U.S. patent application number 17/479958 was filed with the patent office on 2022-01-06 for cannula system and method for partial thickness rotator cuff repair.
The applicant listed for this patent is DePuy Synthes Products, Inc.. Invention is credited to Joseph Hernandez.
Application Number | 20220000472 17/479958 |
Document ID | / |
Family ID | |
Filed Date | 2022-01-06 |
United States Patent
Application |
20220000472 |
Kind Code |
A1 |
Hernandez; Joseph |
January 6, 2022 |
CANNULA SYSTEM AND METHOD FOR PARTIAL THICKNESS ROTATOR CUFF
REPAIR
Abstract
A trans-soft tissue anchor implantation system in one embodiment
includes a positioning wire having a tissue penetrating distal tip,
a cannula for passage through the soft tissue and a suture anchor.
The cannula has an axial lumen therethrough sized to accommodate at
least the positioning wire, a thin-walled distal portion and a
tissue engaging feature, such as an arcuate groove, on at least a
portion of an outer surface of the cannula proximal of and adjacent
to the distal portion. Tissue, such as a tendon, expands into the
groove allowing a surgeon to manipulate the tissue with the
cannula. Also featured is a cannula having a first curved section
having a first thin-walled distal portion and a second curved
section having a second thin-walled distal portion, the first and
second curved sections capable of being moved relative to each
other from an initial, low-profile configuration, with the second
section nesting at least partially within the first section to
present less than a full circumference of cannula to the soft
tissue, to a second, larger configuration defining an axial cannula
lumen therethrough.
Inventors: |
Hernandez; Joseph;
(Sandwich, MA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
DePuy Synthes Products, Inc. |
Raynham |
MA |
US |
|
|
Appl. No.: |
17/479958 |
Filed: |
September 20, 2021 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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14978173 |
Dec 22, 2015 |
11123058 |
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17479958 |
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13249733 |
Sep 30, 2011 |
9241701 |
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14978173 |
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61412579 |
Nov 11, 2010 |
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13249733 |
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International
Class: |
A61B 17/04 20060101
A61B017/04; A61F 2/08 20060101 A61F002/08 |
Claims
1-22. (canceled)
23. A trans-soft tissue anchor implantation system comprising: a
cannula sized for passage through a rotator cuff, the cannula
comprising a distal end and an axial lumen therethrough sized to
accommodate a suture anchor, a sharpened edge on the distal end, a
bevel formed across a portion of the distal end so as to form a
pair of points on the distal end whereby to engage the distal end
against a bone; and an inserter with a distal tip, the inserter
being receivable within the cannula and having the suture anchor
mounted to the distal tip.
24. The system according to claim 23 wherein the bevel is formed at
about a 45 degree angle with respect to an axis of the cannula.
25. The system according to claim 23 wherein a second bevel is
formed across the distal end so as to present an angled cutting
surface at the distal end.
26. The system according to claim 25 wherein the second bevel is
formed at about a 20 degree angle with respect to an axis of the
cannula.
27. The system according to claim 23 and further comprising an
arcuate groove around at least a portion of an exterior surface of
the cannula adjacent the distal end to allow manipulation of a
rotator cuff while the cannula is deployed through the rotator
cuff.
28. The system according to claim 27 wherein the groove encircles
the cannula.
29. The system according to claim 23 wherein the suture anchor is
less than 4 mm in diameter and the cannula is sized to just pass
the suture anchor.
Description
BACKGROUND
[0001] The present application relates to systems and methods for
performing a repair of soft tissue to bone, particularly a partial
thickness rotator cuff tear.
[0002] A common injury, especially among athletes, is the complete
or partial detachment of tendons, ligaments or other soft tissues
from bone. Tissue detachment may occur during a fall, by
overexertion, or for a variety of other reasons. Surgical
intervention is often needed, particularly when tissue is mostly or
completely detached from its associated bone. Currently available
devices for tissue attachment include screws, staples, suture
anchors and tacks.
[0003] Arthroscopic tissue attachment is commonly practiced in
shoulder rotator cuff and instability procedures utilizing at least
one cannula. Typically, an anchor loaded with suture is fixated to
bone using an inserter-type device. The suture is normally slidably
attached to the anchor through an eyelet or around a post, such
that a single length of suture has two free limbs. The suture limbs
typically are carried along the exterior of the inserter, usually
within a groove or other exterior channel, or within the interior
of the inserter. After the anchor is inserted into the bone, one
limb of the suture is passed through soft tissue to be repaired
such as a tendon or labrum. The two ends of the suture are then
tied to each other, thereby capturing the soft tissue in a loop
with the anchor. Upon tightening the loop, the soft tissue is
approximated to the bone via the anchor.
[0004] A PASTA (Partial Articular Surface Tendon Avulsion, also
known as Partial Articular Sided Tendon Avulsion) lesion in a
rotator cuff of a shoulder can be particularly difficult to repair.
The rotator cuff comprises a group of muscles which surround the
shoulder and tendons which attach those muscles to the humeral
head. The tendons have a footprint where they attach to the humeral
head and, in a PASTA lesion, a portion of the articular side of the
rotator cuff tendon's footprint becomes detached from the humeral
head. Such lesions are most commonly found on the supraspinatus
tendon.
[0005] One option for treatment is completion of the partial tear
and then completion of a repair using standard techniques for a
full thickness tear. Preservation of the existing, healthy tissue
attachment is thus lost and the entire tendon must be reattached.
Another option includes screwing a threaded suture anchor through
the tendon and into the humeral head, passing suture through the
tendon and tying down the tendon to effect reattachment. This
causes further trauma to the tendon.
[0006] There has been a long-felt need to provide a surgeon with
access through soft tissue without excessively damaging the soft
tissue. A number of early access devices including radially
expandable dilators are disclosed by Dubrul et al. in U.S. Pat. No.
5,431,676. An appliance for forming an opening through skin is
described by Jackson et al. in U.S. Pat. No. 4,716,901.
[0007] A more recent cannula device is disclosed by Putz in U.S.
Patent Publication No. 2003/0073934. Two cannulas having side gaps
are aligned without the side gaps juxtaposed to define a passage
for a probe. The cannulas are then rotated relative to each other
to facilitate separation from the probe.
[0008] It is therefore desirable to have an improved cannula system
to minimize trauma to soft tissue while accessing bone.
SUMMARY OF THE INVENTION
[0009] An object of the present invention is to provide improved
access to bone through soft tissue such as a tendon.
[0010] Another object of the invention is to enhance manipulation
of the soft tissue.
[0011] This invention features a trans-soft tissue anchor
implantation system including, in one embodiment, a positioning
wire having a tissue penetrating distal tip, a cannula for passage
through the soft tissue and a suture anchor. The cannula has an
axial lumen therethrough sized to accommodate at least the
positioning wire, a thin-walled, preferably sharp, distal portion
and a tissue engaging feature, such as an arcuate groove,
indentation or other recess, which is annular in some embodiments,
on at least a portion of an outer surface of the cannula proximal
of and adjacent to the distal portion. Tissue, such as a tendon,
expands into the groove allowing a surgeon to manipulate the tissue
with the cannula.
[0012] In some embodiments, the system further includes an
obturator having a distal tip, which is sharp in one embodiment and
is blunt in other embodiments. Preferably, the obturator includes a
central lumen having a longitudinal axis and sized to accommodate
the positioning wire, and the distal tip of the obturator is
laterally offset from the longitudinal axis of the central lumen.
Preferably, the offset remains within a nominal radius of the
central lumen.
[0013] Also featured is a cannula having a first curved section
having a first thin-walled distal portion and a second curved
section having a second thin-walled distal portion, the first and
second curved sections capable of being moved relative to each
other from an initial, low-profile configuration, with the second
section nesting at least partially within the first section to
present less than a full circumference of cannula to the soft
tissue, to a second, larger configuration defining an axial cannula
lumen therethrough.
[0014] In certain embodiments, at least one tissue engaging feature
such as an arcuate groove is defined on at least a portion of at
least one of the first and second curved sections. In one
embodiment, at least a portion of the tissue engaging feature is
protected relative to the tissue in the initial configuration and
is exposed to the tissue in the second configuration. In some
embodiments, at least one of the first and second distal portions
has an angled distal surface to progressively, in a proximal
direction extending away from a distal end of that distal portion,
increase the surface area of initial contact with and then
penetration into the soft tissue, and at least one of the first and
second distal portions has a distal edge which is sufficiently
sharp to be capable of cutting through a tendon.
[0015] This invention further features a method for passing a
suture anchor through a soft tissue and into a bone, by locating a
desired anchor receiving site on the bone, passing a locating wire
through the soft tissue and at least onto the bone at the anchor
receiving site, and passing over the locating wire and through the
soft tissue a cannula which comprises a thin-walled distal portion
and an axial lumen therethrough sized to accommodate the
positioning wire. The method further includes engaging a portion of
the soft tissue with a tissue engaging feature on at least a
portion of an outer surface of the cannula proximal of and adjacent
to the thin-walled distal portion, and then manipulating the tissue
with the cannula. A suture anchor is passed through the cannula and
placed into the bone at the anchor site.
[0016] In some embodiments, the method includes passing the cannula
through the tissue while it is in an initial, low-profile
configuration with a second curved section of the cannula being
nested within a first curved section of the cannula to present less
than a full circumference of cannula to the soft tissue. The first
and second curved sections are then moved relative to each other to
a second, larger configuration defining the axial cannula lumen
therethrough. In certain embodiments, the method further includes
manipulating the tissue with the cannula after the first and second
curved sections are moved to the second configuration.
BRIEF DESCRIPTION OF THE DRAWINGS
[0017] In what follows, preferred embodiments of the invention are
explained in more detail with reference to the drawings, in
which:
[0018] FIG. 1 is a perspective view of a novel suture anchor;
[0019] FIG. 2 is a side elevation view of the suture anchor of FIG.
1 loaded onto a driver;
[0020] FIG. 3 is a top plan view of the suture anchor of FIG.
1;
[0021] FIG. 4. is a side elevation view of a humerus and associated
rotator cuff tendon suffering a PASTA lesion showing a K wire being
inserted through the tendon to a desired location for placing a
suture anchor;
[0022] FIG. 5. is a side elevation view of the tendon of FIG. 4
showing a novel cannula system being passed through the tendon over
the K wire;
[0023] FIG. 6 is a perspective view of the cannula system of FIG.
5;
[0024] FIG. 6A is an enlarged side view of the distal portion of
the cannula system of FIG. 6:
[0025] FIG. 6B is a cross-sectional view of the cannula system of
FIG. 6A;
[0026] FIG. 6C is a view similar to FIG. 6B with the K wire
removed;
[0027] FIG. 7 is a side elevation view of the tendon of FIG. 4 with
a suture anchor loaded onto a driver, such as shown in FIG. 2,
being passed through the tendon via an outer portion of the cannula
system;
[0028] FIG. 8 is a side elevation view of the tendon of FIG. 4
showing the suture anchor implanted into the humerus beneath the
tendon and a limb of suture passing from the suture anchor out of
an anterior cannula;
[0029] FIG. 9 is a side elevation of the tendon of FIG. 4 showing a
spinal needle passed through a location on the tendon and a suture
retriever being passed through the spinal needle and out of the
anterior cannula;
[0030] FIG. 10 is a side elevation of the tendon of FIG. 4 showing
both suture limbs passed from the suture anchor and through the
tendon at different locations;
[0031] FIG. 11 is a side elevation of the tendon of FIG. 4 showing
the suture limbs knotted together to compress the tendon to the
humerus thus effecting repair of the PASTA lesion;
[0032] FIG. 12 is a perspective view of a distal portion of an
alternative embodiment of a cannula according to the present
invention;
[0033] FIG. 13 is a side elevation view in cross-section of the
distal portion of the cannula of FIG. 12;
[0034] FIG. 14 is a perspective view of an obturator with the
cannula of FIG. 12;
[0035] FIG. 15 is a partial side cross-sectional view of the distal
portion of the cannula of FIG. 12 passing through and engaging a
tendon for manipulation thereof;
[0036] FIGS. 16-20 are schematic perspective views of two suture
anchors, after being inserted into bone according to the present
invention, with suture limbs being tied through a cannula to fixate
a tendon in the shoulder of a patient;
[0037] FIG. 21 is a schematic perspective view of a cannula
according to the present invention having first and second curved
sections which are rotatable relative to each other;
[0038] FIGS. 22 and 23 are schematic cross-sectional views of the
distal portion of the cannula of FIG. 21 in first and second
configurations relative to a tendon;
[0039] FIGS. 24A-C are schematic underside views of FIGS. 22 and
23; and
[0040] FIGS. 25 and 26 are schematic cross-sectional views of the
distal portion of an alternative multi-section cannula according to
the present invention.
DETAILED DESCRIPTION
[0041] This invention may be accomplished by a trans-soft tissue
anchor implantation system including, in one construction, a
positioning wire having a tissue penetrating distal tip, a cannula
for passage through the soft tissue and a suture anchor. The
cannula has an axial lumen therethrough sized to accommodate at
least the positioning wire, a thin-walled, preferably sharp distal
portion and, preferably, a tissue engaging feature, such as an
arcuate groove, indentation or other recess, on at least a portion
of an outer surface of the cannula proximal of and adjacent to the
distal portion. Tissue, such as a tendon, expands into the groove
allowing a surgeon to manipulate the tissue with the cannula.
Cannulas with tissue engaging features according to the present
invention are shown beginning with FIG. 12. Cannulas with first and
second curved sections according to the present invention, with the
second section nesting at least partially within the first section
to present less than a full circumference of cannula to the soft
tissue, are illustrated beginning with FIG. 21.
[0042] FIG. 1 depicts a novel suture anchor 10, for use with a
novel cannula system and method, with an elongated body 12 having a
pointed distal tip 14 and a proximal end 16. An axial passageway 18
extends into the body 12 from the proximal end 16. The passageway
18 is open along its sides 20. A thread 22 encircles the body 12. A
suture bridge or post 24, FIG. 2, spans the passageway 18 laterally
at a distal portion 26 thereof.
[0043] Turning also now to FIGS. 2 and 3, an inserter 28 fits into
the passageway 18. A length of suture 30 passes around the suture
bridge 24 and is received within longitudinal grooves 32 on the
inserter 28. As best seen in FIG. 3, the cross-sectional shape of
the passageway 18 at the proximal end 16 is essentially a hexagon
34 with a pair of suture passages 36 on opposite corners thereof.
The suture passages 36 lead to either side of the suture bridge 24.
The inserter 28 has a complimentary shape to fit within the hexagon
34 with its grooves 32 in alignment with the suture passages 36 on
the anchor 10.
[0044] The suture anchor 10 as shown with the suture passages 36
penetrating the body 12 to leave the passageway 18 open except for
the thread 22 minimizes its cross section to provide the least
trauma to soft tissue through which it will pass while still having
sufficient mechanical strength for the driver 28 to drive it into
bone. Where additional fixation strength within the bone may be
required the cross section of the anchor 10 could be enlarged, in
which case the suture passages 36 need then not necessarily
penetrate the body 12 laterally. The anchor 10 can be formed of any
suitable biocompatible material such as stainless steel, titanium,
cobalt chrome, PEEK (polyaryletheretherketone), Biocryl Rapide
polymer, other biocompatible polymers, polymer-ceramic composites,
bioabsorbable polymers and the like. Suitable anchor materials and
configurations include those disclosed by Cauldwell et al. in U.S.
Patent Publication No. 2008/0147063 and in U.S. Pat. No. 7,381,213
by Lizardi, both of which are incorporated herein by reference in
their entireties.
[0045] FIGS. 4 to 11 illustrate a procedure to repair a PASTA
lesion using the suture anchor 10 of FIG. 1 and a novel cannula
system 48. As seen in FIG. 4, either percutaneously or
arthroscopically, a Kirschner wire (K wire) 38, also known as a
type of positioning wire or locating wire, is inserted at a first
location 39 through a tendon 40 of a rotator cuff to a desired
anchor site 42 beneath its attachment footprint 44 and positioned
upon an associated humeral head 46. The K wire 38 can be tapped
into the bone or merely positioned at the site 42; in other words,
the wire is positioned at least onto the bone at a desired
location. To ease manipulation of the K wire 38 it is preferably
textured on its outer surface and may be provided with a removable
proximal handle (not shown). This site 42 on the humeral head 46 is
where the suture anchor 10, FIG. 1, will be implanted.
[0046] As seen in FIG. 5, cannula system 48 is passed over the K
wire 38 and through the tendon 40 to the site 42. FIG. 6 shows the
cannula 48 in more detail for one construction, with enlargements
of the distal portion illustrated in FIGS. 6A-C. Cannula 48
comprises an inner cannula 50 having a sharp distal portion 52,
proximal handle 54 and a lumen 56 therethrough, FIG. 6C. The inner
cannula 50 fits within an outer cannula 58 which has a distal end
60, proximal handle 62 and lumen 64 therethrough. The distal
portion 52 of the inner cannula 50 extends slightly beyond the
distal end 60 of the outer cannula 58 and the distal end 60 is
tapered so that rather than core through the tendon 40 the distal
portion 52 creates a small hole and the tapering on the distal
portion 52 and distal end 60 allow the cannula system 48 to push
aside the tissue and create the smaller hole through the tendon 40
with the least damage thereto, in other words, with less cutting of
soft tissue. Prior cannulas were inserted through a slit cut into
the tissue. The cannula system 48 dilates the tissue gently to
minimize trauma to the tissue. The outer cannula 58 has lines 66
which provide a visual indication of depth penetration and also a
visualization window 68 which aids in anchor insertion and
assessment of appropriate depth into the bone. To prevent slippage
of the inner cannula 50 relative to the outer cannula 58 during
insertion so provision is preferably provided to help keep them
together. Shown are an interlocking nub 70 and groove 72, but other
options such as a friction fit, threading, or magnets are employed
in other constructions.
[0047] As seen in FIG. 7, in preparation for insertion of the
anchor 10, the K wire 38 and inner cannula 50 are removed leaving
the outer cannula 58 positioned at the anchor site 42. The suture
anchor 10 is preloaded onto the inserter 28, with the suture 30 in
place around the suture bridge 24 and passing through the suture
passages 36 and grooves 32 (see FIG. 2), is passed down through the
outer cannula lumen 60 to the anchor site 42 and is then driven
into the humeral head 46. If the anchor 10 is formed of a
biocompatible metal such as stainless steel or titanium it can be
simply twisted in via the inserter 28. If instead it is formed of a
bioabsorbable polymer or other material having less strength a
pilot hole should be prepared such as with a drill, tap or awl, at
the site 42 through the cannula 46 prior to inserting the anchor 10
through the lumen 60. The inserter 28 and outer cannula 58 can then
be removed leaving first and second suture limbs, 74 and 76
respectively, passed up through the tendon 40 at the first location
39 through which the cannula 48 had passed. As seen in FIG. 8, the
first suture limb 74 is then retrieved through an auxiliary cannula
78 such as via a grasper (not shown).
[0048] As seen in FIG. 9 a spinal needle 80 is passed through the
tendon 40 at a second location 82 spaced apart from the first
location 39. A flexible wire suture capture device 84 having a
suture capture loop 86 (such as a Chia Percpasser available from
DePuy Mitek, Inc. of Raynham, Mass.) is passed through the spinal
needle 80 and retrieved out through the auxiliary cannula 78 so
that the first suture limb 74 can be threaded through the suture
capture loop 86. When the spinal needle 80 and suture capture
device 84 are pulled back through the skin this pulls the first
suture limb 74 through the tendon 40 at the second location 82. For
a quick procedure, the first and second suture limbs 74 and 76
could now be knotted together tying down the tendon 40. However, it
is preferable to repeat the procedure of FIGS. 8 and 9 with the
second suture limb 76 to pass it through the tendon 40 at a third
location 88 on an opposite side of the first location 39 as shown
in FIG. 10. To ease in knot tying both suture limbs 74 and 76 are
preferably pulled out through a single portal such as the auxiliary
cannula 78 or other portal through the skin. A knot 90 can then be
tied and pushed down to tightly secure the tendon 40 to the humeral
head 46 as shown in FIG. 11. By passing the suture limbs 74 and 76
through the tendon 40 at locations 82 and 88 on opposite sides of
the first location 39 and defect caused at that location via the
passing of the cannula system 48 will be naturally pulled together
when the knot 90 is tightened.
[0049] Depending upon the extent of the PASTA lesion it may be
desirable to place more than one suture anchor 10 beneath the
tendon 40. In such case the suture limbs therefrom can be tied
together. It would still be preferable to pass the suture limbs
through the tendon at separate locations as illustrated in FIGS. 9
and 10 prior to tying them together, preferably in a mattress
pattern. One procedure utilizing two suture anchors is illustrated
in FIGS. 16-20 below. Also, a repair could be fashioned employing
one or more knotless suture anchors (not shown) such as disclosed
in U.S. Published Application No. 2008/0033486 by Whittaker et al.,
incorporated herein by reference in its entirety, placed at a
location 92 laterally of the tendon 40 and wherein the suture limbs
74 and 76 from the one or more anchors 10 can be passed in a dual
row procedure, preferably also employing a mattress pattern. If a
lateral anchor is employed, one such method is to put the a pair of
present suture anchors 10 anterior and posterior and have one limb
74 from each tied to each other and the other limbs 76 spanned to
the lateral anchor, preferably knotless, such that it forms a
triangle.
[0050] The suture anchor 10 and cannula system 48 may also be used
to effect repair of a SLAP (Superior labral tear from Anterior to
Posterior) lesion. Typically a much larger traditional cannula (7-8
mm) is placed thru the rotator cuff to access the superior labrum
for a SLAP repair. The present cannula system is much smaller and
also due to its tendency to dilate the tissue rather than be
inserted through a large slit would inflict less trauma to the
rotator cuff. Such a procedure may be as follows: insert the K wire
38, and then the cannula system 48 in the fashion heretofore
described through the rotator interval; drill a hole in the glenoid
rim; insert the anchor 10; remove the cannula system 48; pass
suture through the labrum using a suture shuttle; and tie
knots.
[0051] The procedure is conveniently performed through a cannula
system 48 which provides both access through the skin and through
the tendon 40. The cannula system 48 is sized to just pass the
anchor 10, not leaving much room for passing instruments to
manipulate the tissue, especially the tendon 40. Although described
in reference to the optimally narrow suture anchor 10, the cannula
system 48 and method of penetrating soft tissue for anchor
placement therewith are suitable for other anchors of larger size,
as are other constructions of cannulas according to the present
invention. For instance they could be employed with the HEALIX or
GRYPHON anchors in sizes 4 mm and above available from DePuy Mitek,
Inc. of Raynham, Mass.
[0052] FIGS. 12 and 13 show a distal portion 200 of an alternative
embodiment of a cannula 202 according to the present invention
which incorporates an ability to manipulate the tendon (not shown
in FIGS. 12 and 13). At least the distal portion and shaft of
cannula 202 are formed of a medical-grade, sterilizable metal such
as a stainless steel material. The leading edge of distal portion
200 is ground on the outside to provide a slight annular chamfer
204 and create a sharp distal edge 206, preferably sufficiently
sharp to be capable of cutting through a tendon. It is also
asymmetric to assist in penetrating tissue. A first angle 208,
preferably about 20 degrees, is ground across the portion 200 to
create a sharper tip 210. A second angle 212, preferably about 45
degrees, is ground across a proximal portion of angle 208 to create
a pair of points 214 which can engage the bone and help hold the
distal portion 200 in position thereagainst. It can also assist in
providing some cutting action if needed, especially if the cannula
202 is rotated as it is passed through tissue. An annular groove
215 about the outer surface of the cannula 202 sits proximal of the
distal portion 200 and provides for tissue engagement which will be
shortly explained. The term "groove" is intended to include
elongated depressions, channels and other recesses.
[0053] Turning also now to FIG. 14, an obturator 216 is sized to
fit closely within the cannula 202 and mates with enlarged proximal
collar or handle 203 of cannula 202 in this construction. Obturator
216 has a central axis 218 and terminates in a distal tip 220 which
is laterally offset from the central axis 218 and is sharp in some
constructions and blunt in other constructions. A central lumen 222
passes down the obturator 216 for receiving the K-wire (not shown
in FIGS. 12-14). By making the tip 220 off-axis it is not
interrupted by the lumen 222.
[0054] In practice, the cannula 202 and obturator 216 work
similarly to the procedure described above. A K-wire, preferably
with a trocar-type tip, is placed through the skin and tendon to
engage the underlying bone at the position for placing the anchor
(not shown in FIGS. 12-14). The cannula 202 with the obturator 216
therein and its distal tip 220 extending distally thereof is passed
over the K-wire. The obturator distal tip 220 mostly dilates tissue
as in passes along the K-wire, especially when distal tip 220 is
blunt, and the chamfer 204 of cannula 202 likewise further dilates
the tissue. Accordingly, the cannula 202 and obturator 216, rather
than cut a cannula-sized hole out of the tissue, expand an opening
through it while removing little tissue to create less damage to
the tissue and ease healing of the tissue after the procedure.
[0055] Turning also now to FIG. 15, once the cannula 202 has
penetrated the tendon 40 the groove 215 provides an engagement with
the tendon 40 which tends to expand slightly into the groove 215,
such as illustrated by tissue bulge 217, and catch sufficiently,
yet gently, on the cannula 202 such that a surgeon can lift the
tendon to enhance visualization of the bone underneath without
damaging the tendon. The tendon 40 can be moved across the bone to
a desired position if the surgeon wishes. The procedure is then
completed as described above with an anchor being placed through
the cannula 202. In other constructions, the tissue engaging
feature is a raised rib or other projection. However, a type of
groove is preferred instead of a projection to minimize trauma to
the soft tissue. A projection may further dilate the tissue, and
less tissue dilation is generally preferred.
[0056] FIGS. 16-20 illustrate an alternative technique for repair
of shoulder S utilizing at least two suture anchors 302 and 310,
each of which preferably has been inserted through tendon T and
into humerus bone H at two desired locations utilizing procedures
described above. Anchor 302 slidably carries suture limbs 304 and
306 while anchor 310 carries suture limbs 312 and 314. An
arthroscope (not shown) is placed in the subacromial space above
the head of humerus H. Cannula 300, FIG. 16, is inserted laterally
in the same portal used for subacromial decompression. One suture
limb is retrieved through cannula 300 from each anchor, such as
limbs 306 and 312, FIG. 17. A clamp 320 is placed on suture limbs
and a knot 321 is tied against clamp 320. The knot 321 is then
shuttled through cannula 300, as indicated by arrow 322, FIG. 18,
by pulling on the other suture limbs 304 and 314 as indicated by
arrows 324 and 326, respectively, until a desired tension on tendon
T is achieved. Suture limbs 304 and 314 are then tied
arthroscopically using a non-sliding knot to complete the repair
with a suture bridge 330, FIG. 20, to fixate tendon T to humerus H.
Excess suture may be removed with a cord cutter as desired.
[0057] Other systems according to the present invention ease
insertion of a cannula through soft tissue by creating a small
initial incision which is then expanded to create a portal,
preferably trans-tendonous, to the desired repair location.
Preferably, the cannula has multiple curved portions or sections
which interact with one another to insert through tissue in a
minimally invasive fashion and then are rotated or otherwise
manipulated to create a full portal through soft tissue as
desired.
[0058] In some constructions, a cannula system according to the
present invention has multiple interacting thin-walled, preferably
sharp-tipped sleeves, cylinders or tubes, also referred to as
curved sections, which are partial-arcs in some constructions and
substantially full-arc, full-circumference cylinders in
cross-section spaced from their distal portions in other
constructions. In an initial configuration, the distal portions of
the tubes are aligned to present less than a full circumference of
cannula to the soft tissue, such as to form a semi-circle,
preferably substantially a half-circle or less, and inserted
through soft tissue to form a "half-moon"-like, crescent-shaped
incision or opening through the soft tissue. The cannula tubes are
then manipulated to form a substantially circular portal through
the soft tissue. Suture anchors or other devices or instruments can
then be passed through the cannula system. After use is completed,
the system preferably is collapsed or otherwise returned to its
initial configuration and removed from the patient while minimizing
trauma to the soft tissue. An initial low-profile, relatively small
incision is thereby dilated by manipulating the cannula to form an
arthroscopic portal.
[0059] Cannula 400 according to the present invention, shown in an
initial, low-profile configuration in FIGS. 21 and 22, has a first
curved outer section 402 and a second curved inner section 404
which is generally coaxial with first section 402. Preferably, at
least the shafts and distal portions of sections 402 and 404 are
formed of a medical-grade, sterilizable metal such as a stainless
steel material. A grip 406 of biocompatible material is positioned
near the proximal end of first section 402 and a grip 408 is
positioned near the proximal end of second section 404 to assist
rotation, either manual or robotic, of the sections 402, 404
relative to each other as indicated by arrows 410 and 412. A
proximal opening 414 is defined in second section 404 to
communicate with an axially-extending cannula lumen 420. First
section 402 has an angled or tapered distal portion 422 terminating
in a distal end 426 with a beveled edge 427, shown in enlarged
cross-section in FIGS. 22 and 23, and second section 404 has an
angled or tapered distal portion 424 terminating in a distal end
428 with a beveled edge 429. In this construction, edges 427 and
429 are sufficiently sharp to be capable of cutting through a
tendon. Also in this construction, both distal portions 422 and 424
define arcuate grooves 430 and 432, respectively.
[0060] First and second sections of cannula 400 are shown in the
initial configuration in FIGS. 22 and 24A relative to tendon T and
in a second, expanded configuration in FIGS. 23 and 24B. Both the
first and second distal portions progressively increase arcuately
as measurable progressing away from distal ends 426 and 428, that
is, both distal portions 422 and 424 have an angled distal surface
to progressively increase the surface area of initial contact with
the soft tissue. Tissue engagement feature 432 is covered in the
initial configuration and is exposed in the expanded configuration
to enhance contact with tendon T to facilitate manipulation of that
tissue by a surgeon.
[0061] Preferably, sections 402 and 404 are returned to the initial
configuration after access through and manipulation with cannula
400 has been completed, as illustrated in FIG. 24C. Further trauma
to the soft tissue is thereby minimized as the cannula 400 is
withdrawn from a patient.
[0062] Alternative cannula 500 is shown in an initial configuration
in FIG. 25 and in an expanded configuration in FIG. 26 having first
curved section 502 and second curved section 504. In this
construction, soft tissue T is fully dilated by the initial
configuration as cannula 500 is passed through tissue T. While both
the first and second distal portions 522 and 524 have an angled
distal surface to progressively increase the surface area of
initial contact with the soft tissue, only the second distal end
528 has a beveled edge in this construction. First distal end 526
is simply thin-walled.
[0063] Cannula systems according to the present invention have been
described herein for use with rotator cuff repair including PASTA
repairs and lesion repairs including SLAP repairs, but those are
not limitations of the invention. Other suitable procedures for
shoulder repair include biceps tenodesis, Bankart repair,
acromio-clavicular separation repair, deltoid repair, capsular
shift and capsulo-labral reconstruction. Suitable foot and ankle
procedures include lateral stabilization, medial stabilization,
Achilles tendon repair, mid-foot reconstruction, hallux valgus
repair, metatarsal ligament and tendon repairs. Suitable knee
procedures include medial collateral ligament repair, lateral
collateral ligament repair, posterior oblique ligament repair, and
ilio-tibial band tenodesis. Suitable elbow repairs include biceps
tendon reattachment, ulnar and radial collateral ligament
reconstruction, and lateral epicondylitis repair. Suitable wrist
procedures include scapholunate ligament reconstruction, and
suitable hip procedures include capsular repair and acetabular
labral repair.
[0064] While the invention has been particularly described in
connection with specific embodiments thereof, it is to be
understood that this is by way of illustration and not of
limitation, and that the scope of the appended claims should be
construed as broadly as the prior art will permit. Thus, while
there have been shown, described, and pointed out fundamental novel
features of the invention as applied to a preferred embodiment
thereof, it will be understood that various omissions,
substitutions, and changes in the form and details of the devices
illustrated, and in their operation, may be made by those skilled
in the art without departing from the spirit and scope of the
invention. For example, it is expressly intended that all
combinations of those elements and/or steps that perform
substantially the same function, in substantially the same way, to
achieve the same results be within the scope of the invention.
Substitutions of elements from one described embodiment to another
are also fully intended and contemplated. It is also to be
understood that the drawings are not necessarily drawn to scale,
but that they are merely conceptual in nature. It is the intention,
therefore, to be limited only as indicated by the scope of the
claims appended hereto.
[0065] Every issued patent, pending patent application,
publication, journal article, book or any other reference cited
herein is each incorporated by reference in their entirety.
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