U.S. patent application number 16/537721 was filed with the patent office on 2019-11-28 for medical apparatus and method for attaching a suture to a bone.
This patent application is currently assigned to T.A.G. Medical Devices - Agriculture Cooperative Ltd.. The applicant listed for this patent is T.A.G. Medical Devices - Agriculture Cooperative Ltd.. Invention is credited to Sumant G. KRISHNAN, Aryeh MIROCHINIK, Shai NACHMIAS, Ran OREN, Lee RANON.
Application Number | 20190357901 16/537721 |
Document ID | / |
Family ID | 41016538 |
Filed Date | 2019-11-28 |
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United States Patent
Application |
20190357901 |
Kind Code |
A1 |
OREN; Ran ; et al. |
November 28, 2019 |
MEDICAL APPARATUS AND METHOD FOR ATTACHING A SUTURE TO A BONE
Abstract
A method of forming a channel in a bone, the method comprising:
providing a first bore in the bone; and forming, a second bore in
the bone at a predefined angle from said first bore, using said
first bore as a reference point for defining the location of the
second bore in the bone, wherein the first and second bores
intersect in the bone.
Inventors: |
OREN; Ran; (Kibbutz Gaaton,
IL) ; KRISHNAN; Sumant G.; (Dallas, TX) ;
RANON; Lee; (Moshav Shavey Tzion, IL) ; NACHMIAS;
Shai; (Nahariya, IL) ; MIROCHINIK; Aryeh;
(Akko, IL) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
T.A.G. Medical Devices - Agriculture Cooperative Ltd. |
Kibbutz Gaaton |
|
IL |
|
|
Assignee: |
T.A.G. Medical Devices -
Agriculture Cooperative Ltd.
Kibbutz Gaaton
IL
|
Family ID: |
41016538 |
Appl. No.: |
16/537721 |
Filed: |
August 12, 2019 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
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12919516 |
Aug 26, 2010 |
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PCT/IL08/01316 |
Oct 5, 2008 |
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16537721 |
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61129394 |
Jun 23, 2008 |
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61064333 |
Feb 28, 2008 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61B 17/1796 20130101;
A61B 17/1778 20161101; A61B 17/0469 20130101; A61B 2017/00358
20130101; A61B 17/1684 20130101; A61B 2017/00424 20130101; A61B
2017/0445 20130101; A61B 17/0485 20130101; A61B 17/0401 20130101;
A61B 17/0482 20130101; A61B 2017/0409 20130101 |
International
Class: |
A61B 17/04 20060101
A61B017/04; A61B 17/17 20060101 A61B017/17; A61B 17/16 20060101
A61B017/16 |
Claims
1. A method of forming a channel in a bone, the method comprising:
providing a first bore in the bone; and forming a second bore in
the bone at a predefined angle from said first bore, using said
first bore as a reference point for defining the location of the
second bore in the bone, wherein the first and second bores
intersect in the bone.
2. A method according to claim 1 wherein defining the location
further comprises defining the depth of the second bore such that
the second bore intersects with the first bore but will not exit
the bone except at a single point.
3. A method according to claim 1 further comprising providing an
implement comprising a hook having an end portion for insertion in
the first bore and a passageway for receiving tools, the passageway
being at a non-zero angle to the end portion of the hook, wherein
using said first bore as a reference point comprises inserting the
hook in said first bore.
4. A method according to claim 3, wherein forming a second bore
comprises forming a second bore using a drill inserted through said
passageway.
5. A method according to claim 3, further comprising clamping the
implement to the bone using the hook as an arm of the clamp.
6. A method according to claim 5, wherein clamping comprises moving
a manipulatable member of the implement rearwardly so as to permit
the passageway to be retracted rearwardly of the hook and, after
inserting the hook into the first bore, releasing the manipulatable
member thereby clamping the passageway to the bone by resilient
force.
7. A method according to claim 3, wherein said angle is between
65.degree. and 75.degree..
8. A method according to claim 1 wherein forming said second bore
comprises forming such that the second bore extends past the
intersection of the first and second bore in the bone.
9. A method according to claim 1 wherein forming said second bore
comprises forming such that the second bore does not cross the
bone.
10. A method according to claim 1, further comprising: threading
the first end of a suture through the second bore, while leaving
the second end outside the bone; capturing the first end of the
suture from the first bore at the intersection of the bores in the
bone; and threading the first end of the suture through the first
bore.
11. A method according to claim 10, wherein capturing the first end
of the suture comprises capturing using a grasper extending from
the hook.
12. A method according to claim 10, wherein capturing comprises
manipulating a second manipulatable member coupled to said grasper
for moving the grasper to an extended with respect to the hook for
facilitating entry of said first end of the suture through said
loop into said first bore of the bone, and to a retracted position
towards said hook for clamping said first end of the suture to
enable threading said first end of the suture through said first
bore of the bone.
13. A method according to claim 12, wherein said second
manipulatable member includes a knob coupled to a stem slidable
through a slot in said handle and coupled to said loop.
14. A method according to claim 13, wherein said stem is coupled to
said loop by a cable extending through a sleeve in said handle
coupled to said hook.
15. A method according to claim 13, wherein said knob is slidable
along an axis parallel to the longitudinal axis of the handle.
16. A method according to claim 13, wherein said knob is pivot
along a pivot axis perpendicular to the longitudinal axis of the
handle.
17. A method according to claim 10, wherein the grasper comprises a
loop.
18. A method according to claim 10 wherein said suture is also
threaded through a tendon.
19. A method according to claim 10 further comprising knotting the
first and second ends of the suture.
20. A method according to claim 1 wherein said bone is a humerus
bone.
Description
RELATED APPLICATIONS
[0001] This application is a division of U.S. patent application
Ser. No. 12/919,516 filed on Aug. 26, 2010, which is a National
Phase of PCT Patent Application No. PCT/IL2008/001316 having
International Filing Date of Oct. 5, 2008, which claims the benefit
of U.S. Provisional Patent Application No. 61/064,333 filed on Feb.
28, 2008 and U.S. Provisional Patent Application No. 61/129,394
filed on Jun. 23, 2008. The contents of the above Applications are
all incorporated herein by reference.
FIELD AND BACKGROUND OF THE INVENTION
[0002] The present invention relates to medical apparatus,
particularly to a medical implement and a kit including such an
implement, and also to a method, for attaching a suture to a bone.
The invention is especially useful in an arthroscopic surgical
procedure for attaching a tendon of a rotator cuff muscle to the
humerus bone for repairing a damaged shoulder joint, and is
therefore described below with respect to such a procedure.
[0003] While the shoulder joint has a great range of motion, it is
not very stable. Four rotator cuff muscles (supraspinatus,
infraspinatus, subscapularis and teres minor) surround the shoulder
joint and provide the power to lift and rotate the arm while
keeping the head of the upper arm bone (humerus) in approximation
to the socket in the shoulder blade (glenoid) for stability. Each
of these muscles is attached by a tendon to the humerus bone. The
supraspinatus muscle is attached by the supraspinatus tendon to the
superior aspect of the greater tubercle. The infraspinatus muscle
is attached by the infraspinatus tendon to the posterolateral
aspect of the greater tubercle. The teres minor muscle is attached
by the teres minor tendon to the lower aspect of the greater
tubercle. The subscapularis muscle is attached by the subscapularis
tendon to the lesser tubercle. As one ages, these muscles and
tendons become thinner and prone to rupture. A rotator cuff tear
may develop gradually or may result suddenly from a single
traumatic event. In a younger patient, rupture is usually
associated with significant trauma. Rotator cuff tears are tears of
one or more of the four tendons of the rotator cuff muscles listed
above. Tears of the surpraspinatus tendon are the most common, most
often involving detachment of the tendon from the bone. The tear of
the supraspinatus tendon usually occurs at its point of insertion
onto the humeral head at the greater tubercle. Since this tear is
the most common, the following description will refer to the
supraspinatus tear. However, it is submitted that the invention
described below is applicable to any of the rotator cuff tears and
in fact to any tear of a tendon from a bone.
[0004] When surgical intervention is indicated to repair a rotator
cuff tear, the procedure can be performed as an open surgical
procedure, or as a minimally invasive (arthroscopic) surgical
procedure. Both procedures aim to re-attach the tendon to the bone
over an area extending from the anatomical neck to the lateral
surface of the tubercle. The relatively large area of attachment is
desirable for strengthening purposes and for assisting recovery and
healing. This procedure of osseointegration of the tendon to the
bone causes bony tissue to be formed around the tendon and anchors
it in place.
[0005] In open surgery, after the joint has been exposed, the
tubercle is accessed laterally, and a row of holes are drilled
aiming to exit in the area of the anatomical neck. Sutures are led
through these holes; the tendon is stretched to lie over the
planned area of attachment; and the suture coming from the exit
point is passed through the tendon. When the sutures leading from
the inlet and exit points are knotted, one strand overlies the
tendon, thus achieving attachment over the surface of the tubercle
from the lateral inlets to the anatomical neck.
[0006] In contrast, the arthroscopic procedures use bone anchors.
Two rows of anchors are implanted, one in the neck area and one on
the lateral surface of the tubercle. Sutures leading from the
anchors are passed through the tendon and are knotted over it.
[0007] Both procedures have shortcomings. With the open method, the
bone tunnels for the sutures can be drilled only in one direction,
from the lateral upwardly to the anatomical neck. Access for
drilling from the anatomical neck at an angle to reach the side of
the tubercle is obstructed by the patient's neck and head. It is
difficult to achieve exactly the desired exit points for the drill.
Exiting on the spherical humeral head must be avoided. Drilling at
a more acute angle for safety may result in being too close to the
surface of the tubercle.
[0008] A minimally invasive (arthroscopic) method is desirable when
not contra-indicated from medical considerations. However, the
conventional arthroscopic procedure uses anchors resulting in
points or lines of attachment, rather than in attachments over a
significant surface.
OBJECTS AND BRIEF SUMMARY OF THE PRESENT INVENTION
[0009] Objects of the present invention are to provide a medical
implement, a kit including such an implement, and a method, for
attaching a suture to a bone having advantages in one or more of
the above respects and particularly useful in an arthroscopic
surgical procedure.
[0010] There is thus provided in accordance with an exemplary
embodiment of the invention a method of forming a channel in a
bone, the method comprising: [0011] providing a first bore in the
bone; an [0012] forming, a second bore in the bone at a predefined
angle from said first bore, using said first bore as a reference
point for defining the location of the second bore in the bone,
wherein the first and second bores intersect in the bone.
[0013] In an exemplary embodiment defining the location further
comprises defining the depth of the second bore such that the
second bore intersects with the first bore but will not exit the
bone except at a single point.
[0014] Optionally, using said first bore as a reference point
comprises inserting a hook in said first bore. Optionally, said
hook and a drill for forming said second bore are linked such that
the second bore is at a predetermined angle from the first
bore.
[0015] Optionally, forming said second bore comprises forming such
that the second bore extends past the intersection of the first and
second bore in the bone. Optionally, forming said second bore
comprises forming such that the second bore does not cross the
bone.
[0016] In an exemplary embodiment said bone is a humerus bone.
[0017] There is further provided in accordance with an exemplary
embodiment of the invention, a method of forming a bore in a bone,
the method comprising: [0018] providing a first bore in the bone;
[0019] providing an implement comprising a hook having an end
portion for insertion in the first bore and a passageway for
receiving tools, the passageway being at a non-zero angle to the
portion; [0020] inserting the hook in the first bore; [0021]
clamping the implement to the bone using the hook as an arm of the
clamp; [0022] forming a second bore using a drill inserted through
said passageway in the implement, such that the first and second
bore intersect in the bone.
[0023] In an exemplary embodiment, said implement further comprises
a locking mechanism for clamping the implement to the bone.
Optionally, forming a second bore comprises forming a second bore
extending past the intersection of the first and second bore in the
bone. Optionally, forming a second bore comprises forming a second
bore which does not exit the bone at more than one point.
[0024] In an exemplary embodiment, said bone is a humerus bone.
[0025] There is further provided in accordance with an exemplary
embodiment of the invention, a method of attaching a suture to a
bone, the method comprising: [0026] providing a first and second
bore in a bone, the first and second bores intersecting in the
bone; [0027] providing a suture having a first and second end;
[0028] threading the first end of a suture through the second bore,
while leaving the second end outside the bone; [0029] capturing the
first end of the suture from the first bore at the intersection of
the bores in the bone; and [0030] threading the first end of the
suture through the first bore.
[0031] Optionally, said suture is also threaded through a tendon.
Optionally, the method further comprises knotting the first and
second ends of the suture.
[0032] In an exemplary embodiment, said bone is a humerus bone.
[0033] There is further provided in accordance with an exemplary
embodiment of the invention, a medical implement for forming a bore
in a bone, comprising: [0034] a hook for inserting in a first bore
in a bone; [0035] a passageway for receiving tools; [0036] wherein
said passageway is adapted for receiving a drill for forming a
second bore in a bone when said hook is inserted in the first bore,
and wherein the second bore is oriented with respect to the hook
such that said second bore intersects with the first bore in the
bone.
[0037] Preferably, the second bore is oriented with respect to the
hook such that the first bore and second bore define a predefined
angle.
[0038] Optionally, said drill comprises a stop adapted to define
the depth of the second bore to be formed. Optionally, said
implement further comprises a locking mechanism for clamping the
implement to the bone.
[0039] In an exemplary embodiment, said locking mechanism consists
of a first and a second element which clamp the bone between them
and wherein said first element is the hook inserted into the first
bore. Preferably, said predefined angle is 70.degree.. Optionally,
said predefined angle is between 65.degree. and 75.degree..
[0040] There is further provided in accordance with an exemplary
embodiment of the invention, a medical implement for forming a bore
in a bone, comprising: [0041] a hook for inserting in a first bore
in a bone; and [0042] a passageway for placement at an entrance to
a second bore in the bone, [0043] wherein said hook comprises a
loop extending thereform, said loop being adapted to grasp an end
of a suture inserted through the passageway and through the second
bore.
[0044] Optionally, said hook is further adapted to extract the
suture through the first bore. Optionally, said implement further
comprises a locking mechanism for clamping the passageway against
the bone when the hook is inserted into the first hole.
[0045] There is further provided in accordance with an exemplary
embodiment of the invention, a medical implement for forming a bore
in a bone, the implement comprising: [0046] a hook for inserting in
a first bore in a bone; [0047] a passageway for placement at an
entrance to a second bore in the bone; and [0048] a locking
mechanism for clamping the passageway against the bone, [0049]
wherein said locking mechanism consists of a first and a second
element which clamp the bone between them and wherein said first
element is the hook inserted into the first bore.
[0050] There is further provided in accordance with an exemplary
embodiment of the invention a medical kit of instruments for
forming a bore in a bone, comprising: [0051] a first drill for
drilling a first bore in a bone; [0052] a second drill for drilling
a second bore in the bone; [0053] a suture for threading through
said first and second bores in the bone; and [0054] a medical
implement according to any of claims 40-51.
[0055] Optionally, said kit further comprises: a drill guide for
receiving said first drill and forming said first bore.
[0056] In an exemplary embodiment said second drill is thinner then
said first drill.
[0057] Optionally, said first and second drills comprise a stop
such that said first bore formed with said drill does not pass
through the bone.
[0058] Optionally, said kit further comprises a suture loader for
threading said suture through said second bore.
[0059] According to one aspect of the invention, there is provided
a medical implement for attaching suture to a bone, particularly
useful in arthroscopic surgical procedures, comprising a handle
having a proximal end for manual grasping and a distal end for
engagement with a bone to which a suture is to be attached, the
bone being pre-formed with a first bore for receiving one end of
the suture; a hook carried at the distal end of the handle, spaced
from an outer surface at the distal end of the handle, and
configured for reception in the first bore of the bone; the hook or
distal end of the handle being in the form of a movable member
movable to an extended position with respect to the other to
facilitate reception of the hook into the first bore, and to a
retracted position with respect to the distal end of the handle for
clamping the handle to the bone at a predetermined angle with
respect to the first bore; and a manually manipulatable member
carried by the proximal end of the handle and coupled to the
movable member for moving the movable member to the extended and
retracted positions; the handle being formed with a passageway
extending longitudinally therethrough from its proximal end to its
distal end, the passageway being configured for receiving a drill,
after the handle has been clamped to the bone, for drilling a
second bore through the bone at the predetermined angle with
respect to the first bore and, after the drill has been removed
from the passageway, for passing through the passageway the one end
of the suture to traverse, and to extend past, the first bore such
that the one end of the suture is accessible through the first bore
for being pulled out therefrom, while the opposite end of the
suture is accessible through the second bore for pulling out
therefrom in order to attach the suture to the bone.
[0060] Two embodiments of the invention are described below for
purposes of example. In one described embodiment, the movable
member is the hook, and is movable to its extended and retracted
positions with respect to the distal end of the handle. In a second
described embodiment, the movable member is the distal end of the
handle, which is movable to its extended and retracted positions
with respect to the hook.
[0061] In both described preferred embodiments, the hook includes a
loop movable to an extended position with respect to the hook for
facilitating entry of the first end of the suture through the loop
into the first bore of the bone, and to a retracted position
towards the hook for clamping the first end of the suture to enable
pulling--out the first end of the suture through the first bore of
the bone. In addition, the handle includes a second manually
manipulatable member carried by the proximal end of the handle and
coupled to the handle for moving the loop to its extended and
retracted positions.
[0062] In another described embodiment, the first end of the suture
is accessed through the first bore in the bone, and pulled out, by
a suture hook.
[0063] According to another aspect of the present invention, there
is provided a medical kit useful for attaching a suture to a bone,
the kit including a medical implement as described above, and a
drill receivable within the passageway of the handle for drilling
the second bore in the bone; the drill including a stop engageable
with the proximal end of the handle to fix the length of the second
bore to extend for a slight distance past the first bore, to
thereby permit the first end of the suture to traverse and extend
past the first bore in order to facilitate its access and
extraction via the first bore.
[0064] According to a still further aspect of the present
invention, there is provided a method for attaching a suture to a
bone particularly in an arthroscopic procedure, comprising: forming
a first bore in the bone; forming a second bore in the bone
intersecting the first bore and extending at a predetermined angle
thereto; introducing into the second bore a first end of a suture
to extend through the second bore past the intersection of the
second bore with the first bore, with the opposite end of the
suture extending outwardly of the second bore; accessing the first
end of the suture via the first bore; and extracting the first end
of the suture via the first bore, to enable attaching the suture to
the bone via the end of the suture.
[0065] As will be described more particularly below, the invention
enables the surgeon to perform bone tunnels in the bone in exactly
the required locations to receive sutures, and thereby to achieve
reattachment of the torn tendon without the use of bone anchors, in
a manner similar to that of the open surgical procedure. The
invention is therefore particularly useful in an arthroscopic
surgical procedure, but may also be used in an open surgical
procedure.
[0066] Further features and advantages of the invention will be
apparent from the description below.
BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS
[0067] The invention is herein described, by way of example only,
with reference to the accompanying drawings, wherein:
[0068] FIGS. 1A, 1B and 1C illustrate the construction of the
shoulder joint to be repaired according to an embodiment of the
present invention, including the construction of the upper part of
the humerus bone (FIG. 1A), a schematic section through the
shoulder joint (FIG. 1B), and a damaged shoulder joint (FIG. 1C) to
be repaired;
[0069] FIG. 2 is a perspective view of one preferred embodiment of
a medical bone-tunneling implement constructed according to the
present invention for use in repairing a damaged shoulder
joint;
[0070] FIG. 3 is an enlarged detailed view of the distal end of the
medical implement of FIG. 2, and particularly the loop projecting
from the hook at the distal end;
[0071] FIG. 4 is a top view of the implement of FIG. 2;
[0072] FIG. 5 is a sectional view along line V-V of FIG. 4;
[0073] FIGS. 6A and 6B are enlarged fragmentary views of the
encircled portions of FIG. 5;
[0074] FIG. 7 is a side view of the medical implement of FIG.
2;
[0075] FIG. 8 is a sectional view along line VIII-VIII of FIG.
7;
[0076] FIG. 9 is an enlarged detail view of the encircled portion
of FIG. 8;
[0077] FIGS. 10A-10D are enlarged views of the hook at the distal
end of the medical implement of FIG. 2;
[0078] FIG. 11 illustrates the contents of a medical kit including
the implement of FIG. 2, together with other implements,
particularly useful for performing an arthroscopic surgical
procedure according a preferred embodiment of the invention
described herein;
[0079] FIG. 12 more particularly illustrates the construction of
the suture loading needle in the medical kit of FIG. 11;
[0080] FIGS. 13A and 13B are enlarged fragmentary views of the
encircled portions of FIG. 12;
[0081] FIG. 14 illustrates a suture hook which may be included in
the medical kit of FIG. 11 for use in performing the arthroscopic
surgical procedure according to another embodiment of the
invention;
[0082] FIG. 15 is an enlarged fragmentary view of the encircled
portion of FIG. 14;
[0083] FIG. 16 is a perspective view of a second preferred
embodiment of a medical bone-tunneling implement constructed
according to the present invention for use in repairing a damaged
shoulder joint;
[0084] FIGS. 17 and 18 are top and side views, respectively, of the
medical implement of FIG. 16;
[0085] FIG. 19 is a longitudinal sectional view along section line
A-A of FIG. 17;
[0086] FIG. 20 is an enlarged fragmentary view of encircled portion
B of FIG. 19;
[0087] FIG. 21 is an enlarged fragmentary view of the encircled
portion C of FIG. 19;
[0088] FIG. 22 is a flow diagram of a method of attaching a suture
to a bone in accordance with an exemplary embodiment of the
invention;
[0089] FIGS. 23A-23J are schematic illustrations of phases of the
method of FIG. 22; and
[0090] FIG. 24 is a schematic illustration of an implement used for
repairing a damaged shoulder joint in accordance with another
exemplary embodiment of the invention.
[0091] It is to be understood that the foregoing drawings, and the
description below, are provided primarily for purposes of
facilitating understanding the conceptual aspects of the invention
and possible embodiments thereof, including what is presently
considered to be a preferred embodiment. In the interest of clarity
and brevity, no attempt is made to provide more details than
necessary to enable one skilled in the art, using routine skill and
design, to understand and practice the described invention. It is
to be further understood that the embodiments described are for
purposes of example only, and that the invention is capable of
being embodied in other forms and applications than described
herein.
DESCRIPTION OF PREFERRED EMBODIMENTS OF THE INVENTION
[0092] An aspect of some embodiments of the invention relates to
attaching a tendon to a bone by threading a suture through a
channel in the bone and through the tendon. In an exemplary
embodiment of the invention, the channel comprises of a first and a
second bore intersecting in the bone. In an exemplary embodiment of
the invention, the intersection of the bores define a predetermined
angle between them, suitable for attaching a tendon to the bone by
threading a suture through the bores and the tendon. Preferably,
the first and second bores are formed in an arthroscopic
procedure.
[0093] In an exemplary embodiment, the first bore is formed first
and is then used to assist forming the second bore. Optionally, the
first bore is used as a reference point for determining the
location and/or alignment of the second bore in the bone.
Alternatively or additionally, the reference point is used for
determining the depth of the second bore such that the first and
second bores intersect in the bone. Optionally, at least one of the
first and second bore extends past the intersection of the bores in
the bone such that a hook or loop may be inserted in one of the
bores, crossing the intersection of the bores in the bone, to
conveniently capture a suture inserted via the other bore.
[0094] In an exemplary embodiment of the invention, a hook inserted
into the first bore is used for clamping an implement, with which
the second bore is formed, to the bone, thereby stabilizing the
implement when drilling the second bore. Optionally, the hook
extending from the implement is inserted into the first bore and is
used as an arm for the clamp. The implement is then locked in a
position clamped to the bone, with the first bore as both a
reference and a holding point for the implement. The second bore is
then formed by a tool preferably guided by a passageway in the
implement. Optionally, the hook has a tip in the form of a rod,
inserted in the first bore.
[0095] An aspect of some embodiments of the invention relates to
threading a suture though the second bore and extracting the suture
through the first bore. In an exemplary embodiment of the invention
an end of a suture is threaded through the second bore and grasped
at the intersection of the bores in the bone by a loop extending
from the hook inserted through the first bore. The loop with the
suture is then extracted through the first bore. Optionally, said
loop is replaced with any other suitable mechanism known in the art
for grasping a suture, for example, a hook.
[0096] In an exemplary embodiment of the invention there is
provided an implement comprising a hook for insertion into a first
bore. In an exemplary embodiment, the hook comprises a mechanism
configured to grasp an end of a suture threaded through the second
bore at the intersection of the bores in the bone. Optionally, the
mechanism is further configured to thread the end of the suture
through the first bore when extracting the hook from the bore.
Optionally, said mechanism comprises a loop. Optionally, the loop
is movable between an extracted position in which it is removed
from the bore and an extended position in which it is extended into
the intersection of the bores to grasp the end of the suture.
[0097] In an exemplary embodiment of the invention, the implement
comprising a hook further comprises a passageway for receiving
tools for forming of or inserting into a second bore. Optionally,
the hook and the passageway are located such that when the hook is
inserted into the first bore, a drill inserted through the
passageway is configured to drill a second bore at a predefined
angle from the first bore. Optionally, the predefined angle is
70.degree.. Alternatively, the predefined angle is between
65.degree. and 75.degree.. Alternatively, the predefined angle is
between 30.degree. and 120.degree..
[0098] Optionally. The drill is further configured to aid in
determining the depth of the second bore to be drilled, by
reference to the position of the hook which is inserted in the
first bore. In an exemplary embodiment of the invention, the drill
is configured such that the depth of the second bore to be drilled
is suitable for different bones of a plurality of subjects and does
not require adjustment for specific bones.
[0099] Optionally, the implement further comprises a locking
mechanism for clamping the implement to the bone when the hook is
inserted into the first bore.
[0100] In an exemplary embodiment, the first and second bores are
formed with a same implement comprising of two channels for
receiving tools such as a drill and a suture. In this embodiment
the two bores are formed at the same side of the bone and the angle
formed between the bores is preferably less than 45.degree..
[0101] In the following description reference will be made to
attaching a supraspinatus tendon to a humerus bone. However, it is
understood that the invention may be adapted to attach any tendon
or other soft tissue to any bone of a body.
The Shoulder Joint and its Repair (FIGS. 1A-1C)
[0102] FIG. 1A schematically illustrates the structure of the upper
part of a humerus bone 2. It includes a spherical head 3 for
reception in the glenoid socket 4, and an anatomical neck 5 joined
to a greater tubercle 6 and a lesser tubercle 7. The juncture of
the latter with the humerus bone 2 is a surgical neck 8.
[0103] FIG. 1B is a schematic coronal section through the shoulder
joint, showing: a supraspinatus tendon 10 of a supraspinatus muscle
11, the greater tubercle 6, and a shoulder blade (scapula) 12.
[0104] FIG. 1C schematically shows the separation of the tendon 10
from the greater tubercle 6 in a damaged shoulder joint which is to
be repaired by the reattachment of the tendon.
[0105] As will be described below, this is accomplished, according
to some embodiments of the present invention, by forming two bores
B.sub.1 and B.sub.2 (FIG. 1C). The tendon is captured and drawn
toward the left in the figure, so that it covers bore B.sub.2, as
described below and a suture or sutures are passed through the two
bores and through the tendon 10; and knotting the two ends of the
suture or sutures, to thereby firmly attach the tendon to the bone.
As will also be described below, the invention enables the two
bores B.sub.1, B.sub.2 to be conveniently made in their required
locations and at a predetermined angle to each other to achieve the
reattachment of the torn tendon by sutures, rather than by bone
anchors, in a manner similar to the open surgical procedures,
thereby enabling an arthroscopic surgical procedure to be used for
repairing a damaged shoulder joint.
The Medical Implement of FIGS. 2-10D
[0106] The medical implement illustrated in FIGS. 2-10D is a
bone-tunneling implement according to an embodiment of the
invention, designed for use in a medical procedure, particularly an
arthroscopic surgical procedure for attaching a suture to a bone,
utilizing the two-bore technique of FIG. 1C for receiving the
suture through the two bores B.sub.1, B.sub.2, as briefly described
above, and as to be described more particularly below.
[0107] FIG. 2 illustrates the medical implement used for producing
bore B.sub.2 (FIG. 1C) after bore B.sub.1 has been formed, so that
the two bores are located to intersect each other at a preselected
angle for receiving the suture. The implement illustrated in FIG. 2
includes a handle 20 having a proximal end 21 for manual grasping,
and a distal end 22 for engagement with the bone to which the
suture is to be attached after bore B.sub.1 has been formed in the
bone. As shown in FIG. 2, the distal end 22 of the illustrated
implement is optionally formed with a ribbed outer surface 23 to
enable secure engagement with the bone.
[0108] Handle 20 is further preferably formed with a passageway 20a
therethrough extending from the proximal end toward its distal end
(FIGS. 2 and 5). As will be described more particularly below, this
passageway is located and configured first to receive a drill for
making bore B.sub.2 (FIG. 1C), and then to receive one end of a
suture to be attached to the bone.
[0109] The proximal end 21 of the implement illustrated in FIG. 2
is optionally of an octagonal shape. It is further optionally
formed with an elongated slot 24 longitudinally of its upper face
terminating in a transversely extending slot formed through its two
opposed side faces.
[0110] The proximal end 21 of handle 20 further carries an optional
manually manipulatable member 26 optionally including two opposed
finger pieces 26a, 26b connected by a central stem 26c (FIG. 9)
located within slots 24 and 25 and movable therealong preferably to
the ends of the two slots 24 and 25. The distal end 21 of handle 20
further carries an optional lock nut 27 having internal threads
threadedly received on threads 27a formed in the side walls in the
proximal end 21 of handle 20. As will be described more
particularly below, manipulatable member 26 is slidable within slot
25, and lock nut 27 is effective to lock member 26 in its moved
position.
[0111] The distal end 21 of handle 20 further includes another
manipulatable member 28 having a stem 28a (FIG. 4) extending
through the upper slot 24, and an optional knob 28b engageable by
the user for moving member 28 to its forward position illustrated
in FIG. 2, or to its rearward position at the end of slot 24.
[0112] The distal end 22 of handle 20 is formed with a slot 29
(FIG. 2) for the reception of a hook, generally designated 30,
coupled to manipulatable member 26 so as to be movable from an
extended position, illustrated in FIG. 2, to a retracted position
towards the ribbed distal outer surface 23 of the handle.
Manipulatable member 26 is used for extending hook 30 to its
illustrated extended position to facilitate reception of the hook
into the first bore B.sub.1 (FIG. 1C) of the bone, and to its
retracted position for clamping the handle to the bone such that
the passageway 20a, which is used for making the second bore
B.sub.2 (FIG. 1C), is at a predetermined angle (in this case
90.degree.) with respect to, and in alignment with, the first bore
B.sub.1. Optionally, the angle is 70.degree.. Alternatively, the
angle is between 65.degree. and 75.degree.. alternatively, the
angle is between 30.degree. and 120.degree.. Thus, as shown in
FIGS. 2 and 10B, hook 30 includes a first section 31 received
within slot 29 of the handle, an upwardly-extending section 32
joined to a horizontal section 33, and a downwardly-extending end
section 34 to be received within bore B.sub.1, as shown in FIG.
23.
[0113] A loop 35 is optionally received within the
downwardly-extending end section 34 of hook 30. It includes a pair
of parallel legs 35a, 35b (FIGS. 3 and 10D) joined by a bridging
section 35c. As will be described more particularly below, hook 35
is coupled to manipulatable member 28. Manipulatable member moves
the hook to an extended position, as illustrated in FIGS. 2 and 3
or to a retracted position towards the tip of the
downwardly-extending section 34 of hook 30. The position of the
hook in the extended position enables a suture to pass between the
two legs 35a, 35b. Optionally, the hook is then moved to a
retracted position for extraction from bore B.sub.1 (FIG. 1C) of
the bone to which the suture is to be attached.
[0114] The manner in which the hook 30 is coupled to manipulatable
member 26, in the preferred embodiment, for moving the hook to its
illustrated extended position or to its retracted position, is more
particularly seen in FIGS. 8 and 9. As shown particularly in FIG.
8, the central pin 26c of manipulatable member 26 is formed with a
bore 26d into which is threaded a screw 26e for securing
manipulatable member 26 to an elongated sleeve 40 (FIG. 9)
integrally formed with or fixed to the hook 30.
[0115] As shown in FIG. 5, and more particularly in FIGS. 2, 3 and
10A-10D, loop 35 is slidably received within hook 30. The two legs,
35a, 35b of the loop normally extend outwardly of the distal end of
the hook and are joined at juncture 35d to a wire 35e passing
through sleeve 40 of the hook. The proximal end of wire 35e is
fixed to a connector 35f receiving the stem 28a of manipulatable
member 28 (FIGS. 6A and 6B).
[0116] In an exemplary embodiment of the invention, the arrangement
is such that hook 30 and loop 35 are normally in their extended
positions as illustrated in FIG. 2, wherein the leg 34 of loop 30
is spaced away from the distal end 22 of handle 20, and loop 35 is
extended outwardly of the hook leg 34. In this condition, in
accordance with this embodiment, the hook 30 is inserted within
bore B.sub.1 (FIG. 1C) of the bone to which the suture is to be
attached, with the loop 35 straddling bore B.sub.1 and spaced away
from the distal tip of leg 34 of the hook in order to receive one
end of the suture to be attached to the bone. This arrangement
enables the loop to be positioned for receiving the suture from
bore B2 and not to collide with residues from drilling bore B2. In
this embodiment, bore B2 is narrower than bore B1 thereby enabling
the drill forming bore B2 to pass through the loop which is
inserted through bore B1.
[0117] In another embodiment of the invention, hook 30 and loop 35
are in their retracted position, as shown in FIG. 5, when inserted
into bore B1. The retracted position of hook 30 and loop 35 easies
the insertion of the hook into the bore since the end of the hook
is more rigid in its retracted position. Optionally, loop 35 is
moved to its retracted position before forming bore B2 such that
the drill forming bore B2 will pass through loop 35.
[0118] After the hook has thus been inserted into bore B.sub.1 of
the bone, in accordance with the above described embodiments,
manipulatable member 26 is moved rearwardly and is locked in
position for example by optional locking nut 27 to firmly clamp the
hook to the bone, with the passageway 20a within handle 20 in
alignment with bore B.sub.1 and at a predetermined angle therewith
(in this case 90.degree.). A drill is then passed through
passageway 20a of handle 20 to drill bore B.sub.2 in the bone
intersecting bore B.sub.1 and extending slightly past that bore.
After the drill is removed, the loop is moved to its extracted
position if necessary. One end of the suture to be attached to the
bone is then passed through passageway 20a, and between legs 35a
and 35b of loop 35 to the end of bore B.sub.2.
[0119] Knob 28 is then moved rearwardly to move loop 35 to its
retracted position, i.e, towards the end hook leg 34, to firmly
grasp the suture. The arrangement is such that the two bores
B.sub.1, B.sub.2 are located for attaching the suture to the bone,
one end of the suture may be extracted via bore B.sub.1, and the
other end of the suture may be extracted via bore B.sub.2.
The Medical Kit of FIG. 11
[0120] FIG. 11 illustrates the contents of a medical kit which may
be supplied for use in performing the arthroscopic surgical
procedure described above, and to include the medical implement as
described above with respect to FIGS. 2-10D.
[0121] Such a kit would include one or more of the following
additional tools: a drill guide 51, an obturator 52, and a drill
bit 53, for use in forming bore B.sub.1 (FIG. 1C) through the bone
to which the suture is to be attached; a drill 54 for forming bore
B.sub.2 via passageway 20a of implement 50; and a suture loader 55
for forcing the suture, via passageway 20a, into bore B.sub.2.
[0122] As shown particularly in FIG. 11, drill 54 used for forming
bore B.sub.2 includes a stop 54a at its proximal end to define the
depth of bore B.sub.2 to be produced thereby. The depth of bore
B.sub.2 should be coordinated with the length of bore B.sub.1 and
with the distance between distal end 22 of implement 50 and hook 30
after the implement is extended and clamped to the bone. This
distance is varies for different bodies depending on the bone
structure of the treated body. Optionally, stop 54a is not fixed
and can be moved to vary the depth of bore B.sub.2 for different
bones. In some embodiments, markings are provided on the extended
portion of implement 50 to indicate the distance of extension.
Drill 54 also includes markings which coordinate with the markings
on implement 50 and allows positioning of stop 54a according to the
distance between distal end 22 and hook 30 of implement 50.
Alternatively, stop 54a is fixed and such that the depth of bore
B.sub.2 will suit any bone in a body.
[0123] In an exemplary embodiment, drill 53 used for forming bore
B.sub.1 also includes a stop 53a. In this embodiment, the position
of stop 53a and stop 54a are coordinated so that the depth of bores
B.sub.1 and B.sub.2 are defined and the bores intersect in the
bone.
[0124] In an exemplary embodiment, drill 54 is narrower than drill
53 such that drill 54 will pass through a loop inserted in bore
B.sub.1 which was formed by drill 53. Alternatively, drill 54 is
used for forming both bore B.sub.1 and bore B.sub.2.
[0125] In an exemplary embodiment, suture loader 55, as more
particularly illustrated in FIGS. 12 and 13A-13B, includes a shank
55a formed with a notch 55b at its distal end and handle 55c at its
proximal end, which shank is formed with a pair of opposed flat
surfaces 55d parallel to notch 55b, to facilitate aligning the
suture received within notch 55b to bore B.sub.1 formed in the
bone. Other designs of suture manipulators can also be used.
[0126] In an exemplary embodiment, cannulated drill guide 51 is
inserted into passageway 20a of implement 50 and is adapted to
receive both obturator 52 and drill 53. The obturator 52 is
inserted within drill guide 51 in order to locate the exact
location of bore B.sub.1 and to clear a path through the soft
tissue surrounding the bone for the drill to drill bore B1 in the
bone. The obturator is then removed to enable drill 53 to drill
bore B.sub.1 via guide 51. After bore B.sub.1 has been drilled,
medical implement 50 is then used to drill bore B.sub.2 by
inserting hook 30 into bore B.sub.1 to locate passageway 20a of
implement 50 in precise alignment with bore B.sub.1 and at a
predetermined optimum angle thereto. In some situations an
obturator may not be required.
[0127] Drill 54 is then passed through passageway 20a of implement
50 to drill bore B.sub.2. Drill 54 is then removed and knob 28 is
moved to extend loop 35 from hook 30, if it was not already
extended during the drilling of bore B.sub.2. The suture to be
attached to the bone is then fed through passageway 20a by suture
loader 55 traversing bore B.sub.1 between the two legs 35a, 35b of
loop 35 to the end of bore B.sub.2. Optionally, drill 54 is
cannulated and the suture is threaded through cannulated drill 54.
In this option, the drill is removed after the thread is already in
place or together with the entire implement. Loop 35 is then
retracted within the end of hook 30 and to firmly clamp the suture
to the end of hook 30. Hook 30 is removed from bore B.sub.1 to
expose the clamped end of the suture, and handle 20 of implement 50
is also removed to expose the other end of the suture. Accordingly,
with the suture passing through the two bores B.sub.1 and B.sub.2,
and the two ends of the suture exposed outwardly of these bores,
the sutures may now be used for attaching the bone tendon to the
bone, or for any other purpose, instead of the anchor pins as
previously used.
[0128] It will thus be seen that the implement and kit described
are particularly useful for arthroscopic medical procedures to
attach a tendon to a bone, such as to repair a damaged shoulder
joint. However, the invention could also be used in open surgical
procedures, or for other procedures requiring the attachment of a
suture to a bone instead of anchor pins heretofore used for such
purposes.
Variation in Use of Medical Kit
[0129] FIGS. 14 and 15 illustrate a variation wherein one end of
the suture is accessed and extracted via bore B.sub.1, not by the
loop 35 as described above, but rather by a suture hook, generally
designated 56 in FIGS. 14 and 15. Such a suture hook includes a
shank 56a formed with a crochet notch 56b at its distal end, and an
optional handle 56c at its proximal end. Such a suture hook enables
the end of the suture received within bore B.sub.2 to be accessed
and extracted via bore B.sub.1, thereby obviating the need for the
loop 35 in implement 50 as described above with respect to FIGS.
2-10D. Suture hook 56 illustrated in FIGS. 14 and 15 may thus also
be included in the tool kit illustrated in FIG. 11 to be used
instead of the loop 35 of implement 50.
The Medical Implement of FIGS. 16-21
[0130] FIGS. 16-21 illustrate another bone-tunneling implement
constructed in accordance with an embodiment of the present
invention, generally corresponding to the implement described above
with respect to FIGS. 2-10D, but incorporating a number of
modifications.
[0131] In the bone-tunneling implement illustrated in FIGS. 2-10D,
the hook 30 is the movable element movable with respect to the
distal end of the handle 20 in order to facilitate the reception of
the hook into the first bore B.sub.1, and for clamping the handle
to the bone at a predetermined angle with respect to the first
bore. In the medical implement of FIGS. 16-21 this arrangement in
reversed; that is, in the medical implement of FIGS. 16-21, the
movable member is the distal end of the handle, which is movable
towards and away from the hook. Such an arrangement has the
advantage of simplifying the mechanism for moving the movable
element.
[0132] Another difference in the structure of the medical implement
of FIGS. 16-21, over that of FIGS. 2-10D, is that the manipulatable
member or knob 28 in FIGS. 2-10D is not slidable along an axis
parallel to the longitudinal axis of the handle, but rather is
pivotal along a pivot axis perpendicular to the longitudinal axis
of the handle. In addition, the lock nut 27 used in the medical
implement of FIGS. 2-10D to lock the manually-manipulatable member
26, is omitted. Such features not only simplify the structure, but
also facilitate its use by the surgeon.
[0133] The medical implement illustrated in FIGS. 16-21 is
generally designated 100. It includes a handle 120 having a
proximal end 121 for manual grasping, and a distal end 122 for
engagement with a bone in which a suture is to be attached. As in
the previously-described embodiment, the bone would be pre-formed
with a first bore B.sub.1 (FIG. 1C). The medical implement of FIGS.
16-21 also includes a hook 130 at the distal end of the handle, and
a loop 135 movable to an extended position with respect to the hook
for facilitating entry of one end of the suture through the loop,
and to a retracted position for clamping the respective end of the
suture, as described above with respect to FIGS. 2-10D.
[0134] In the implement of FIGS. 2-10D, the hook (30) is the
movable element with respect to the distal end (22) of the handle;
the construction of FIGS. 16-21 reverses these parts. That is, in
the construction of FIGS. 16-21, the hook 130 is fixed, and the
distal end 122 of the handle is movable towards and away from the
hook in order to facilitate the entry and removal of the hook into
the first bore B.sub.1.
[0135] This feature can be best seen in FIG. 19, wherein it will be
seen that the handle 120 is hollow, and slidably receives a core
123 having a distal end 122 movable towards and away from the hook
130.
[0136] As clearly seen in FIG. 19, core 123 is urged by a spring
124 in the direction of bringing the distal end 122 into engagement
with the hook 130, but may be manually moved rearwardly by means of
manipulatable member 126 having a stem passing through longitudinal
slots 127 (FIG. 18) in handle 120 so as to permit the distal end
122 to be retracted rearwardly of hook 130 against the bias of
spring 124. As further seen particularly in FIG. 19, the core 123
is formed with passageway 120a (corresponding to passageway 20a in
FIGS. 2-10D) used for making a second bore B.sub.2 shown in FIG.
1C. At the distal end 122, passageway 120a is a slot in core
123.
[0137] Loop 135 received within hook 130 is basically of the same
construction as described above with respect to loop 35 in FIGS.
2-10D, in that it is coupled to knob 128 to move the hook to its
extended and retracted positions in order to grasp a suture passed
between the two legs of the hook for extraction from bore B.sub.1,
as described above with respect to FIGS. 2-10D. The coupling of the
loop 135 to knob 128 is also effected by means a wire 135e passing
through the distal end of handle 120.
[0138] In the implement of FIGS. 16-21, however, manipulatable knob
128 for loop 135 is pivotal about an axis 128a extending
perpendicularly to the longitudinal axis of the handle 120 and
located slightly above that longitudinal axis, as can be seen
particularly in FIG. 19. Thus, as shown in FIG. 19, loop 135 would
normally be urged, by spring 124 to its retracted position within
hook 130 (FIG. 19), but is conveniently movable to its extended
position, shown in FIG. 18, by merely pivoting knob 128 forwardly,
whenever it is desired to extend the loop for receiving the end of
the suture. Releasing the knob will then effect the retraction of
the loop to firmly grasp the suture, as described above with
respect to the implement of FIGS. 2-10D.
[0139] In addition, whereas hook 30 shown in FIG. 2 formed an angle
of about 90.degree. between horizontal section 33 and end section
34, in the embodiment shown in FIGS. 16-21, hook 130 forms a larger
angle of about 110.degree.-115.degree. between horizontal section
33 and end section 34. Accordingly, with this embodiment, the angle
between bores B.sub.1 and B.sub.2 formed using implement 100 is
about 65.degree.-70.degree..
[0140] In substantially all other respects, the bone-tunneling
implement illustrated in FIGS. 16-21 is constructed, and operates,
in the same manner as described above.
[0141] It is to be understood that, where applicable, implements
according to various embodiments of the invention can include
features taken from both described embodiments of the
bone-tunneling implements. Furthermore, it should be clear that
other methodologies to provide the functions performed by the two
above embodiments can also be used.
Method of Attaching a Suture to a Bone (FIGS. 22 and 23A-G)
[0142] FIG. 22 is a block diagram of a method 220 of attaching a
suture to a bone in accordance with an exemplary embodiment of the
invention. FIGS. 23A-G are illustrations of stages of method 220.
the illustrations and description below refers to implement 100
shown in FIGS. 16-21. It is noted that method 220 with appropriate
changes may be applied with implement 50 shown in FIGS. 2-10D or
other variations of the implement.
[0143] A first bore B1 is formed in the humerus bone at 222.
Preferably, bore B1 is formed near the greater tubercle 6 shown in
FIG. 23A and FIGS. 1A-1C and is not long enough to exit the bone.
Optionally, as shown in FIG. 23A, bore B1 is drilled with a drill
bit 53 inserted through drill guide 51. Optionally, an obturator is
first inserted through drill guide 51 in order to clear a path
through the soft tissue surrounding the bone. Alternatively, bore
B1 is formed by any other method known in the art.
[0144] Hook 130 is then inserted into bore B1 at 224. Optionally,
the hook is inserted through drill guide 51, as indicated in FIG.
23B, in order to ease locating bore B1 and the drill guide is
removed after insertion.
[0145] Optionally, the insertion of the hook into bore B1 is used
as a reference point for forming bore B2, such that bores B1 and B2
intersect at a predetermined angle. Alternatively or additionally,
hook 130 is used as an arm clamping implement 100 to the bone.
Before inserting hook 130 to bore B1, manipulatable member 126 is
moved rearwardly so as permit distal end 122 of the core to be
retracted rearwardly of hook 130. After insertion of hook 130 in
bore B1, manipulatable member 126 is released and distal end 122 is
clamped to the bone by bias of spring 124 as shown in FIG. 19, or
otherwise.
[0146] FIG. 23C depicts the hook inserted into the first hole and
distal end 122 clamped to the bone. As further shown in FIG. 23C,
manipulatable knob 128 is moved to shift loop 135 to its extended
position.
[0147] At 226 a second bore B2 is formed through the bone (FIG.
23D) at a predetermined angle from bore B1. Bore B2 is drilled to a
depth such that bore B2 meets bore B1 in the humerus bone thereby
enabling a suture to be threaded through the two bores. Preferably,
bores B1 and B2 extend past the intersection of the bores in the
bone such that drill 54 passes through loop 135 in bore B1.
Preferably, bore B2 is not long enough to exit the bone.
Optionally, bores B1 and B2 define a 70.degree. angle in the bone.
Preferably, bores B1 and B2 define an angle of between 65.degree.
and 75.degree. in the bone.
[0148] Optionally, before drilling bore B2, an obturator, such as
the obturator 52 shown in FIG. 11, is used to clear the path and
locate the exact location of bore B2. Bore B2 is then drilled at
the location indicated by the obturator, using a drill such as
drill 54 shown in FIG. 11.
[0149] After forming bore B2 a first end of a suture 57 is threaded
through bore B2 at 228. As shown in FIG. 23E, a suture loader such
as suture loader 55 depicted in FIG. 12 is optionally used for
threading suture 57 through bore B2 and through loop 135 extending
from hook 130. Suture loader 55 is then removed, leaving suture 57
in the bore.
[0150] At 230 the first end of the suture is caught at the
intersection of bores B2 and B1 by loop 135. Manipulatable knob 128
is moved to shift loop 135 to its retracted position inside hook
130. Suture 57 which was threaded through loop 135 is now caught
inside hook 130.
[0151] At 232 manipulatable member 126 is moved to release distal
end 122 from being clamped to the bone. Hook 130 is removed from
bore B1 and suture 57 which is clamped in hook 130 is thereby
threaded through bore B1. The end of the suture is then extracted
from the bone by threading through bore B1 at 232. As shown in the
magnified section of FIG. 23G, suture 57 is now threaded through a
channel in the bone consisting of bores B1 and B2.
[0152] In an alternative embodiment, the suture is first threaded
into bore B1 and caught through bore B2.
[0153] At 233 the suture is threaded through the tendon according
to any procedure known in the art. The tendon is then pulled into
place by means known in the art. At 234 the two ends of the suture,
the first end extending from bore B1 and the second end extending
from bore B2 and tendon 10 may be knotted together thereby
attaching the tendon to the humerus bone. FIG. 23H is a coronal
section view of a humerus bone illustrating a suture knotted
through the bone and tendon. The suture, threaded through a into
bore B1 is exited bore B2 at b, retrieved through tendon 10 at c
and is knotted at d. FIG. 23I is a lateral view of a row of sutures
tied over tendon 10 in accordance with an exemplary embodiment of
the invention. A first suture is passed through the bone at a1 to
b1 and retrieved through the tendon at c1 and then knotted at d1. A
second suture is passed through a channel in the bone from a2 to b2
and passed through the tendon at c2 to be knotted at d2, etc.
[0154] FIG. 23J illustrates a lateral view of another embodiment of
the invention where two sutures are passed through a single bone
channel and are tied over different locations through the tendon.
For example, a first and a second suture are threaded through a
bone channel from a1 to b1. The first suture is retrieved through
the tendon at c11 and knotted at d11. The second suture is
retrieved through the tendon at c12 and knotted at d12.
[0155] It is noted that a plurality of ways of tying the sutures
are known in the art. FIGS. 23I-J are provided an example and other
methods such as for example crossing the sutures over the tissue,
to increase the area of the tendon held against the bone, are also
covered by the present invention.
The Medical Implement of FIG. 24
[0156] In another embodiment of the invention, bores B1 and B2 are
formed with a same implement 240 as shown in FIG. 24.
[0157] Implement 240 includes two channels 242 and 244 for
receiving tools such as drills, holders, etc. Instrument 240 is
brought close to the bone at the greater tubercle 6. A drill, such
as drill 53 shown in FIG. 11, is inserted into channel 242 for
forming a first bore B1. Optionally, an obturator, such as
obturator 52 shown in FIG. 11, is first inserted into channel 242
for clearing the path through the soft tissue and indicating the
location of bore B1.
[0158] A pin or hook is then inserted into channel 242 and bore B1
for positioning implement 240 to the bone in order to stabilize the
implement when forming a second bore B2. Optionally, the drill used
for forming bore B1 is kept in the bore for stabilization of
implement 240 and a second drill is used for forming bore B2.
[0159] A drill is then inserted through channel 244 and second bore
B2 is formed. Channels 242 and 244 are located in implement 240
such that bores B1 and B2 formed with drills inserted through the
channels, intersect in the bone. Preferably, bores B1 and B2 are
not long enough to exit the bone. Optionally, a stop on the drill
forming bores B1 and B2 causes the bores to be formed to a certain
depth such that the bores will intersect in the bone and will not
cross the bone.
[0160] In the embodiment shown in FIG. 24, the angles formed
between the bores is preferable less than 90.degree. so as to allow
the two bores to be formed from the same side of the bone.
Optionally, the bores define an angle of less than 45.degree. in
the bone. Optionally, the bores define an angle of less than
30.degree. in the bone.
[0161] Implement 240 further comprises two channels 246 and 248 for
receiving a suture. Channels 246 and 248 join with channels 242 and
248 at intersection points 250 and 252 respectively. After bores B1
and B2 are formed, a suture is inserted through channel 246 and
bore B1 and is retrieved through bore B2 and channel 248 in a
manner similar to that described with respect to the embodiments
shown in FIGS. 2 and 16 above.
[0162] It will be appreciated that other variations, modifications
and applications of the invention may be made. For example, other
means may be used for extracting the end of the suture via bore B1
than those described above. In addition, other constructions of the
slidable manipulatable members 26 and 28 may be used for removing
the hook and/or the loop. The couplings of manual manipulatable
member 26 may include a slip or yielding coupling in order to
prevent excessive force from being applied by hook 30 to the bone,
and thereby reduce the possibility of breakage of the bone.
[0163] Many other variations, modifications and applications of the
invention will be apparent.
[0164] All publications, patents and patent applications mentioned
in this specification are herein incorporated in their entirety by
reference into the specification, to the same extent as if each
individual publication, patent or patent application was
specifically and individually indicated to be incorporated herein
by reference. In addition, citation or identification of any
reference in this application shall not be construed as an
admission that such reference is available as prior art to the
present invention. To the extent that section headings are used,
they should not be construed as necessarily limiting. In addition,
any priority document(s) of this application is/are hereby
incorporated herein by reference in its/their entirety.
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