in shape to the peg 2340 as shown in FIG. 15L. As will be
appreciated by those of skill in the art, the recess 2344 can be
sized to snugly encompass the peg or can be sized larger than the
peg to allow limited lateral and rotational movement. The recess
can be composed of a metal or other hard insert 544.
[0513] As illustrated in FIG. 15M the surface of the mold 2310 can
be configured such that the upper surface forms a convex dome 2350
that fits within a concave well 2352 provided on the interior
surface of the cutting block 2320. This configuration enables
greater rotational movement about the mechanical axis while
limiting lateral movement or translation.
[0514] Other embodiments and configurations could be used to
achieve these results without departing from the scope of the
invention.
[0515] As will be appreciated by those of skill in the art, more
than two pieces can be used, where appropriate, to comprise the
system. For example, the patient specific interior piece 2310 can
be two pieces that are configured to form a single piece when
placed on the tibia. Additionally, the exterior piece 2320 can be
two components. The first component can have, for example, the
cutting guide apertures 2328. After the resection using the cutting
guide aperture 2328 is made, the exterior piece 2320 can be removed
and a secondary exterior piece 2320' can be used which does not
have the guide plate 2326 with the cutting guide apertures 2328,
but has the aperture 2330 which facilitates boring into the tibial
surface an aperture to receive a stem of the tibial component of
the knee implant. Any of these designs could also feature the
surface configurations shown in FIGS. 15J-15M, if desired.
[0516] FIG. 15N illustrates an alternative design of the cutting
block 2320 that provides additional structures 2360 to protect, for
example, the cruciate ligaments, from being cut during the
preparation of the tibial plateau. These additional structures can
be in the form of indented guides 2360, as shown in FIG. 15N or
other suitable structures, including other types of external
anatomical relief surfaces.
[0517] FIG. 15O illustrates a cross-section of a system having
anchoring pegs 2362 on the surface of the interior piece 2310 that
anchor the interior piece 2310 into the cartilage or meniscal
area.
[0518] FIGS. 15P AND 15Q illustrate a device 2300 configured to
cover half of a tibial plateau such that it is
unicompartmental.
[0519] FIG. 15R illustrates an interior piece 2310 that has
multiple contact surfaces 2312 with the tibial 2302, in accordance
with one embodiment. As opposed to one large contact surface, the
interior piece 2310 includes a plurality of smaller contact
surfaces 2312 separated by one or more anatomical relief surfaces.
In various embodiments, the multiple contact surfaces 2312 are not
on the sample plane and are at angles relative to each other to
ensure proper positioning on the tibia 2302. Two or three contact
surfaces 2312 may be desirable to ensure proper positioning. In
various embodiments, only the contact surfaces 2312 of the interior
piece may be molded, the molds attached to the rest of the template
using methodologies known in the art, such as adhesives. The molds
may be removably attached to the template. It is to be understood
that multiple contact surfaces 2312 may be utilized in template
embodiments that include one or a plurality of pieces.
[0520] Turning now to FIG. 16, a femoral mold system is depicted
that facilitates preparing the surface of the femur such that the
finally implanted femoral implant will achieve optimal mechanical
and anatomical axis alignment.
[0521] FIG. 16A illustrates the femur 2400 with a first portion
2410 of the mold placed thereon. In this depiction, the top surface
of the mold 2412 is provided with a plurality of apertures. In this
instance the apertures consist of a pair of rectangular apertures
2414, a pair of square apertures 2416, a central bore aperture 2418
and a long rectangular aperture 2420. The side surface 2422 of the
first portion 2410 also has a rectangular aperture 2424. Each of
the apertures is larger than the eventual cuts to be made on the
femur so that, in the event the material the first portion of the
mold is manufactured from a soft material, such as plastic, it will
not be inadvertently cut during the joint surface preparation
process. Additionally, the shapes can be adjusted, e.g.,
rectangular shapes made trapezoidal, to give a greater flexibility
to the cut length along one area, without increasing flexibility in
another area. As will be appreciated by those of skill in the art,
other shapes for the apertures, or orifices, can be changed without
departing from the scope of the invention.
[0522] FIG. 16B illustrates a side view of the first portion 2410
from the perspective of the side surface 2422 illustrating the
aperture 2424. As illustrated, the exterior surface 2411 has a
uniform surface which is flat, or relatively flat configuration
while the interior surface 2413 has an irregular surface that
conforms, or substantially conforms, with the surface of the
femur.
[0523] FIG. 16C illustrates another side view of the first, patient
specific molded, portion 2410, more particularly illustrating the
irregular surface 2413 of the interior. FIG. 16D illustrates the
first portion 2410 from a top view. The center bore aperture 2418
is optionally provided to facilitate positioning the first piece
and to prevent central rotation.
[0524] FIG. 16D illustrates a top view of the first portion 2410.
The bottom of the illustration corresponds to an anterior location
relative to the knee joint. From the top view, each of the
apertures is illustrated as described above. As will be appreciated
by those of skill in the art, the apertures can be shaped
differently without departing from the scope of the invention.
[0525] Turning now to FIG. 16E, the femur 2400 with a first portion
2410 of the cutting block placed on the femur and a second,
exterior, portion 2440 placed over the first portion 2410 is
illustrated. The second, exterior, portion 2440 features a series
of rectangular grooves (2442-2450) that facilitate inserting a saw
blade therethrough to make the cuts necessary to achieve the femur
shape illustrated in FIG. 11E. These grooves can enable the blade
to access at a 90.degree. angle to the surface of the exterior
portion, or, for example, at a 45.degree. angle. Other angles are
also possible without departing from the scope of the
invention.
[0526] As shown by the dashed lines, the grooves (2442-2450) of the
second portion 2440, overlay the apertures of the first layer.
[0527] FIG. 16F illustrates a side view of the second, exterior,
cutting block portion 2440. From the side view a single aperture
2450 is provided to access the femur cut. FIG. 16G is another side
view of the second, exterior, portion 2440 showing the location and
relative angles of the rectangular grooves. As evidenced from this
view, the orientation of the grooves 2442, 2448 and 2450 is
perpendicular to at least one surface of the second, exterior,
portion 2440. The orientation of the grooves 2444, 2446 is at an
angle that is not perpendicular to at least one surface of the
second, exterior portion 2440. These grooves (2444, 2446)
facilitate making the angled chamfer cuts to the femur. FIG. 16H is
a top view of the second, exterior portion 2440. As will be
appreciated by those of skill in the art, the location and
orientation of the grooves will change depending upon the design of
the femoral implant and the shape required of the femur to
communicate with the implant.
[0528] FIG. 16I illustrates a spacer 2401 for use between the first
portion 2410 and the second portion 2440. The spacer 2401 raises
the second portion relative to the first portion, thus raising the
area at which the cut through groove 2424 is made relative to the
surface of the femur. As will be appreciated by those of skill in
the art, more than one spacer can be employed without departing
from the scope of the invention. Spacers can also be used for
making the tibial cuts. Optional grooves or channels 2403 can be
provided to accommodate, for example, pins 2460 shown in FIG.
16J.
[0529] Similar to the designs discussed above with respect to FIG.
15, alternative designs can be used to control the movement and
rotation of the cutting block 2440 relative to the mold 2410. As
shown in FIG. 16J a series of protrusions, illustrated as pegs
2460, are provided that extend from the superior surface of the
mold. These pegs or protrusions can be telescoping to facilitate
the use of molds if necessary. As will be appreciated by those of
skill in the art, one or more pegs or protrusions can be used
without departing from the scope of the invention. For purposes of
illustration, two pegs have been shown in FIG. 16J. Depending on
the control desired, the pegs 2460 are configured to fit within,
for example, a curved slot that enables rotational adjustment
similar to the slots illustrated in FIG. 15K or within a recess
that conforms in shape to the peg, similar to that shown in FIG.
15L and described with respect to the tibial cutting system. As
will be appreciated by those of skill in the art, the recess 2462
can be sized to snugly encompass the peg or can be sized larger
than the peg to allow limited lateral and rotational movement.
[0530] As illustrated in FIG. 16K the surface of the mold 2410 can
be configured such that the upper surface forms a convex dome 2464
that fits within a concave well 2466 provided on the interior
surface of the cutting block 2440. This configuration enables
greater rotational movement about the mechanical axis while
limiting lateral movement or translation.
[0531] In installing an implant, first the tibial surface is cut
using a tibial block, such as those shown in FIG. 16. The patient
specific mold is placed on the femur. The knee is then placed in
extension and spacers 2401, such as those shown in FIG. 16M, or
shims are used, if required, until the joint optimal function is
achieved in both extension and flexion. The spacers, or shims, are
typically of an incremental size, e.g., 5 mm thick to provide
increasing distance as the leg is placed in extension and flexion.
A tensiometer can be used to assist in this determination or can be
incorporated into the mold or spacers in order to provide optimal
results. The design of tensiometers are known in the art and are
not specifically described herein. Suitable designs include, for
example, those described in U.S. Pat. No. 5,630,820 to Todd issued
May 20, 1997.
[0532] As illustrated in FIGS. 16N (sagittal view) and 26O (coronal
view), the interior surface 2413 of the mold 2410 can include small
teeth 2465 or extensions that can help stabilize the mold against
the cartilage 2466 or subchondral bone 2467.
[0533] 3D guidance templates may be used to create more that one
cut on the same and/or on the opposite articular surface or
opposite articular bone, in accordance with an embodiment. These
cuts may be cross-referenced with other cuts using one or more
guidance template(s).
[0534] In accordance with one embodiment, the 3D guidance
template(s) are utilized to perform more than one cut on the same
articular side such as the femoral side of a knee joint. In another
embodiment, a 3D guidance template may be utilized to cross
reference surgical interventions on an opposing articular surface.
In a knee, for example, the first articular surface can be the
femoral surface. The opposing articular surface can be the tibial
surface or the patella surface. In a hip, the first articular
surface can be the acetabulum. The opposing articular surface or
the opposing bone can be the proximal femur.
[0535] Thus, in a knee, a horizontal femur cut can be
cross-referenced with an anterior or posterior femur cut or
optionally also chamfer, oblique cuts. Similarly, a tibial
horizontal cut can be cross-referenced with any tibial oblique or
vertical cuts on the same articular side or surface.
[0536] In accordance with another embodiment, one or more femur
cuts can be crossed-referenced with one or more tibial cuts. Or, in
a hip, one or more acetabular cuts or surgical interventions can be
cross-referenced with one or more femoral cuts or surgical
interventions such as drilling, reaming or boring. Similarly, in a
knee again, one or more femur cuts can be cross-referenced with one
or more patella cuts. Any combination and order is possible.
[0537] The cross-referencing can occur via attachments or linkages
including spacers or hinge or ratchet like devices from a first
articular bone and/or cartilage surface, to a second articular,
bone and/or cartilage surface. The resulting positioning of the cut
on the opposing articular, bone or cartilage surface can be
optimized by testing the cut for multiple pose angles or joint
positions such as flexion, extension, internal or external
rotation, abduction or adduction. Thus, for example, in a knee a
distal femur cut can be performed with a mold. Via a linkage or an
attachment, a tibial template may be attached thereto or to the cut
or other surgical intervention, thus a cross-reference can be
related from the femoral cut to a tibial cut or other surgical
intervention. Cross-referencing from a first articular surface to a
second articular surface via, without limitation, attachments or
linkages to a template has the advantage of insuring an optimal
alignment between the implant or other therapeutic device
components of the first articular surface to that on a second
articular surface. Moreover, by cross-referencing surgical
interventions on a first articular surface to a second articular
surface, improved efficiencies and time savings can be obtained
with the resulted surgical procedure.
[0538] Cross-referencing the first, the second and, optionally a
third or more articular surface, such as in a knee joint, may be
performed with a single linkage or attachment or multiple linkages
or attachments. A single pose angle or position of a joint or
multiple pose angles or positions of a joint may be tested and
optimized during the entire surgical intervention. Moreover, any
resulting surgical interventions on the opposite, second articular
surface, bone or cartilage may be further optimized by optionally
cross-referencing to additional measurement tools such as standard
alignment guides.
[0539] For example, in a knee joint, a 3D template may be utilized
to perform one or more surgical interventions on the femoral side,
such as a femoral cut. This can then be utilized via a linkage, an
attachment or via indirect cross-referencing directly onto the site
of surgical intervention, to guide a surgical intervention such as
a cut of the tibial side. Prior to performing the surgical
intervention on the tibial side, a traditional tibial alignment
guide with cross-reference to the medial and lateral malleolus of
the ankle turn may be used to optimize the position, orientation
and/or depth and extent of the planned surgical intervention such
as the cut. For example, cross-referencing to the femoral cut can
aid in defining the relative superior inferior height of the tibial
cut, while cross-referencing a tibial alignment guide can
optionally be utilized to determine the slant of the cut in the
interior posterior direction.
[0540] An exemplary system and methodology is now described in
which a femoral template is used to make a cut on the femur, which
is then cross-referenced to properly align a tibial template for
making a cut on the tibial plateau. Initially, an electronic
image(s) of the leg is obtained using imaging techniques elaborated
in above-described embodiments. For example, a pre-operative CT
scan of a patient's leg may be obtained to obtain electronic image
data.
[0541] Image processing is then applied to the image data to
derive, without limitation, relevant joint surfaces, axis, and/or
cut planes. Image processing techniques may include, without
limitation, segmentation and propagation of point clouds.
[0542] Relevant biomechanical and/or anatomical axis data may be
obtained by identifying, for example, the central femoral head,
central knee joint and center of the distal tibia. The cutting
planes may then be defined based on at least one of these axis. For
example, the tibial implant bearing surface may be defined as being
perpendicular to the axis defined by the center of the tibial
plateau 2496 and the center of the distal tibia 2497, as
illustrated in FIG. 16P; the tibial implant's medial margin may
project towards the femoral head, as illustrated in FIG. 16Q; and
the anterior to posterior slope of the tibia may be approximated by
the natural anatomical slope (alternatively, excessive tibial slope
may be corrected).
[0543] The tibial and femoral templates and implants may be
designed based, at least in part, on the derived joint surfaces,
axis and/or cut planes. FIGS. 16R and 16S show isometric views of a
femoral template 2470 and a tibial template 2480, respectively, in
accordance with an embodiment. The femoral template 2470 has an
interior surface that, in various embodiments, conforms, or
substantially conforms, with the anatomic surface (bone and/or
cartilage) of the femur 2475. Furthermore, the interior surface of
the femoral template may extend a desired amount around the
anatomical boney surfaces of the condyle to further ensure proper
fixation. The interior surface of the tibial cutting block 2480 may
conform, or substantially conform to the surface (bone and/or
cartilage) of the tibia 2481.
[0544] In an exemplary use, the femoral template 2470 is placed on
the femoral condyle 2475, for example, when the knee is flexed. The
femoral template 2470 may be fixed to the femoral condyle 2475
using, without limitation, anchoring screws/drill pins inserted
through drill bushing holes 2471 and 2472. The position of holes
2471 and 2472 on the condyle may be the same used to anchor the
final implant to the femur. In various embodiments, the holes 2471
and 2472 may include metal inserts/bushings to prevent degradation
when drilling. Fixing the template 2470 to the femoral condyle 2475
advantageously prevents movement of the template during subsequent
cutting or other surgical interventions thereby ensuring the
accuracy of the resultant surgical cuts.
[0545] To assist in accurately positioning the femoral template
2470, a femoral guide reference tool 2473 may be attached to the
femoral template 2470, as shown in FIG. 16T. The femoral guide
reference tool 2473 may, without limitation, attach to one of holes
2471 and 2472. The femoral guide reference tool 2473 may reference
off the tangential margin of the posterior condyle, and aid, for
example, in correct anterior-posterior positioning of the femoral
template 2470.
[0546] Upon proper fixation of the femoral template 2470 to the
femoral condyle 2475, a cut to the femoral condyle is made using
cut guide surface or element 2474. The cut guide surface or element
2474 may be integral to the femoral template 2470, or may be an
attachment to the femoral template 2470, with the attachment made
of a harder material than the femoral template 2470. For example,
the cut guide surface or element 2474 may be a metal tab that
slides onto the femoral template 2470, which may be made, without
limitation, of a softer, plastic material.
[0547] Upon making the femoral cut and removing the femoral
template 2475, a sample implant template 2476 (not the final
implant) is optionally positioned on the condyle, as shown in FIG.
16U, in accordance with an embodiment. The sample implant template
2474 may be attached to the condyle by using, without limitation,
anchoring screws/drill pins inserted through the same holes used to
anchor the final implant to the femur.
[0548] The sample implant template 2476 includes an attachment
mechanism 2494 for attaching the tibial template 2480, thereby
cross-referencing the placement of the distal tibial cut with
respect to the femoral cut/implant's placement. The attachment
mechanism 2494 may be, without limitation, a boss, as shown in FIG.
16U, or other attachment mechanism known in the art, such as a
snap-fit mechanism. Note that in alternative embodiments, a sample
implant template 2476 may not be required. For example, the tibial
template 2480 may attach directly to the femoral template 2470.
However, in the subject embodiment, the drill bushing features of
the femoral template 2475 can interfere with the knee going into
extension, possibly preventing the tibial cut.
[0549] In illustrative embodiments, the thickness of the sample
implant template 2476 may not only include the thickness of the
final femoral implant, but may include an additional thickness that
corresponds to a desired joint space between tibial and femoral
implants. For example, the additional thickness may advantageously
provide a desired joint space identified for proper ligament
balancing or for flexion, extension, rotation, abduction,
adduction, anteversion, retroversion and other joint or bone
positions and motion.
[0550] FIG. 16V is an isometric view of the interior surface of the
sample implant template 2476, in accordance with an embodiment. In
various embodiments, the femoral implant can often rest on
subchondral bone, with the cartilage being excised. In embodiments
where the sample implant template 2474 extends beyond the
dimensions of the femoral implant such that portions of the sample
implant template 2476 rests on cartilage, an offset 2477 in the
interior surface of the sample implant template 2476 may be
provided.
[0551] FIG. 16W is an isometric view of the tibial template 2480
attached to the sample implant 2476 when the knee is in extension,
in accordance with an embodiment. A crosspin 2478 inserted through
boss 2494 fixes the tibial template 2480 to the sample implant
template 2474. Of course, other attachment mechanisms may be used,
as described above. In various embodiments, the tibial template
2480 may also be fixed to the tibia 2481 using, without limitation,
anchoring screws/drill pins inserted through drill bushing hole
2479. In various embodiments, the holes 2479 include metal inserts
(or other hard material) to prevent degradation when drilling. As
with the femoral template 2475, the cut guide surface or element of
the tibial template 2480 may be integral to the tibial template
2475, or may be an attachment to the tibial template 2480, the
attachment made of a harder material than the tibial template 2480.
Upon fixing the position of the tibial template 2480, the cut guide
of the tibial template 2475 assists in guiding the desired cut on
the tibia.
[0552] FIG. 16X shows a tibial template 2490 that may be used,
after the tibial cut has been made, to further guide surgical tools
in forming anchoring apertures in the tibia for utilization by the
tibial implant (e.g., the tibial implant may include pegs and/or
keels that are used to anchor the tibial implant into the tibia),
in accordance with another embodiment. The outer perimeter of a
portion of the tibial template 2490 may mimic the perimeter of the
tibial implant. Guide apertures in the tibial template 2490
correspond to the tibial implants fixation features. A portion of
the tibial template 2490 conforms to, without limitation, the
anterior surface of the tibia to facilitate positioning and
anchoring of the template 2490.
[0553] FIG. 16Y shows a tibial implant 2425 and femoral implant
2426 inserted onto the tibia and femur, respectively, after the
above-described cuts have been made, in accordance with an
embodiment.
[0554] Thus, the tibial template 2480 used on the tibia can be
cross-referenced to the femoral template 2476, femoral cut and/or
sample implant 2474. Similarly, in the hip, femoral templates can
be placed in reference to an acetabular mold or vice versa. In
general, when two or more articular surfaces will be repaired or
replaced, a template can be placed on one or more of them and
surgical procedures including cutting, drilling, sawing or rasping
can be performed on the other surface or other surfaces in
reference to said first surface(s).
[0555] In illustrative embodiments, three-dimensional guidance
templates may be utilized to determine an optimized implant
rotation. Examples are provided below with reference to the knee,
however it is to be understood that optimizing implant rotation may
be applied other joints as well.
Femoral Rotation:
[0556] The optimal rotation of a femoral component or femoral
implant for a uni-compartmental, patello femoral replacement or
total knee replacement may be ascertained in a number of different
ways. Implant rotation is typically defined using various anatomic
axes or planes. These anatomic axes may include, without
limitation, the transepicondylar axis; the Whiteside line, i.e. the
trochlea anteroposterior axis, which is typically perpendicular to
at least one of the cuts; and/or the posterior condylar axis.
Another approach for optimizing femoral component rotation is a
so-called balancing gap technique. With the balancing gap
technique, a femoral cut is made parallel to the tibia, i.e. the
tibia is cut first typically. Prior to performing the femoral cut,
the femoral cut plate is optimized so that the medial and lateral
ligament and soft tissue tension are approximately equal.
[0557] By measuring the relevant anatomic axis or planes, the
optimal implant rotation may be determined. In various embodiments,
the measurement may be factored into the shape, position or
orientation of the 3D guidance template. Any resultant surgical
interventions including cuts, drilling, or sawings are then made
incorporating this measurement, thereby achieving an optimal
femoral component rotation.
[0558] Moreover in order to achieve an optimal balancing, the
rotation of the template may be changed so that the cuts are
parallel to the tibial cut with substantially equal tension
medially and laterally applied.
Tibial Rotation:
[0559] A 3D guidance template may also be utilized to optimize
tibial component rotation for uni-compartmental or total knee
replacements, in accordance with an embodiment. Tibial component
rotation may be measured using a number of different approaches
known in the art. In one example of a tibial component rotation
measurement, the anteroposterior axis of the tibia is determined.
For a total knee replacement, the tibial component can be placed so
that the axis of the implant coincides with the medial one-third of
the tibial tuberosity. This approach works well when the tibia is
symmetrical.
[0560] In another embodiment, the symmetrical tibial component is
placed as far as possible posterolateral and externally rotated so
that the posteromedial corner of the tibial plateau is uncovered to
an extent of between three (3) and five (5) millimeters.
[0561] The above examples are only representative of the different
approaches that have been developed in the literature. Other
various anatomic axis, plane and area measurements may be performed
in order to optimize implant rotation.
[0562] In illustrative embodiments, these measurements may be
factored into the design of a 3D guidance template and the
position, shape or orientation of the 3D guidance template may be
optimized utilizing this information. Thus, any subsequent surgical
intervention such as cutting, sawing and/or drilling will result in
an optimized implant rotation, for example, in the horizontal or in
a near horizontal plane.
[0563] Turning now to FIG. 17, a variety of illustrations are
provided showing a patellar cutting block and mold system. FIGS.
17A-17C illustrates the patellar cutting block 2700 in conjunction
with a patella 2702 that has not been resected. In this depiction,
the cutting block 2700 can consist of only one piece or a plurality
of pieces, if desired. The inner surface 2703 is patient specific
and designed to mate, or substantially mate, with the existing
geography of the patient's patella 2702. Small openings are present
2707 to accept the saw. The mold or block can have only one or
multiple openings. The openings can be larger than the saw in order
to allow for some rotation or other fine adjustments. FIG. 17A is a
view in the sagittal plane S. The quadriceps tendon 2704 and
patellar tendon 2705 are shown.
[0564] FIG. 17B is a view in the axial plane A. The cartilage 2706
is shown. The mold can be molded to the cartilage or the
subchondral bone or combinations thereof. FIG. 17C is a frontal
view F of the mold demonstrating the opening for the saw 2707. The
dashed line indicates the relative position of the patella
2702.
[0565] FIGS. 17D (sagittal view) and E (axial view) illustrate a
patellar cutting block 2708 in conjunction with a patella 2702 that
has not been resected. In this depiction, the cutting block 2708
consists of at least two pieces. The first piece is a patient
specific interior piece 2710 or mold that is designed on its
inferior surface 2712 to mate, or substantially mate, with the
existing geography of the patient's patella 2702, and may
optionally include one or more anatomical relief surfaces 2713 in
areas to avoid various anatomical features (for one or more
reasons) or where imaging of the anatomical structures is
suboptimal or uncertain. The posterior surface 2714 and side
surfaces 2716 of the first piece 2710 are configured to mate within
the interior of an exterior piece 2720. The reusable exterior piece
2720 fits over the interior piece 2710 and holds it onto the
patella. The reusable exterior piece has an interior surface 2724
that mates with the first piece 2710. The reusable exterior piece
2720 includes cutting guides 2707, to assist the surgeon in
performing the patellar surface cut. A plurality of cutting guides
can be provided to provide the surgeon a variety of locations to
choose from in making the patellar cut. If necessary, additional
spacers can be provided that fit between the first patient
configured, or molded, piece 2710 and the second reusable exterior
piece, or cutting block, 2720.
[0566] The second reusable exterior piece, or cutting block, 2720,
can have grooves 2722 and extensions 2725 designed to mate with
surgical instruments such as a patellar clamp 2726. The patellar
clamp 2726 can have ring shaped graspers 2728 and locking
mechanisms, for example ratchet-like 2730. The opening 2732 in the
grasper fits onto the extension 2725 of the second reusable
exterior piece 2720. Portions of a first portion of the handle of
the grasper can be at an oblique angle 2734 relative to the second
portion of the handle, or curved (not shown), in order to
facilitate insertion. Typically the portion of the grasper that
will be facing towards the intra-articular side will have an
oblique or curved shaped thereby allowing a slightly smaller
incision.
[0567] The variable nature of the interior piece facilitates
obtaining the most accurate cut despite the level of disease of the
joint because it positions the exterior piece 2720 in the desired
plane. Either the interior piece 2710 or the exterior piece 2720
can be formed out of any of the materials discussed above in
Section II, or any other suitable material. Additionally, it should
be understood that that the various embodiments described herein
may include one, two or more piece configurations. The reusable
exterior piece 2720 and the patient specific interior piece 2710
can be a single piece that is either patient specific (where
manufacturing costs of materials support such a product) or is
reusable based on a library of substantially defect conforming
shapes developed in response to known or common tibial surface
sizes and defects.
[0568] The interior piece 2710 is typically molded to the patella
including the subchondral bone and/or the cartilage.
[0569] From this determination, an understanding of the amount of
space needed to optimally balance the knee is determined and an
appropriate number of spacers is then used in conjunction with the
cutting block and mold to achieve the cutting surfaces and to
prevent removal of too much bone. Where the cutting block has a
thickness of, for example, 10 mm, and each spacer has a thickness
of 5 mm, in preparing the knee for cuts, two of the spacers would
be removed when applying the cutting block to achieve the cutting
planes identified as optimal during flexion and extension. Similar
results can be achieved with ratchet or jack like designs
interposed between the mold and the cut guide.
[0570] vii. Hip Joint
[0571] Turning now to FIG. 18, a variety of views showing sample
mold and cutting block systems for use in the hip joint are shown.
FIG. 18A illustrates femur 2510 with a mold and cutting block
system 2520 placed to provide a cutting plane 2530 across the
femoral neck 2512 to facilitate removal of the head 2514 of the
femur and creation of a surface 2516 for the hip ball
prosthesis.
[0572] FIG. 18B illustrates a top view of the cutting block system
2520. The cutting block system 2520 includes an interior, patient
specific, molded section 2524 and an exterior cutting block surface
2522. The interior, patient specific, molded section 2524 can
include a canal 2526 to facilitate placing the interior section
2524 over the neck of the femur. As will be appreciated by those of
skill in the art, the width of the canal will vary depending upon
the rigidity of the material used to make the interior molded
section. The exterior cutting block surface 2522 is configured to
fit snugly around the interior section. Additional structures can
be provided, similar to those described above with respect to the
knee cutting block system, that control movement of the exterior
cutting block 2524 relative to interior mold section 2522, as will
be appreciated by those of skill in the art. Where the interior
section 2524 encompasses all or part of the femoral neck, the
cutting block system can be configured such that it aids in removal
of the femoral head once the cut has been made by, for example,
providing a handle 2501.
[0573] FIG. 18C illustrates a second cutting block system 2550 that
can be placed over the cut femur to provide a guide for reaming
after the femoral head has been removed using the cutting block
shown in FIG. 18A. FIG. 18D is a top view of the cutting block
shown in FIG. 18C. As will be appreciated by those of skill in the
art, the cutting block shown in FIG. 18C-18D, can be one or more
pieces. As shown in FIG. 18E, the aperture 2552 can be configured
such that it enables the reaming for the post of the implant to be
at a 90.degree. angle relative to the surface of femur.
Alternatively, as shown in FIG. 18F, the aperture 2552 can be
configured to provide an angle other than 90.degree. for reaming,
if desired.
[0574] FIGS. 19A (sagittal view) and 19B (frontal view, down onto
mold) illustrates a mold system 2955 for the acetabulum 2957. The
mold can have grooves 2959 that stabilize it against the acetabular
rim 2960. Surgical instruments, e.g. reamers, can be passed through
an opening in the mold 2956. The side wall of the opening 2962 can
guide the direction of the reamer or other surgical instruments.
Metal sleeves 2964 can be inserted into the side wall 2962 thereby
protecting the side wall of the mold from damage. The metal sleeves
2964 can have lips 2966 or overhanging edges that secure the sleeve
against the mold and help avoid movement of the sleeve against the
articular surface.
[0575] FIG. 19C is a frontal view of the same mold system shown in
FIGS. 19A and 19B. A groove 2970 has been added at the 6 and 12
o'clock positions. The groove can be used for accurate positioning
or placement of surgical instruments. Moreover, the groove can be
useful for accurate placement of the acetabular component without
rotational error. Someone skilled in the art will recognize that
more than one groove or internal guide can be used in order to not
only reduce rotational error but also error related to tilting of
the implant. As seen FIG. 19D, the implant 2975 can have little
extensions 2977 matching the grooves thereby guiding the implant
placement. The extensions 2977 can be a permanent part of the
implant design or they can be detachable. Note metal rim 2979 and
inner polyethylene cup 2980 of the acetabular component.
[0576] FIG. 19D illustrates a cross-section of a system where the
interior surface 2960 of the molded section 2924 has teeth 2962 or
grooves to facilitate grasping the neck of the femur.
[0577] Various steps may be performed in order to design and make
3D guidance templates for hip implants, in accordance with an
embodiment.
[0578] For example, in an initial step, a discrepancy in the length
of the left leg and right leg may be determined, for example, in
millimeters. Leg length discrepancy may be determined, for example,
using standing x-rays, typically including the entire leg but also
cross-sectional imaging modalities such as CT or MRI.
[0579] A CT scout scan may be utilized to estimate leg length.
Alternatively, select image slices through the hip and ankle joint
may be utilized to estimate leg length either using CT or MRI.
[0580] Pre-operative planning is then performed using the image
data. A first 3D guidance template is designed to rest on the
femoral neck. FIG. 33 shows an example of an intended site 4300 for
placement of a femoral neck mold for total hip arthroplasty. A cut
or saw plane integrated into this template can be derived. The
position, shape and orientation of the 3D guidance mold or jig or
template may be determined on the basis of anatomical axis such as
the femoral neck axis, the biomechanical axis and/or also any
underlying leg length discrepancy (FIG. 29). Specifically, the
superoinferior cut or saw guide height can be adapted to account
for leg length discrepancy. For example, if the left leg is five
(5) millimeters shorter than the right leg, then the cut height can
be moved by five (5) millimeters to account for this difference.
The femoral neck cut height ultimately determines the position of
the femoral stem. Thus, in this manner, using this type of
pre-operative planning, the femoral neck cut height can be
optimized using a 3D guidance template.
[0581] FIG. 29 is a flow diagram of a method wherein measurement of
leg length discrepancy can be utilized to determine the optimal cut
height of the femoral neck cut for total hip arthroplasty.
Initially, imaging is performed, e.g. CT and/or MRI, through,
without limitation, the hip, knee and ankle joint. Leg length
discrepancy is determined, using the imaging data obtained. The
desired implant size may then be optionally determined. The femoral
neck cut position can be determined based, at least in part, on
correcting the leg length discrepancy for optimal femoral component
placement.
[0582] FIG. 34 shows another example of a femoral neck mold 4400
with handle 4410 and optional slot 4420.
Acetabulum:
[0583] In the acetabulum, the position and orientation of the
acetabular component or acetabular cup is also critical for the
success of hip surgery. For example, the lowest portion of the
acetabular cup may be placed so that it is five (5) millimeters
lateral to an anatomic landmark on a pelvic x-ray coinciding with
the inferior border of the radiographic tear drop. If the
acetabular component is, for example, placed too far superiorly,
significant bone may be lost.
[0584] Placing the acetabular component using the 3D guidance
template may include, for example, the following steps:
[0585] Step One: Imaging, e.g. using optical imaging methods, CT or
MRI.
[0586] Step Two: Determining the anterior rotation of the
acetabulum and the desired rotation of the acetabular cup.
[0587] Step Three: Find best fitting cup size.
[0588] Step Four: Determine optimal shape, orientation and/or
position of 3D guidance template.
[0589] The template may be optionally designed to rest primarily on
the margin of the acetabular fossa. In this manner, it is possible
to ream through the template.
[0590] FIG. 35 shows an example of a posterior acetabular approach
for total hip replacement. Tissue retractors 4510 are in place. The
acetabular fossa is visible 4520.
[0591] FIG. 36 shows an example of a guidance mold used for reaming
the site for an acetabular cup. The mold 4600 can be optionally
attached to a generic frame 4610. A guide for the reamer is shown
4620. The reamer 4630 or the mold can have optional stops 4640. In
this example, the stops 4640 are attached to the reamer 4630 and
engage the guide 4620 for the reamer.
[0592] For purposes of reaming, the template may be fixed to the
pelvis, for example, using metal spikes or K-wires. The template
may also have a grip for fixing it to the bone. Thus, a surgeon may
optionally press the template against the bone while a second
surgeon will perform the reaming through the opening in the
template. The grip or any stabilizers can extend laterally, and
optionally serve as tissue retractors, keeping any potentially
interfering soft tissue out of the surgical field. The template may
also include stoppers 4640 to avoid over penetration of the reamer.
These stoppers may be designed in the form of metal stops defining
the deepest penetration area for the peripheral portion or other
portions of the reamer. Optionally, the template may also taper and
decrease in inner radius thereby creating a stop once the reamer
once the reaches the innermost portion of the template. Any stop
known in the art can be used. The imaging test can be used to
design or shape the mold in a manner that will help achieve the
optimal reaming depth. The stops can be placed on the mold or
reamer in reference to the imaging test in order to achieve the
optional reaming depth.
[0593] A 3D guidance template may be utilized to optimize the
anteversion of the acetabular cup. For example, with the posteral
lateral approach, typically an anteversion of forty to forty-five
degrees is desired in both males and females. With an anterolateral
approach, zero degrees anteversion may be desired. Irrespective of
the desired degree of anti-version, the shape, orientation and/or
position of the template may be optimized to include the desired
degree of anteversion.
[0594] Similarly, on the femoral side, the 3D guidance template may
be optimized with regard to its shape, orientation and position in
order to account for neutral, varus or valgus position of the
femoral shaft. A 3D guidance template may also be utilized to
optimize femoral shaft anteversion.
[0595] Thus, after a first template has been utilized for
performing the femoral neck cut and a second template has been
utilized for performing the surgical intervention on the acetabular
side, a third template may optionally be utilized to be placed onto
the femoral cut.
[0596] Optionally, modular hip implant components may be utilized
such as a modular stem. Such modular designs can be helpful in
further optimizing the resultant femoral anteversion by selecting,
for example, different stem shapes.
[0597] In another embodiment, the surgeon may perform a femur first
technique wherein a first cut is applied to the femur using a first
3D guidance mold. Optionally, the broach in the cut femoral shaft
may be left in place. Optionally, a trial implant head may be
applied to the broach. The trial implant head may be variable in
radius and superoinferior diameter and may be utilized to determine
the optimal soft tissue tension. Optionally, the trial head may
also be utilized to determine the acetabular cup position wherein
said acetabular cup position is derived on the basis of the femoral
cut. Thus, the acetabular position can be optionally derived using
the opposite articular surface. In a reverse acetabulum first
technique, the acetabulum can be prepared first and, using soft
tissue balancing techniques, the femoral component can be placed in
reference to the acetabular component. Optionally, the femoral cut
may even be placed intentionally too proximal and is subsequently
optimized by measuring soft tissue tension utilizing various trial
heads with the option to then change the height of the optimal
femoral cut.
[0598] viii. Positioning of Template
[0599] In an illustrative embodiment, in order to make a guidance
template reliably and reproducibly, a portion of the joint is
identified in a first step wherein said portion of the joint has
not been altered by the arthritic process. In a second step, the
surface or a point cloud of said portion of the joint is derived,
and may, optionally, be used to derive a virtual 3D model and, in a
third step, to generate a physical model as part of the guidance
template. Using a portion of the joint that has not been altered by
the arthritic process can advantageously improve the
reproducibility and the accuracy of the resultant mold or jig or
template.
[0600] The step of identifying said portion of the joint may be
visual, semiautomatic or fully automatic. Anatomic models may
assist in the process. Anatomic reference standards may be
utilized.
[0601] As known in the art, various methods for image segmentation
may be used to derive the point cloud or the surface. Suitable
algorithms include, for example, but are not limited to snakes,
live wire, thresholding, active contours, deformable models and the
like. Artificial neural networks may be employed to improve the
accuracy of the molds.
[0602] In another embodiment, the current biomechanical axis may
determined or estimated in a first step. In a second step, the
desired biomechanical axis is determined. In a third step
adjustments, for example via change in slot position or position
for openings for saws and drills and the like, may be made to alter
the cut or drill position in order to correct the biomechanical
axis in a fourth step. In a fifth step, the position of the slot or
openings for saws and drills and the like may be adjusted for
ligament balancing and/or for optimizing flexion and extension gap.
This adjustment may be performed in the 3D model prior to the
manufacturing process. Alternatively, adjustments may be made
intraoperatively, for example via spacers or ratchet like devices
or pins to allow for some degree of rotation.
[0603] In another embodiment, at least a portion of the surface of
the mold or jig or template is derived from a portion of the joint
that is affected by the arthritic process. Optionally, adjustment
means can be performed, for example via the software, to simulate a
normal shape. The difference between the actual shape and the
adjusted shape can be utilized to optimize the position of the
slots or openings in the mold or template or jig.
[0604] In one embodiment, at least a portion of the surface of the
mold or jig or template that is in contact with the joint may be
derived from a portion of the joint that is affected by the
arthritic process and a portion of the joint that has not been
altered by the arthritic process. By spanning both normal and
diseased portions of the joint, the interface between normal and
diseased portions of the joint is included in the surface of the
mold. The interface between normal and diseased portions of the
joint is typically characterized by a sudden change in contour or
shape, e.g. a reduction in cartilage thickness, a change in
subchondral bone contour, a cyst or a bone spur. This change in
joint contour or shape provides additional reference points for
accurately placing the mold or jig or template. In addition, this
change in joint contour or shape provides also additional
stabilization or fixation of the mold or jig or template on the
surface of the joint, in particular while performing surgical
interventions such as cutting, drilling or sawing.
[0605] ix. Anatomical Relief
[0606] In deriving and manufacturing various embodiments, it may be
advantageous to provide one or more anatomical relief surfaces or
portions (of varying degrees) to the surgical tools and/or implants
disclosed herein. Where an implant or surgical tool incorporates a
surface that substantially matches or conforms to one or more
anatomical structures, it may be desirable to avoid or specifically
preclude certain areas of the matching/conforming surface from
contacting and/or conforming/matching to the underlying anatomy by
offsetting, subtracting or otherwise modifying sections of the
surface portions adjacent to such areas. Specific instances where
such anatomical relief could be particularly advantageous can
include, but are not limited to, anatomical areas that are
difficult to access; difficult to denude, clean, debride or
otherwise prepare; areas that are incompatible with minimal access
procedures and/or other areas that are desirable to avoid for other
surgical reasons.
[0607] Anatomical relief can be achieved during the construction or
modification of the surface prior to any rapid prototyping or CNC
or other manufacturing method of an instrument or an implant with
patient-adapted or patient-specific features. Anatomic relief can
also be achieved after manufacturing of such components for example
by subtraction of physical material, e.g. through some grinding,
CNC, polishing, heat, air or laser abrasion or other methods known
in the art or developed in the future for removing material.
Similarly, anatomical relief may be accomplished by additive
manufacturing process that "build up" or otherwise alter conforming
surfaces to the joint.
[0608] Anatomical relief surfaces can form part of (or be
encompassed by) the conforming surface, such that a perimeter of
the anatomical relief surface is completely surrounded by the
conforming surface. In other embodiments, the anatomical relief
surface may be partially surrounded by the conforming surface. In
still other embodiments, the anatomical relief surface may by
separated from the conforming surface, such as where the anatomical
relief surface is on the periphery of the tool or implant, and/or
on the "joint facing, "externally facing" and/or articulating
surfaces of the tool or implant.
[0609] FIGS. 37 through 41 depict one embodiment of a procedure for
incorporating and/or designing an anatomical relief into a surgical
tool. In this embodiment, a two or three-dimensional computer model
of an intended surgical site (a femur, in this example) is
referenced, and an inner surface 5100 (including, for example, a
trochlear groove) is selected. An offset surface 5110 (see FIG. 38)
can then be derived from the inner surface 5100. In one embodiment,
the offset surface 5110 can be derived by sampling a plurality of
discrete points or pixels/voxels of the inner surface 5100, and
displacing the points from inner surface 5100 a set amount, such as
0.1 mm, 0.25 mm, 0.5 mm, 0.75 mm, 1 mm, 2 mm or any desired spacing
and/or in any direction (generally perpendicular in this example or
at an angle other than 90 degrees), thereby constructing the offset
surface. If desired, the creation of the offset surface 5110 may
duplicate the underlying anatomy, or it may further include a
filtering or planarizing function which desirably smooths or
otherwise modifies the offset surface to some degree relative to
the inner surface. Depending upon the type and/or features of the
inner surface, as well as the location of the anatomy, varying
spacings, displacements and/or directions may be utilized, with
varying results (i.e., the offset may be constant for the entire
surface, or may vary in different locations along the surface.
[0610] Once the offset surface 5110 has been derived, the inner
surface 5100 and/or anatomical model can be removed and/or hidden,
and a surgical tool 5120 can be overlaid onto the offset surface
5110, as best seen in FIG. 39. One or more relevant portions of the
surgical tool 5120 are then merged onto the offset surface 5110, as
shown in FIG. 40. Once the surgical tool has been merged and
modeled, the model can be utilized to manufacture the surgical tool
incorporating the desired anatomical relief 5130 (or can be used to
modify a pre-existing tool or implant). In the embodiment shown in
FIG. 41, the surgical tool incorporates an anatomical relief or
clearance zone that corresponds to a region adjacent to the
trochlear groove of the femur, which desirably reduces or obviates
the need for complete removal of all structures and/or soft tissues
(e.g., cartilage and/or osteophytes) within the groove and directly
surrounding areas.
[0611] Derivation and use of the offset surface in this manner
desirably provides substantially conforming and/or matching
surfaces for alignment and placement of surgical tools and
implants, but allowing clearance for areas of anatomical concern
and/or avoidance. In addition, maintaining a desired minimal
clearance allows avoidance of specific anatomy while, for example,
optionally maintaining a minimal thickness of the tool material to
ensure tool integrity. The disclosed procedure also provides a
repeatable and easily identifiable method of identifying a region
of interest and quickly and easily constructing an appropriate
anatomical relief structure to accommodate some or all of the
region.
[0612] FIGS. 42 through 45 depict an alternative embodiment of a
procedure for incorporating an anatomical relief into a surgical
tool. In this example, a two or three-dimensional computer model of
an intended surgical site (a femur, in this example) is referenced,
and a trochlear groove sketch 5200 is derived by creating a
sagittal silhouette sketch of the central trochlea, for example, at
its most proximal point (FIGS. 42 and 43) or its central or its
most distal point. If desired, the trochlear groove sketch may
follow the natural contour(s) of the trochlear groove, or may
comprise an actual or stylized two-dimensional representation of
the three dimensional trochlear groove as projected on a plane
passing through the femur at a desired angle and/or inclination
relative to the groove. The same applies to any other anatomic
site, e.g. a glenoid including the center of a glenoid or an
acetabular fossa. In this example, the trochlear groove sketch 5200
is then laterally expanded 5205 (i.e., along one or more
medial/lateral or other direction(s)) and then overlaid onto a
relevant region of a surgical tool 5210 (see FIG. 44). One or more
relevant portions of the surgical tool 5210 is then merged onto the
laterally expanded sketch 5205, as shown in FIG. 44, which in
effect "subtracts" or removes a portion of the substantially
conforming and/or matching surface in one or more regions of
interest. Once the surgical tool has been merged and modeled, the
model can be utilized to manufacture the surgical tool
incorporating the desired anatomical relief 5230. In the embodiment
shown in FIG. 45, the surgical tool incorporates an anatomical
relief or clearance zone 5230 that corresponds to a region adjacent
to the trochlear groove of the femur, which desirably reduces or
obviates the need for complete removal of all structures and/or
soft tissues (e.g., cartilage and/or osteophytes) within the groove
and/or surrounding anatomical regions. Moreover, the anatomical
relief obviates, to some degree, the need to measure and duplicate
the exact anatomy of the entirety of the trochlear groove, while
still providing for accurate tool placement using the remaining
conforming and/or matching surfaces to align the tool in a desired
manner.
[0613] In another embodiment, an anatomic relief can be achieved by
not including or excluding select regions of anatomy from an image
segmentation or 2D or 3D rendering or reconstruction of a
surface.
[0614] In another embodiment, an anatomic relief can be obtained by
editing one or more contours on the original, native images, e.g.
CT, MRI or ultrasound, for example, by moving an articular surface
in a desired direction to achieve or simulate the anatomic
relief.
[0615] In a further embodiment, shown in FIG. 51B, a
cross-sectional view of a surgical tool 5266 depicts a "sawtooth"
pattern reference surface having multiple anatomical relief
surfaces 5267. The tool incorporates a plurality of reference
surfaces 5268 that can be designed to contact and/or substantially
conform to portions of the natural anatomy of the trochlear groove
5200. The reference surfaces 5268 can be designed and/or selected
to contact the natural articular surface(s), damaged articular
surface(s) and/or subchondral bone surface(s) (either or with or
without articular cartilage removed), or combinations thereof.
[0616] FIGS. 46 through 51A depict additional alternative
embodiments of surgical tools incorporating anatomical reliefs. The
surgical tools of these embodiments desirably include one or more
portions of the laterally expanded trochlear groove sketch 5205 of
FIG. 44, and these tools desirably comprise additional components
for use in implanting a partial or total joint knee joint
replacement. The tools of FIGS. 42 through 51A, and the derivations
and constructions thereof, would be especially well suited for use
with the total knee implants and surgical tools described in U.S.
Provisional Patent Application No. 61/443,155 to Bojarski et al,
filed Feb. 15, 2011, and entitled "Patient-Adapted and Improved
Articular Implants, Designs and Related Guide Tools," the
disclosure of which is incorporated by reference herein. FIGS. 46
and 47 depict an alignment jig 5240 with an anatomical relief or
clearance zone 5245 that corresponds to a region adjacent to the
trochlear groove of the femur. FIGS. 48 and 49 depict an alignment
jig 5250 with an anatomical relief or clearance zone 5255 that
corresponds to a region adjacent to the trochlear groove of the
femur. FIGS. 50 and 51A depict an alignment jig 5260 with an
anatomical relief or clearance zone 5265 that corresponds to a
region adjacent to the trochlear groove of the femur.
[0617] It should be understood that such anatomical reliefs may be
utilized to accommodate anatomical variations in all joints,
including those of the knee, shoulder, hip, vertebrae, elbow,
ankle, wrist, etc. In addition, the anatomical relief surfaces
described herein would have equal utility for incorporation into
various implants, including partial or total joint replacement
implants, as well as surgical tools and/or molds.
[0618] VI. Kits
[0619] Also described herein are kits comprising one or more of the
methods, systems and/or compositions described herein. In
particular, a kit can include one or more of the following:
instructions (methods) of obtaining electronic images; systems or
instructions for evaluating electronic images; one or more computer
means capable of analyzing or processing the electronic images;
and/or one or more surgical tools for implanting an articular
repair system. The kits can include other materials, for example,
instructions, reagents, containers and/or imaging aids (e.g.,
films, holders, digitizers, etc.).
[0620] The following examples are included to more fully illustrate
the various disclosures herein. Additionally, these examples
describe various specific embodiments, they are not meant to limit
the scope thereof of the systems and methods described herein.
Example 1
Design and Construction of a Three-Dimensional Articular Repair
System
[0621] Areas of cartilage are imaged as described herein to detect
areas of cartilage loss and/or diseased cartilage. The margins and
shape of the cartilage and subchondral bone adjacent to the
diseased areas are determined. The thickness of the cartilage is
determined. The size of the articular repair system is determined
based on the above measurements. In particular, the repair system
is either selected (based on best fit) from a catalogue of
existing, pre-made implants with a range of different sizes and
curvatures or custom-designed using CAD/CAM technology. The library
of existing shapes is typically on the order of about 30 sizes.
[0622] The implant is a chromium cobalt implant. The articular
surface is polished and the external dimensions slightly greater
than the area of diseased cartilage. The shape is adapted to
achieve perfect or near perfect joint congruity utilizing shape
information of surrounding cartilage and underlying subchondral
bone. Other design features of the implant can include: a slanted
(60- to 70-degree angle) interface to adjacent cartilage; a
broad-based base component for depth control; a press fit design of
base component; a porous coating of base component for ingrowth of
bone and rigid stabilization; a dual peg design for large defects
implant stabilization, also porous coated; a single stabilizer
strut with tapered, four fin and step design for small, focal
defects, also porous coated; and a design applicable to femoral
resurfacing (convex external surface) and tibial resurfacing
(concave external surface).
Example 2
Minimally Invasive, Arthroscopically Assisted Surgical
Technique
[0623] The articular repair systems are inserted using arthroscopic
assistance. The device does not require the 15 to 30 cm incision
utilized in unicompartmental and total knee arthroplasties. The
procedure is performed under regional anesthesia, typically
epidural anesthesia. The surgeon can apply a tourniquet on the
upper thigh of the patient to restrict the blood flow to the knee
during the procedure. The leg is prepped and draped in sterile
technique. A stylette is used to create two small 2 mm ports at the
anteromedial and the anterolateral aspect of the joint using
classical arthroscopic technique. The arthroscope is inserted via
the lateral port. The arthroscopic instruments are inserted via the
medial port. The cartilage defect is visualized using the
arthroscope. A cartilage defect locator device is placed inside the
diseased cartilage. The probe has a U-shape, with the first arm
touching the center of the area of diseased cartilage inside the
joint and the second arm of the U remaining outside the joint. The
second arm of the U indicates the position of the cartilage
relative to the skin. The surgeon marks the position of the
cartilage defect on the skin. A 3 cm incision is created over the
defect. Tissue retractors are inserted and the defect is
visualized.
[0624] A translucent Lucite block matching the 3D shape of the
adjacent cartilage and the cartilage defect is placed over the
cartilage defect. For larger defects, the Lucite block includes a
lateral slot for insertion of a saw. The saw is inserted and a
straight cut is made across the articular surface, removing an area
slightly larger than the diseased cartilage. The center of the
Lucite block contains two drill holes with a 7.2 mm diameter. A 7.1
mm drill with drill guide controlling the depth of tissue
penetration is inserted via the drill hole. Holes for the
cylindrical pegs of the implant are created. The drill and the
Lucite block are subsequently removed.
[0625] A plastic model/trial implant of the mini-repair system
matching the outer dimensions of the implant is then inserted. The
trial implant is utilized to confirm anatomic placement of the
actual implant. If indicated, the surgeon can make smaller
adjustments at this point to improve the match, e.g. slight
expansion of the drill holes or adjustment of the cut plane.
[0626] The implant is then inserted with the pegs pointing into the
drill holes. Anterior and posterior positions of the implant are
color-coded; specifically the anterior peg is marked with a red
color and a small letter "A", while the posterior peg has a green
color and a small letter "P". Similarly, the medial aspect of the
implant is color-coded yellow and marked with a small letter "M"
and the lateral aspect of the implant is marked with a small letter
"L". The Lucite block is then placed on the external surface of the
implant and a plastic hammer is used to gently advance the pegs
into the drill holes. The pegs are designed to achieve a press
fit.
[0627] The same technique can be applied in the tibia. The implant
has a concave articular surface matching the 3D shape of the tibial
plateau. Immediate stabilization of the device can be achieved by
combining it with bone cement if desired.
Example 3
Design and Construction of a Implant and/or Surgical Tool
Incorporating a Negative Anatomical Relief
[0628] Anatomical relief features can be used to accommodate or
otherwise address osteophytes, subchondral voids, residual normal
or diseased cartilage or combinations thereof and other
patient-specific defects or abnormalities. In the case of
osteophytes, the osteophyte can be integrated into the shape of the
bone or joint facing surface of the implant component or guide
tool. FIGS. 52A and 52B are exemplary drawings of an end of a femur
1010 having an osteophyte 1020. In the selection and/or design of
an implant component for a particular patient, an image or model of
the patient's bone that includes the osteophyte or other surface
feature can be utilized as a model for creating, designing and/or
selecting an implant and/or surgical tool having one or more
conforming surfaces. If desired, the portion of the image having
the surface feature may be modified, transformed, cross-referenced,
smoothed and/or enhanced, which could be utilized to increase the
imaging accuracy of the osteophyte and/or account for inaccuracies
or potential inaccuracies in detection and/or modeling of the
osteophyte's surface. In one embodiment, as shown in FIG. 52B, an
implant (or surgical tool) component 1050 can be selected and/or
designed to include a negative anatomical relief conforming to the
shape of the osteophyte 1020. In alternative embodiments, the
anatomical relief could be sized and/or configured to accommodate
more than the osteophyte (i.e., the anatomical relief cavity could
be larger than the osteophyte, or could be shaped differently or
"filtered" to accommodate more than the osteophyte). In certain
embodiments, the anatomical relief may contact part, but not all,
of the osteophyte or other anatomical structure (i.e., the
anatomical relief may be oversized to encompass the entirety of the
osteophyte, with optionally some portion of the osteophyte touching
a wall of the anatomical relief). In other embodiments, the
anatomical relief may encompass only a portion of the osteophyte or
other anatomical structure, such as where a portion of the
anatomical structure lies within the anatomical relief and other
portions of the anatomical structure extend outside of the
anatomical relief.
[0629] As another example, a tibial component can be designed
either before or after virtual modification of various features of
the tibial bone, including surface features, have been
accomplished. In one embodiment, the initial design and placement
of the tibial tray and associated components can be planned and
accomplished utilizing information directly taken from the
patient's natural anatomy. In various other embodiments, the design
and placement of the tibial components can be planned and
accomplished after virtual modification of various bone portions,
including the removal, modification and/or enhancement of one or
more cut planes (to accommodate the tibial implant) as well as the
virtual removal, modification and/or enhancement of various
potentially-interfering structures (i.e., overhanging osteophytes,
etc.). Someone skilled in the art will readily recognize that this
is readily achievable also with a procedure that is based on
burring. Prior virtual removal, modification, enhancement and/or
filling of such structures can facilitate and improve the design,
planning and placement of tibial components, and prevent anatomic
distortion from significantly affecting the final design and
placement of the tibial components. For example, once one or more
tibial cut planes has been virtually removed or once an implant bed
has been designed for a burring procedure including a robotic
procedure, the size, shape and rotation angle of a tibial implant
component can be more accurately determined from the virtually cut
surface, as compared to determining the size, shape and/or tibial
rotation angle of an implant from the natural tibial anatomy prior
to such cuts. In a similar manner, structures such as overhanging
osteophytes can be virtually removed (either alone or in addition
to virtual removal of the tibial cut plane(s)), modified (such as,
for example, by incorporating a cut plane in the osteophyte that
forms an addition or extension to an existing cut plane on the
bone) with the tibial implant structure and placement (i.e., tibial
implant size, shape and/or tibial rotation, etc.) subsequently
planned. Of course, virtually any unusual and/or undesirable
anatomical features or deformity, including (but not limited to)
altered bone axes, flattening, potholes, cysts, scar tissue,
osteophytes, tumors and/or bone spurs may be similarly virtually
removed, modified, modeled and/or otherwise utilized in the implant
and/or surgical tool design and placement.
Example 4
Design and Construction of a Implant and/or Surgical Tool
Incorporating a Positive Anatomical Relief
[0630] Similarly, to address a subchondral void, a selection and/or
design for the bone-facing surface of an implant component can
include a positive anatomical relief integrated into the shape of
the bone-facing surface of the implant component. FIGS. 53A and 53B
are exemplary drawings of an end of a femur 1110 having a
subchondral void 1120. During development of an implant, an image
or model of the patient's bone that includes the void can be
utilized in creating, designing and/or selecting an implant and/or
surgical tool surface that conforms to the shape of void 1120, as
shown in FIG. 53B. In various other embodiments, the image may be
virtually altered to include additional removal, filling,
modification, filtering, smoothing and/or enhancement of voids,
etc., including virtual removal of the void, if desired. Moreover,
it may be desirous that the positive anatomical relief does not
completely conform to the void 1120, such as where the implant 1150
might not practically be able to be inserted into the void.
Therefore, in certain embodiments, the implant and/or surgical tool
may only partially protrude into a void in the bone. Optionally, a
surgical strategy and/or one or more guide tools can be selected
and/or designed to reflect the correction and correspond to the
implant component.
[0631] In addition to osteophytes and subchondral voids, the
methods, surgical strategies, guide tools, and implant components
described herein can be used to address various other
patient-specific joint defects or phenomena. In certain
embodiments, correction can include the virtual removal of tissue,
for example, to address an articular defect, to remove subchondral
cysts, and/or to remove diseased or damaged tissue (e.g.,
cartilage, bone, or other types of tissue), such as osteochondritic
tissue, necrotic tissue, and/or torn tissue. In such embodiments,
the correction can include the virtual removal or other
modification of the tissue image data (e.g., the tissue
corresponding to the defect, cyst, disease, or damage) and the
bone-facing surface of the implant component can be derived after
the tissue has been virtually removed or modified. For example, if
bone is several eburnated, it is feasible to add material to the
bone virtually and then form or design an implant. In certain
embodiments, the implant and/or surgical tool component can be
selected and/or designed to include a thickness or other anatomical
features that substantially matches the positive and/or negative
(or various combinations thereof) of the surface features,
including any virtually removed or added tissues. Alternatively,
the modification can include optimizing additional functional or
one or more other parameters of the joint. Optionally, a surgical
strategy and/or one or more guide tools can be selected and/or
designed to reflect the correction and correspond to the implant
component
Example 5
Design and Construction of a Surgical Tool Incorporating Multiple
Anatomical Reliefs
[0632] In certain embodiments, one or more additional models or
sets of models of the patient's biological structure also can be
generated and conveyed to the surgeon or clinician to show an
additional presence, or absence, of one or more defects of
interest, one or more resection cuts, one or more guide tools,
and/or one or more implant components, or any combination of these.
FIGS. 54A through 54D and 55A through 55D illustrate models for one
particular patient receiving a single compartment knee implant
having both femoral and tibial implant components. FIGS. 54A and
54B depict two perspective views of a patient's distal femur, and
FIGS. 54C and 54D depict two images of the patient's proximal
tibia, with patient-adapted guide tools shown in FIGS. 54B and 54D.
In these figures, anatomical defects or other surface structures,
which are osteophytes in this example, are categorized and
differentiated into two shades, lighter and darker. The
lighter-colored osteophytes 1210 depict osteophytes that do not
interfere with placement of a surgical guide tool or implant
components. The darker-shaded osteophytes 1220 depict osteophytes
that are anticipated to interfere with placement of a surgical
guide tool or implant component. Accordingly, this embodiment
includes the categorization of the osteophytes or other surface
features to serve as a guide or reference to the surgeon or
clinician in determining which, if any, osteophytes should be
removed prior to placement of the guide tools or implant components
and/or which, if any, osteophytes should be accommodated using, for
example, an anatomical relief, during placement of either or both
of the surgical guide tool (or tools) or implant components
[0633] FIGS. 55A and 55B depict two images, respectively, of a
patient's distal femur with a patient-adapted guide tool and with a
patient-adapted unicompartmental femoral implant component. FIGS.
55C and 55D depict two images, respectively, of the patient's
proximal tibia, with a patient-adapted guide tool and with a
patient-adapted unicompartmental tibial implant component. While
the images in this figure show no osteophytes, it should be
understood that in various embodiments such osteophytes could have
been surgically removed, while in other embodiments, the
osteophytes could remain and be accommodated using, for example,
anatomical reliefs on the various surgical tools and/or implants.
In a similar manner, various other embodiments could include tools
and/or implants that include anatomical reliefs to accommodate some
surface features (i.e., osteophytes, etc.), while other surface
features are surgically removed.
[0634] FIGS. 55C and 55D further depict a further embodiment where
the surgical tool of FIG. 55C incorporates an anatomical relief
(not shown) while the corresponding implant FIG. 55D does not
include an anatomical relief surface. The surgical tool, which
serves as an alignment guide for creation of a cutting plane, uses
the anatomical surface of the tibia (including surface features
such as osteophytes, etc.), which, in this embodiment, optionally
mandates the inclusion of one or more anatomical relief surfaces to
accommodate these surface features. The implant, however, rests
completely upon the surgically cut plane, and thus need not include
an anatomical relief, as desired, for proper placement and fixation
on the cut tibial surface.
[0635] FIGS. 56A through 56D and 57A through 57D illustrate models
for a different patient receiving a bicompartmental knee implant
having both femoral and tibial implant components. The features in
FIGS. 56A through 56D and 57A through 57D are similar to those
described above for FIGS. 54A through 54D and 55A through 55D. In
comparing the models for the two different individuals, the
individual receiving the unicompartmental knee implant possesses
substantially more osteophyte coverage than the individual
receiving the bicompartmental knee implant.
Example 6
Identification, Classification and/or Modification of Relevant
Surface Defects and/or Other Anatomical Features Relevant to the
Potential Inclusion of Anatomical Relief Surfaces
[0636] In certain embodiments, the reference points and/or
anatomical features of a patient can be can be processed using
mathematical functions to derive virtual, corrected features, which
may represent a restored, ideal or desired feature from which a
patient-adapted implant component can be designed. For example, one
or more features, such as surfaces or dimensions of a biological
structure can be modeled, altered, added to, changed, deformed,
eliminated, corrected and/or otherwise manipulated (collectively
referred to herein as "variation" of an existing surface or
structure within the joint). While it is described in the knee,
these embodiments can be applied to any joint or joint surface in
the body, e.g. a knee, hip, ankle, foot, toe, shoulder, elbow,
wrist, hand, and a spine or spinal joints.
[0637] Variation of the joint or portions of the joint can include,
without limitation, variation of one or more external surfaces,
internal surfaces, joint-facing surfaces, uncut surfaces, cut
surfaces, altered surfaces, and/or partial surfaces as well as
surface/subsurface and/or external features such as osteophytes,
subchondral cysts, geodes or areas of eburnation, joint flattening,
contour irregularity, and loss of normal shape. The surface or
structure can be or reflect any surface or structure in the joint,
including, without limitation, bone surfaces, ridges, plateaus,
cartilage surfaces, ligament surfaces, or other surfaces or
structures. The surface or structure derived can be an
approximation of a healthy joint surface or structure or can be
another variation. The surface or structure can be made to include
pathological alterations of the joint. The surface or structure
also can be made whereby the pathological joint changes are
virtually removed in whole or in part.
[0638] Computer software programs to generate models of
patient-specific renderings of implant assembly and defects (e.g.,
osteophyte or other anatomical structures), together with bone
models, to aid in surgery planning can be developed using various
publicly available programming environments and languages, for
example, Matlab 7.3 and Matlab Compiler 4.5, C++ or Java. In
certain embodiments, the computer software program can have a user
interface that includes one or more of the components identified in
FIG. 58. Alternatively, one or more off-the-shelf applications can
be used to generate the models, such as SolidWorks, Rhinoceros, 3D
Slicer or Amira.
[0639] An illustrative flow chart of the high level processes of an
exemplary computer software program is shown in FIG. 59. Briefly, a
data path associated with one or more patient folders that include
data files, for example, patient-specific CT images, solid models,
and segmentation images, is selected. The data files associated
with the data path can be checked, for example, using file filters,
to confirm that all data files are present. For example, in
generating models for a knee implant, a data path can confirm the
presence of one, several, or all coronal CT or MRI data files,
sagittal CT or MRI data files, a femoral solid model data file, a
tibial solid model data file, a femoral guide tool model, a tibial
guide tool model, a femoral coronal segmentation model, a femoral
sagittal segmentation model, a tibial coronal segmentation model,
and a tibial sagittal segmentation model. If the filter check
identifies a missing file, the user can be notified. In certain
instances, for example, if a tibial or femoral guide tool model
file is unavailable, the user may elect to continue the process
without certain steps, for example, without guide tool--defect
(e.g., osteophyte or other surface feature) interference
analysis.
[0640] Next, a patient-specific cartilage or bone-surface model is
obtained and/or rendered. The cartilage or bone surface model
provides basic patient-specific features of the patient's
biological structure and serves as a reference for comparison
against a model or value that includes the defect(s) and/or surface
features of interest. As an illustrative example, previously
generated patient-specific files, for example, STL files exported
from "SOLID" IGES files in SolidWorks, can be loaded, for example,
as triangulation points with sequence indices and normal vectors.
The triangles then can be rendered (e.g., using Matlab TRISURF
function) to supply or generate the cartilage or bone-surface
model. The cartilage or bone surface model can include defects
and/or other surface features, such as osteophytes. If desired,
some or all of these surface features may selectively be analyzed,
assessed, corrected, filtered, removed, filled, smoothed, modified
in shape or size or composition, enhanced or otherwise manipulated
and/or cross-referenced with other features in the same image or
with similar features from other images. In this fashion, one or
more cartilage and/or bone models, implant models and/or surgical
tool models can be obtained and/or rendered.
[0641] Next, a patient-specific model or values of the patient's
biological feature that include the defect of interest (or other
surface features) can be obtained, rendered and/or otherwise
manipulated. For example, patient-specific surface features such as
osteophytes can be identified from analysis of the patient's
segmentation images and corresponding CT scan images. The
transformation matrix of scanner coordinate space to image matrix
space can be calculated from image slice positions (e.g., the first
and last image slice positions). Then, patient-specific
segmentation images for the corresponding scan direction can be
assessed, along with CT image slices that correspond to the loaded
segmentation images. Images can be processed slice by slice or as a
volume and, using selected threshold values (e.g., intensity
thresholds, Hounsfield unit thresholds, or neighboring pixel/voxel
value thresholds), pixels and/or voxels corresponding to the
surface feature of interest (e.g., osteophytes) can be identified.
The identified voxels can provide a binary cartilage or bone
surface volume that includes the surface features of interest as
part of the surface of the patient's biological structure. If
desired, various masks can be employed to mask out surface features
that are not of interest, for example, an adjacent biological
surface. In some instances, masking can generate apparent
unattached portions of an osteophyte defect or other surface
feature, for example, when a mask covers a portion of an osteophyte
extension.
[0642] Next, the surface features of interest are isolated by
comparing the model that does not include the defects of interest
(e.g., cartilage or bone-surface model) with the model or value
that does include the surface features of interest (e.g., the
binary cartilage or bone surface volume). For example, the
triangulation points of the cartilage or bone surface model can be
transformed onto an image volume space to obtain a binary
representation of the model. This volume binary can be dilated and
thinned to obtain a binary cartilage or bone model. The binary bone
model then can serve as a mask to the binary cartilage or bone
surface volume to identify surface feature volume separate from the
binary cartilage or bone surface volume. For example, for
osteophyte detection, the osteophyte volume (e.g., osteophyte
binary volume), as well as the osteophyte position and attachment
surface area, can be distinguished from the patient's biological
structure using this comparative analysis. Various thresholds and
filters can be applied to remove noise and/or enhance surface
feature detection in this step. For example, structures that have
less than a minimum voxel volume (e.g., less than 100 voxels) can
be removed. Alternatively, or in addition, rules can be added to
"reattach" any portion of an osteophyte or other surface feature
that appears unattached, e.g., due to a masking step.
[0643] In an alternative approach, surface data can be used instead
of voxel or volume data when comparing the bone surface model with
corrected surface features and the patient's actual bone surface.
The bone surface model, for example, can be loaded as a mesh
surface (e.g. in an STL file) or a parametric surface (e.g. in an
IGES file) without conversion to volumetric voxel data. The
patient's natural cartilage or bone surface can be derived from the
medical image data (e.g. CT data) using, for example, a marching
cubes or isosurface algorithm, resulting in a second surface data
set. The cartilage or bone surface model and the natural cartilage
or bone surface can be compared, for example, by calculating
intersection between the two surfaces.
[0644] In another alternative approach, the 3D representation of
the biological structure can be generated or manipulated, for
example, smoothed or corrected, for example, by employing a 3D
polygon or mesh surface, a subdivision surface or parametric
surface, for example, a non-uniform rational B-spline (NURBS)
surface, or an implicit surface. For a description of various
parametric surface representations see, for example Foley, J. D. et
al., Computer Graphics: Principles and Practice in C;
Addison-Wesley, 2nd edition (1995). Various methods are available
for creating a parametric surface. For example, the 3D
representation can be generated directly as a parametric surface
from image data of the biological structure, for example CT or MR
images, by approximating the contours of the biological structure
with the surface. Alternatively, a parametric surface can be
best-fit to the 3D representation by connecting data points to
create a surface of polygons and applying rules for polygon
curvatures, surface curvatures, and other features, or using
publicly available software such as Geomagic.RTM. software
(Research Triangle Park, N.C.). Other possible 3D representations
of the biological structure can be defined as implicit surfaces,
such as level sets, isosurfaces, or adaptive data structures.
Alternatively, the surface can be represented volumetrically or as
a point cloud.
[0645] Next, optionally, the models can be used to detect
interference between any surface feature volume and the placement
of one or more guide tools and/or implant components. For example,
guide tool model triangulation points can be transformed onto an
image volume space to obtain a binary representation of the guide
tool. The binary structure then can be manipulated (e.g., dilated
and eroded using voxel balls having pre-set diameters) to obtain a
solid field mask. The solid field mask can be compared against the
surface feature volume, for example, the osteophyte binary volume,
to identify interfering surface feature volume, for example,
interfering osteophyte binary volume. In this way, interfering
surface feature volume and non-interfering surface feature volume
can be determined (e.g., using Matlab ISOSURFACE function), for
example, using representative colors or some other distinguishing
features in a model. The resulting model image can be rendered on a
virtual rendering canvas (e.g., using Matlab GETFRAME function) and
saved onto a computer-readable medium.
[0646] Finally, optionally, as exemplified by FIGS. 54A through
57D, one or more combinations of model features can be combined
into one or models or sets of models that convey desired
information to the surgeon or clinician. For example,
patient-specific cartilage or bone models can be combined with any
number of surface features and/or surface feature types, any number
of resection cuts, any number of drill holes, any number of axes,
any number of guide tools, and/or any number of implant components
to convey as much information as desired to the surgeon or
clinician. The patient-specific cartilage or bone model can model
any biological structure, for example, any one or more (or portion
of) a femoral head and/or an acetabulum; a distal femur, one or
both femoral condyle(s), and/or a tibial plateau; a trochlea and/or
a patella; a glenoid and/or a humeral head; a talar dome and/or a
tibial plafond; a distal humerus, a radial head, and/or an ulna;
and a radius and/or a scaphoid. Surface features that can be
combined with a patient-specific cartilage or bone model can
include, for example, osteophytes, voids, subchondral cysts,
articular shape defects (e.g., rounded or flattened articular
surfaces or surface portions), varus or valgus deformities, or any
other deformities or other surface or subsurface or external (i.e.,
non-surface or subsurface) features known to those in the art.
[0647] The models can include virtual corrections and/or
modifications reflecting a surgical plan, such as one or more
removed or modified surface features such as osteophytes, cut
planes, drill holes, realignments of mechanical or anatomical axes.
The models can include comparison views demonstrating the
anatomical situation before and after applying the planned
correction. The individual steps of the surgical plan can also be
illustrated in a series of step-by-step images wherein each image
shows a different step of the surgical procedure.
[0648] The models can be presented to the surgeon as a printed or
digital set of images. In another embodiment, the models are
transmitted to the surgeon as a digital file, which the surgeon can
display on a local computer. The digital file can contain image
renderings of the models. Alternatively, the models can be
displayed in an animation or video. The models can also be
presented as a 3D model that is interactively rendered on the
surgeon's computer. The models can, for example, be rotated to be
viewed from different angles. Different components of the models,
such as cartilage or bone surfaces, surface features and/or
defects, resection cuts, axes, guide tools or implants, can be
turned on and off collectively or individually to illustrate or
simulate the individual patient's surgical plan. The 3D model can
be transmitted to the surgeon in a variety of formats, for example
in Adobe 3D PDF or as a SolidWorks eDrawing.
Example 7
The Use of External Anatomical Relief Surfaces to Accommodate
Non-Joint Surfaces and/or Structures
[0649] Implant and or surgical tool selection, design and modeling
can also incorporate external anatomical relief surfaces to
facilitate surgical procedures and implants that are ligament
sparing, as well as for other soft and or hard tissues forming part
of, or adjacent to, the treated anatomical structures. For example,
with regard to the PCL and/or the ACL, an imaging test can be
utilized to identify, for example, the origin and/or the insertion
of the PCL and the ACL on the femur and tibia. The origin and the
insertion can be identified by visualizing, for example, the
ligaments directly, as is possible with MRI or spiral CT
arthrography, or by visualizing bony landmarks known to be the
origin or insertion of the ligament such as the medial and lateral
tibial spines. Such structures can be subsequently modeled on a
suitable computing system, or imaged directly from the structures,
or a combination thereof.
[0650] An implant system and/or surgical tool can then be selected
or designed based on the image data so that, for example, the
femoral component preserves the ACL and/or PCL origin, and the
tibial component preserves the ACL and/or PCL attachment. The
implant can be selected or designed so that bone cuts adjacent to
the ACL or PCL attachment or origin do not weaken the bone to
induce a potential fracture. If desired, a motion study or other
three-dimensional analysis can be conducted to determine if
portions of the implant will directly or indirectly contact or
otherwise influence (i.e., force other structures into contact
with) surrounding soft or hard tissue structures. Similar studies
can analyze the implant and/or surrounding hard or soft tissues to
determine what, if any, effects the implant will have on the
surrounding tissues, including through the effect of the surgical
procedure, e.g. cutting, drilling, burring, depth of cut, etc.
[0651] For ACL preservation, the implant can have two
unicompartmental tibial components that can be selected or designed
and placed using the image data. Alternatively, the implant can
have an anterior bridge component. The width of the anterior bridge
in AP dimension, its thickness in the superoinferior dimension or
its length in mediolateral dimension can be selected or designed
using the imaging data and, specifically, the known insertion of
the ACL and/or PCL.
[0652] As can be seen in FIGS. 60A and 60B, the posterior or any
margin of an implant component, e.g. a polyethylene- or
metal-backed tray with polyethylene inserts, can be selected and/or
designed using the imaging data or shapes derived from the imaging
data so that the implant component includes one or more external
anatomical relief surfaces 1300 that desirably will not interfere
with and stay clear of the PCL or other tendons such as the
popliteus tendon. This can be achieved, for example, by including
external anatomical relief surfaces comprising one or more
concavities or removal of other structures in the outline of the
implant that are specifically designed or selected or adapted to
avoid the ligament insertion. In various other embodiments, an
implant can include an external anatomical relief surface
comprising one or more projections or other surfaces that contact,
guide or otherwise influence other tissues in some manner to
prevent unwanted contact or other interaction with other portions
of the implant (e.g., a projection could act as a guide or other
feature to prevent a tendon or other structure from being "pinched"
and/or severed by interacting articulating surfaces of the implant
and/or other surfaces of the implant and/or natural joint. Such
external anatomical relief surfaces could prevent structures from
contacting moving portions of the implant, as well as prevent the
structures from moving into contact with surfaces that could sever,
abrade and/or otherwise damage or injure the structures (either
quickly or after long-term repetitive contact).
[0653] If desired and/or as necessary, any implant component can be
selected and/or adapted to include external anatomical relief
surfaces that desirably stay clear of important ligament
structures. Imaging data can help identify or derive shape or
location information on such ligamentous structures. For example,
the lateral femoral condyle of a unicompartmental, bicompartmental
or total knee system can include a concavity or divot to avoid the
popliteus tendon. Imaging data can be used to design a tibial
component (all polyethylene or other plastic material or metal
backed) that avoids the attachment of the anterior and/or posterior
cruciate ligament; specifically, the contour of the implant can be
shaped so that it will stay clear of these ligamentous structures.
A safety margin, e.g. 2 mm or 3 mm or 5 mm or 7 mm or 10 mm can be
applied to the design of the edge of the component to allow the
surgeon more intraoperative flexibility. In a shoulder, the glenoid
component can include one or more external anatomical relief
surfaces, such as concavities or divots, to avoid a subscapularis
tendon or a biceps tendon or other tendons. In a hip, the femoral
component can include an external anatomical relief surface
selected or designed to avoid an iliopsoas or adductor tendon or
other tendons.
[0654] With regards to a tibial tray component, various embodiments
could include external anatomical relief surface features to avoid
undesirable contact with surrounding ligaments and/or tendons,
include (1) depth of dish optionally adapted to presence or absence
of intact anterior and/or posterior cruciate ligaments, and (2)
depth of trough optionally adapted to presence or absence of intact
anterior and/or posterior cruciate ligaments.
[0655] Additional tibial tray designs could include features to
avoid additional soft tissue structures including those disclosed
in FIGS. 61A THROUGH 61D. For example, FIG. 61C depicts a tibial
tray and insert having an undesirable medial-lateral width that
results in contact with the medial-collateral ligament (MCL) on one
side and the lateral collateral ligament (LCL) on the other side of
the tray/insert. If desired, the tray and/or insert could include
one or more indentations or voids (not shown) on one or more sides
that accommodate the MCL and/or LCL ligaments, allowing the knee to
flex and extend without undue contact and/or wear of the ligaments
along the sides of the tray and/or insert.
[0656] Alternatively, or in combination with one or more anatomical
relief surfaces, indentations and/or voids, the tray and/or insert
can incorporate one or more shape(s) that accommodate the various
ligaments of the knee and desirably avoid and/or reduce undesirable
contact with such ligamentous structures, to include designs such
as shown in dotted lines in FIGS. 61A and 61B as well as the design
shown in 61D.
Example 8
Adjustable Contact Surfaces and Anatomical Relief Surfaces in
Surgical Tools
[0657] FIGS. 62A through 62C depict a series of jigs designed to
make patient-specific cuts to the tibia. An exemplary tibial jig,
depicted in FIG. 62A, is first placed on the anterior tibial
cortex, with extenders onto the tibial plateau. The extenders can
include cartilage or bone facing surfaces that are patient
specific. A Steinmann or other pin can be placed in the medial
and/or lateral tibial plateau through a hole in the extender. The
Steinmann pin can then be used as a guide for a tool used to core
or surgically remove the cartilage surrounding the pin. In this
manner, it is possible to design the extenders so that the patient
specific shape is derived from the subchondral bone rather than the
cartilage, e.g. subchondral bone subjacent to cartilage, and so
that the extender can rest on the subchondral bone after the coring
procedure. This technique can be beneficial when various degrees of
cartilage loss in one plateau or differences in cartilage loss
between a medial plateau and a lateral plateau are not well
visualized on a CT scan or MRI scan.
[0658] FIGS. 62A through 62C depict one embodiment of a surgical
tool or jig that incorporates adjustable contact surfaces that can
be extended and/or retracted to account for differing thicknesses
of the articular cartilage including normal and diseased cartilage.
In various embodiments, the various contact surfaces can
incorporate and/or be separated by one or more anatomical relief
surfaces.
[0659] Where the patient-specific imaging information has been
collected using x-rays and/or CT scans or the like (or where
artifacts are adjacent to or in the line-of-sight of areas being
imaged), it is often difficult (if not impossible) to visualize the
articular cartilage and other soft tissues, which potentially
results in an unknown depth of cartilage during the surgical
procedure. In this embodiment, the subchondral bone contact
surfaces comprise an adjustable screw arrangement or other
adjustable mechanism, which can be advance and/or retracted as
desired, to account for varying thickness of articular cartilage
and/or accommodate other variations or unknown quantities regarding
the anatomical surfaces. One or more such screws or adjustment
mechanisms can be advanced to equal depths, or can be asymmetric
lengths, as desired by the surgeon. Optionally, the screws can be
printed during the generation of the disposable jig with a 3D
printing process. In various alternative embodiments, the
patient-specific surgical tool can be designed to contain portions
that rest on cartilage, other portions that rest on bone
(subchondral, cortical, trabecular, and/or various anatomical
relief surfaces as described herein). For example, a tool may rest
on the articular cartilage of a femoral condyle and also curve
around the condylar edges to contact bone. The surgical tool can
also include anatomical relief surfaces that rest on or otherwise
contact or accommodate areas that include osteophytes, or that
otherwise avoid contact with various portions of the underlying
anatomical surfaces.
[0660] In various embodiments, the patient's anatomical information
for the surgical tools may be derived using different 2D or 3D
imaging techniques. Since some imaging techniques do not display
soft tissue, cartilage surface information may be estimated by
offsetting the underlying bone surface by the expected cartilage
thickness. If a surgical tool is designed to rest on cartilage and
on bone, anatomical relief surfaces (i.e., "offset" surfaces) and
non-offset surfaces may desirably be combined to design the
patient-specific tool. This can be achieved by calculating smooth
transitions between portions of offset and non-offset surfaces.
Alternatively, an offset surface may be used to trim a non-offset
surface or vice versa.
Example 9
Anatomical Relief Surfaces in Surgical Tools for Various
Anatomy
[0661] If desired, one or more sets of jigs can be designed to
include anatomical relief surfaces that desirably facilitate and/or
accommodate surgical procedures on bones and joint other than the
knee. Desirably, the surgical tools/jigs are designed in connection
with the design of a patient-specific implant component. The
designed jigs guide the surgeon in performing one or more
patient-specific cuts to the bone so that those cut bone surface(s)
negatively-match the patient-specific bone cuts of the implant
component.
[0662] FIG. 63A depicts a normal humeral head and upper humerus
which forms part of a shoulder joint. FIG. 63B depicts the humeral
head having an alignment jig designed to identify and located
various portions of the humeral anatomy. In this embodiment, a jig
having a plurality of conforming surfaces has been designed using
patient-specific information regarding one or more of the humerus,
the humeral neck, the greater tuberosity and/or the lesser
tuberosity of the humerus. Desirably, the conforming surfaces will
fit onto the humerus on only one position and orientation, thereby
aligning to the humerus in a known position. This embodiment can
incorporate an alignment hole 18400 which aligns with an axis 18410
of the humeral head. After proper positioning of the jig, a pin or
other mechanism (i.e., drill, reamer, etc.) can be inserted into
the hole 18400, and provide a secure reference point for various
surgical operations, including the reaming of the humeral head
and/or drilling of the axis 18400 in preparation for a humeral head
resurfacing implant or other surgical procedure. The alignment
mechanisms may be connected to the one or more conforming surfaces
by linkages (removable, moveable and/or fixed) or other devices, or
the entire jig may be formed from a single piece and extend over a
substantial portion of the humeral head and/or other bone.
[0663] FIG. 63C depicts an alternative embodiment of a humeral head
jig that utilizes a single conforming surface to align the jig. In
this embodiment, the jib includes an anatomical relief surface that
is substantially a negative and engages one or more protrusions or
osteophytes of the anatomical surface, which facilitates alignment
and positioning of the jig in a known manner.
[0664] FIG. 64A depicts a humeral head with osteophytes, and FIGS.
64B and 64C depict the humeral head with a more normalized surface
that has been corrected by virtual removal of the osteophytes. FIG.
65A depicts a humeral head with voids, fissures or cysts, and FIGS.
65B and 65C depict the humeral head with a more normalized surface
that has been corrected by virtual removal of the voids, fissures
or cysts. As previously disclosed, various embodiments of the
surgical tools and/or implants described herein can incorporate
anatomical relief surfaces that conform to, are substantially a
negative, encompass, engulf or otherwise engage and/or avoid
engagement of such anatomical features, which can include the
virtual and/or actual removal of some, but not all, of such surface
features from the patient's anatomy prior to introduction of the
surgical tools and/or implant.
[0665] FIG. 66A depicts a glenoid component with osteophytes, and
FIG. 66B depicts the glenoid component with a more normalized
surface that has been corrected by virtual removal of the
osteophytes. FIGS. 66C and 66D depict two alternative embodiments
of a glenoid jig for use with the glenoid, each of which
incorporates conforming surfaces with anatomical relief surfaces
that accommodate the osteophytes. If desired, the jig of FIG. 66C
can be formed from an elastic or flexible material to allow it to
"snap fit" over the glenoid component and associated osteophytes.
As previously noted, the jigs can include various alignment holes,
slots, etc., to allow placement of pins or other surgical
actions.
[0666] FIG. 67A depicts a glenoid component with voids, fissures or
cysts, and FIG. 67B depicts the glenoid component with a more
normalized surface that has been corrected by virtual "filling" of
the voids, fissures or cysts. FIG. 67C depicts an embodiment of a
glenoid jig for use with the glenoid component, which incorporates
various conforming surfaces with anatomical relief surfaces that
accommodate the voids, fissures and/or cysts (and other surfaces)
of the glenoid component.
[0667] The foregoing description of embodiments have been provided
for the purposes of illustration and description. It is not
intended to be exhaustive or to be limited to the precise forms
disclosed. Many modifications and variations will be apparent to
the practitioner skilled in the art. The embodiments were chosen
and described in order to best explain the principles and their
practical applications, thereby enabling others skilled in the art
to understand the disclosure and the various embodiments and with
various modifications that are suited to the particular use
contemplated. It is intended that the scope be defined by the
following claims equivalents thereof.
* * * * *
References