US20110112639A1 - Positioning Systems and Methods for Implanting an Energy Absorbing System - Google Patents

Abstract

Positioning instruments and related methods are described for implanting an energy absorbing system for treating joints. The positioning instruments and methods allow the energy absorbing system to be positioned at a joint such that the desired motion will occur for the particular design of a particular energy absorbing system which is to be implanted. The positioning instruments include a locating instrument for locating an anatomical feature and a target location for implantation of the energy absorbing system, a verification instrument for verification of the target location, a placement guide for guiding placement of a part of the energy absorbing system, and positioning device for aligning portions of the energy absorbing system.

Description

BACKGROUND
• The present disclosure is directed towards positioning instruments and related methods for implanting an energy absorbing system, and more particularly to tools and surgical procedures for implanting an energy absorbing system for treating joint members.
• Joint replacement is one of the most common and successful operations in modern orthopaedic surgery. It consists of replacing painful, arthritic, worn or diseased parts of a joint with artificial surfaces shaped in such a way as to allow joint movement. Osteoarthritis is a common diagnosis leading to joint replacement. Such procedures are a last resort treatment as they are highly invasive and require substantial periods of recovery and permanently alter the joint. Total joint replacement, also known as total joint arthroplasty, is a procedure in which all articular surfaces at a joint are replaced. This contrasts with hemiarthroplasty (half arthroplasty) in which only one bone's articular surface at a joint is replaced and unincompartmental arthroplasty in which the articular surfaces of only one of multiple compartments at a joint (such as the surfaces of the thigh and shin bones on just the inner side or just the outer side at the knee) are replaced.
• Arthroplasty as a general term, is an orthopaedic procedure which surgically alters the natural joint in some way. This includes procedures in which the arthritic or dysfunctional joint surface is replaced with something else, and procedures which are undertaken to reshape or realign the joint by osteotomy or some other procedure. As with joint replacement, these other arthroplasty procedures are also highly invasive procedures characterized by relatively long recovery times. A previously popular form of arthroplasty was interpositional arthroplasty in which the joint was surgically altered by insertion of some other tissue like skin, muscle or tendon within the articular space to keep inflammatory surfaces apart. Another previously done arthroplasty was excisional arthroplasty in which articular surfaces were removed leaving scar tissue to fill in the gap. Among other types of arthroplasty are resection(al) arthroplasty, resurfacing arthroplasty, mold arthroplasty, cup arthroplasty, silicone replacement arthroplasty, and osteotomy to affect joint alignment or restore or modify joint congruity. When successful, arthroplasty results in new joint surfaces which serve the same function in the joint as did the surfaces that were removed. Any chondrocytes (cells that control the creation and maintenance of articular joint surfaces), however, are either removed as part of the arthroplasty, or left to contend with the resulting joint anatomy. Because of this, none of the therapies which remove the joint surfaces are chondro-protective.
• A widely-applied type of osteotomy is one in which bones are surgically cut to improve alignment. A misalignment due to injury, bone abnormality or disease in a joint relative to the direction of load can result in an imbalance of forces and pain in the affected joint. The goal of osteotomy is to surgically re-align the bones at a joint and thereby relieve pain by shifting forces across the joint to less damaged joint surfaces. This can also increase the lifespan of the joint. When addressing osteoarthritis in the knee joint, this procedure involves surgical re-alignment of the joint by cutting and reattaching part of one of the bones at the knee to change the joint alignment, and this procedure is often used in younger, more active or heavier patients. Most often, high tibial osteotomy (HTO) (the surgical re-alignment of the upper end of the shin bone (tibia) to address knee malalignment) is the osteotomy procedure done to address osteoarthritis and it often results in a decrease in pain and improved function. However, HTO does not address ligamentous instability—only mechanical alignment. HTO is associated with good early results, but results deteriorate over time.
• It has been found that excess loading of the joint is the primary contributing factor in the progression of osteoarthritis disease. It has also been shown that a decrease in load, such as by weight loss can result in decrease in disease progression and in pain relief.
• Certain approaches to treating osteoarthritis contemplate external devices such as braces or fixators which attempt to control the motion of the bones at a joint or apply cross-loads at a joint to shift load from one side of the joint to the other. A number of these approaches have had some success in alleviating pain by reducing loads on diseased joints but have ultimately been unsuccessful due to lack of patient compliance or the inability of the devices to facilitate and support the natural motion and function of the diseased joint.
• Certain prior approaches to treating osteoarthritis have also failed to account for all of the basic functions of the various structures of a joint in combination with its unique movement. In addition to addressing the loads and motions at a joint, an ultimately successful approach should both acknowledge the dampening and energy absorption functions of the anatomy, and be implantable via a minimally invasive technique. Device constructs which are relatively rigid do not allow substantial energy storage. For these relatively rigid constructs, energy is transferred rather than stored or absorbed relative to a joint. By contrast, the natural joint is a construct comprised of elements of different compliance characteristics such as bone, cartilage, synovial fluid, muscles, tendons, ligaments, etc. as described above. These dynamic elements include relatively compliant ones (ligaments, tendons, fluid, cartilage) which allow for substantial energy absorption and storage, and relatively stiffer ones (bone) that allow for efficient energy transfer. The cartilage in a joint compresses under applied force and the resultant force displacement product represents the energy absorbed by cartilage. The fluid content of cartilage also acts to stiffen its response to load applied quickly and dampen its response to loads applied slowly. In this way, cartilage acts to absorb and store, as well as to dissipate energy.
• Approaches for surgically implanting extra-articular mechanical energy absorbing apparatus have been developed. As precise and effective placement are important to the efficacy of an implanted extra-articular mechanical absorbing apparatus, further advancements in patient preparation and device-to-anatomy juxapositional relationships have been found to be both useful and necessary.
• With the foregoing applications in mind, it has been found to be necessary to develop effective systems and tools for mounting an extra-articular energy absorbing apparatus to body anatomy.
• For energy absorbing apparatus to function optimally, they must not cause an adverse disturbance to joint motion. Therefore, what is needed is a refined surgical approach to implanting a device which addresses both joint movement and varying loads as well as complements underlying or adjacent anatomy.
• The present disclosure satisfies these and other needs.
SUMMARY OF THE DISCLOSURE
• Briefly and in general terms, the present disclosure is directed towards treating diseased or mal-aligned body joints, typically affected by osteoarthritis, using an energy absorbing system without limiting the range of motion of the patient's articulating joint. The positioning instruments and related methods are described herein for implanting such energy absorbing system.
• A method of implanting a device at a joint comprising inserting a first reference marker into a first bone of the joint, inserting a second reference marker into a second bone of the joint, connecting the first and second reference markers to a verification tool, moving the joint through a predetermined range of motion and utilizing the verification tool to determine whether the first and second reference markers move in a desired kinematic pattern with respect to one another throughout the predetermined range of motion, relocating one of the reference markers if the desired kinematic pattern is not achieved, and implanting the device across the joint.
• A verification tool for verification of a location for implantation of an extra-articular energy absorbing device at a joint, the tool comprising a tool body, a first connection member on the tool body, the first connection member configured to be connected to a first reference marker located in a first bone, the first connection member allowing rotation of the tool with respect to the first bone, a second connection member on the tool body, the second connection member configured to be connected to a second reference marker located in a second bone, the second connection member allowing rotation of the tool with respect to the second bone, wherein at least one of the first and second connection members is movable with respect to the tool body, and a gauge configured to provide a user with information about the location of at least one of the first and second reference markers as the joint is articulated.
• A system for placing an energy absorbing device at a joint comprising a base configured to be secured to a bone adjacent a joint, a placement guide removably attachable to the base, wherein the placement guide includes an offset member one end of which is connected to the placement guide and an opposite end of which is configured to contact the bone.
• A method for locating a center of rotation for an implantable articulating joint device, the method comprising locating an anatomical reference location on a bone with a tool having radiopaque markers, and marking a target location for an implantable articulating joint device at a predetermined distance and direction away from the anatomical reference location by inserting a marker through an opening in the tool.
• A method of implanting an energy absorbing device at a joint comprising securing a first base member to a bone on a first side of a joint, affixing an absorber to the first base member, the absorber having at least one articulation, temporarily restraining the articulation of the absorber to a limited range of motion less the a full range of motion of the articulation with a removable restraint, positioning and securing a second base member to a bone on a second side of the joint while the articulation of the absorber is temporarily restrained, and removing the restraint.
• A system for placing an energy absorbing device at a joint comprising a base configured to be secured to a bone adjacent a joint and including a first placement guide mounting surface and a first connector component, a placement guide including a second placement guide mounting surface, a second connector component adapted to mate with the first connector component, and an offset member, the placement guide being attachable to the base in an attached position such that the first and second placement guide mounting surfaces abut when the first and second connector components mate.
• A method for positioning a base for an implant at a joint, comprising inserting a first elongated reference marker into a first bone of the joint so that one end of the first reference marker is inserted into the bone and the other end of the first reference marker is free, placing a preassembled combination of a base and a placement guide on the bone of the joint so that the first reference marker extends through a first guide hole in the placement guide, inserting a second elongated reference marker through a second guide hole in the placement guide and into the bone of the joint while orienting the combination and the second reference marker so that, when the second reference marker is inserted into the bone, the second reference marker extends in a predetermined relation to the first bone and a second bone of the joint.
• A tool for selecting one base from among a plurality of bases having different base geometries for an implant at a joint, comprising, a tool body having a bone contacting surface shape generally corresponding to a bone contacting surface shape of the plurality of bases from which the one base is to be selected, a guide opening on the tool body through which an elongated reference marker is adapted to extend, indicia corresponding to at least some of the plurality of bases, wherein, when the tool body is positioned on a bone of the joint so that the reference marker extends through the guide opening and the tool body is in a desired alignment with the bone, the reference marker is disposed in a position relative to the indicia that indicates one base is to be selected.
• A method for selecting a base from among a plurality of bases having different base geometries for an implant at a joint, comprising, inserting an elongated reference marker into a bone of the joint so that one end of the reference marker is inserted into the bone and the other end of the reference marker is free, positioning a trial so that a surface of the trial is in a desired alignment with the portion of the bone and so that the free end of the reference marker extends through a guide opening on the trial, and selecting one base from among the plurality bases depending upon a position of the reference marker relative to one or more indicia associated with the guide opening.
• Other features of the energy absorbing system and device will become apparent from the following detailed description, taken in conjunction with the accompanying drawings, which illustrate, by way of example, the principles of the embodiments.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a perspective view, depicting an extra-articular implantable mechanical energy absorbing system;
• FIG. 2 is a side view, depicting the absorber of the system ofFIG. 1 with the sheath removed;
• FIG. 3 is a side view, of a position verification tool for location of a correct position for the energy absorbing system ofFIG. 1;
• FIG. 4 is a perspective view, of the verification tool ofFIG. 3 in use on a patient;
• FIG. 5 is a perspective view, of the verification tool ofFIG. 3;
• FIG. 6A is a perspective view of a bullseye tool for inserting a reference marker into a bone at a desired location;
• FIG. 6B is a top view of a portion of the bullseye tool ofFIG. 6A;
• FIG. 7A is a top perspective view of a placement guide used to facilitate correct positioning of the base;
• FIG. 7B is a side perspective view of the placement guide ofFIG. 7A;
• FIG. 8 is a top view of the placement guide ofFIG. 7A temporarily attached to a base;
• FIG. 9 is a perspective view of the placement guide and base as they are positioned for attachment of the base to a bone of a patient;
• FIG. 10 is a perspective view of the base attached to the bone of a patient with the placement guide removed;
• FIG. 11A is a side perspective view of an absorber positioning collar;
• FIG. 11B is a bottom perspective view of the absorber positioning collar ofFIG. 11A;
• FIG. 12 is a top view of the positioning collar ofFIG. 11A positioned between a base and absorber;
• FIGS. 13A-13C are perspective, top, and side views of a femoral trial according to an aspect of the present invention;
• FIGS. 14A-14B are top and perspective views of a base for forming part of a system for placing an energy absorbing device at a joint according to an aspect of the present invention;
• FIGS. 15A-15B are top and perspective views of a placement guide for forming part of a system for placing an energy absorbing device at a joint according to an aspect of the present invention;
• FIG. 16 is a side view of a locking pin forming part of a system for placing an energy absorbing device at a joint according to an aspect of the present invention; and
• FIGS. 17A-17B are perspective and top views of a system for placing an energy absorbing device at a joint according to an aspect of the present invention.
DETAILED DESCRIPTION
• Referring now to the drawings, which are provided by way of example and not limitation, the present disclosure is directed towards apparatus for treating body tissues. In applications relating to the treatment of body joints, the described approach seeks to alleviate pain associated with the function of diseased or malaligned members forming a body joint. Whereas the present invention is particularly suited to address issues associated with osteoarthritis, the energy manipulation accomplished by the present invention lends itself well to broader applications. Moreover, the present invention is particularly suited to treating synovial joints such as the knee, finger, wrist, ankle and shoulder.
• In one particular aspect, the presently disclosed energy absorbing systems involve varying energy absorption and transfer during the rotation of a joint, such as a knee joint.FIG. 1 illustrates an implantable energy absorbing system for absorption of forces normally transmitted through a joint in order to relieve pain, such as pain associated with osteoarthritis.
• U.S. Patent Publication No. 2009/0014016, which is incorporated herein by reference in its entirety, describes certain embodiments of extra-articular energy absorbing systems. These energy absorbing systems include geometry which accomplishes variable energy absorption designed to minimize and complement the dampening effect and energy absorption provided by the anatomy of the body, such as that found at a body joint. It has been postulated that to minimize pain, in an osteoarthritic joint absorption of 1-40% of forces, in varying degrees, may be necessary. Variable absorption in the range of 5-20% can be a target for certain applications. In certain specific applications, temporary distraction (e.g., less than 3 months) is employed in the energy manipulation approach.
• Referring now toFIG. 1, one embodiment of anenergy absorbing system50 is shown affixed to a knee joint to absorb at least a portion of the energy normally transmitted by the knee anatomy. Theenergy absorbing system50 includes a proximal52 base positioned on thefemur56 and a distal54 base positioned on thetibia58 of the typical knee joint. It is noted that portions of thebase52,54 are contoured to match potential mounting surfaces of the femur andtibia56,58. Also shown is anenergy absorbing device60 that is located between and mounted to thebases52,54. InFIG. 1A, theenergy absorbing system60 is shown with asheath61 which covers internal components, protects the moving elements from impingement by surrounding tissues and prevents the devices from damaging surrounding tissue. For viewing purposes thesheath61 is omitted fromFIG. 2.
• Theenergy absorbing system50 as shown includes twosprings62,64, however other numbers of springs may also be used. Theenergy absorbing system50 has the capacity to absorb energy in addition to transferring energy from the joint.FIG. 1 shows the knee joint at full extension. In the example ofFIG. 1, maximum load is applied to thesprings62,64 of theenergy absorbing device50 at full extension during the stance phase of the gait cycle. When the knee joint is flexed to 90°, such as during the swing phase of the gait cycle or when the patient is seated, zero load is absorbed from the knee by thesprings62,64. In this example, when theenergy absorbing device50 is correctly positioned on the knee, the device is actively working in compression when the knee is at or near full extension. Theenergy absorbing device50 lengthens as the knee swings from full extension to flexion and subsequently shortens as the knee swings from flexion to full extension such that the springs begin to be compressed between the ends of the device to absorb at least a portion of the load that the knee articulating surfaces normally would experience.
• Theenergy absorbing device50 andbases52,54 are mounted across the joint such that once the spring has achieved a predetermined amount of compression, and therefore load, the articulating surfaces of the knee then carry a portion of the load in combination with the energy absorbing device such that the energy absorbing device does not “bottom out”.
• Still referring toFIG. 1, as well asFIG. 2, one embodiment of anenergy absorbing device60 includes two machinedsprings62,64. Thesesprings62,64 are each positioned about guides (not shown) which support the springs allowing the springs to act in compression when the knee is in extension or at low flexion angles and support the springs in an unloaded position when the knee is at higher flexion angles. The guides about which thesprings62,64 are located may be in the form of telescoping members, such as a piston and barrel which allow the opposite ends of theenergy absorbing device60 to move in a linear path toward and away from each other. The energy absorbing device also includes a proximal (femoral) end66 and a distal (tibial) end68 which are connectable to thebases52,54 by a knownconnection mechanism70, such as a taper lock.
• Theenergy absorbing device60, as illustrated, also includes two ball and socket joints within the proximal and distal ends66,68 which allow anterior/posterior, medial/lateral, and axial rotation of theenergy absorbing device60 with respect to thebases52,54. The range of motion of the components of the system can be determined by the bearing/socket geometry, base/absorber geometry and relative position of the base to absorber at final implantation. Identical ball/sockets arrangements can be provided on both sides of a knee joint but different arrangements are also contemplated. The absorber springs62,64 act to absorb load from the medial compartment of the knee while the articulation of the ball/sockets and the telescoping of piston assemblies of the absorber allow the device to accommodate full knee range of motion.
• For best performance of theenergy absorbing system50, thefemoral base52 and the associated ball and socket articulating surfaces at thefemoral end66 of theenergy absorbing device60 should be precisely positioned. In order to more easily locate the accurate position for thisproximal base52 and articulation a position verification tool and related method have been developed.
• Conventional or surgical or minimally invasive approaches are taken to gain access to a body joint or other anatomy requiring attention. Arthroscopic approaches are contemplated when reasonable to both implant the energy manipulation assembly as well as to accomplish adjusting an implanted assembly.
• In one approach for treating a knee, an implantable extra-articular energy absorber system is designed to reduce medial compartment loads of the knee. The absorber system is comprised of two contoured base components, a kinematic load absorber and a set of bone screws. The implanted system is both extra articular and extra capsular and resides in the subcutaneous tissue on the medial aspect of the knee. The device is inserted through two small incisions superior to the medial femoral condyle and inferior to the tibial plateau. The contoured base components are fixed to the medial cortices of the femur and tibia using bone screws.
• Anenergy absorber60 having a spring value of about twenty pounds can provide therapeutic benefit for patients of 300 pounds or less. Higher spring forces would provide greater reduction in joint load and may correlate to greater symptom (i.e., pain) relief.
• It has been found that a medial compartment of a knee of an average person with osteoarthritis can benefit from an absorber set for compression between 1 mm and 10 mm, and preferably 3-6 mm with a spring or absorber element that accommodates a range from 20-60 pounds. In one preferred embodiment, the absorber is set for about 4 mm of such compression and a pre-determined load of about 40 pounds. An absorber of 40 pounds load absorption can unload the medial compartment of a patient's knee from 25-40 pounds.
• The femoral and tibial base components can be contoured to ensure optimal fit to the bony surfaces and can be plasma sprayed coated with porous titanium and/or coated with hydroxyapatite on bone contacting surfaces to promote bony ingrowth and enhance osteointegration.
• Theposition verification tool100 shown inFIGS. 3-5 is used during surgery to verify a position of thefemoral base52 and the femoral articulation surface of theabsorber60 to achieve the most functional position of thesystem50. The preferred implantation position of thesystem50 is achieved when thesprings62,64 are in a compressed orientation during the swing phase of the gait including full extension and low flexion angles of the knee joint. The springs are in a less compressed or in an uncompressed position at 45 degrees of flexion of the knee, and by 90 degrees flexion of the knee the springs are preferably uncompressed or nearly uncompressed. This configuration corresponds to the composition of the gait cycle where the largest forces are exerted on the knee joint near full extension and these forces are greatly decreased when the knee is flexed during the swing phase of the gait.
• Theposition verification tool100 as described herein verifies that the desired motion will occur for the particular design of a particular energy absorbing system which is to be implanted. Although theposition verification tool100 has been described for use with theenergy absorbing system50, it should be understood that the verification tool can also be used to verify fixation positions of other implantable systems are designed to have a particular desired kinematic pattern as a joint moves through a particular range of motion.
• Theposition verification tool100 is used in a method of implanting theenergy absorbing system50 by inserting first and second reference markers into first and second bones on opposite sides of the joint and connecting the first and second reference markers to the verification tool. Theverification tool100 then is used to determine whether the first and second reference markers move in a desired kinematic pattern with respect to one another. Examples of kinematic patterns include 1) reference markers moving away from each other as the joint moves from extension to flexion; 2) reference markers staying within a certain defined distance of each other as the joint moves from extension to flexion; 3) reference markers moving toward each other as the joint moves from extension to flexion; and 4) reference markers moving away from each other and then toward each other as the joint moves.
• In addition to verification of the position for placing one or more of thebases52,54, theposition verification tool100 can also be used to select anenergy absorbing member60 when different sizes or configurations of energy absorbing members are available, such as those as described in U.S. Patent Publication No. 2009/0014016.
• Theposition verification tool100 includes abody102 having afirst end110 for attachment to reference markers in the patient and asecond gauge end112 which extends at an angle from the first end for monitoring relative motion of the reference markers and the bones. Thefirst end102 of thetool100 has afirst connection point104 with a fixed longitudinal location on the body. Thefirst connection point104 may include a guide hole and a guide ball which allows a marker to pivot within thetool body102 but does not allow the first connection point to translate. The first connection point may also include an offset105, shown inFIG. 5, which causes the tool to sit off the bone by a distance of the offset allowing the tool to rotate more easily without interference from the bone. Thetool100 has asecond connection point106 with a longitudinally movable location. Thesecond connection point106 may also include a guide hole through a guide ball which allows a marker to pivot within thetool body102. The guide ball at thesecond connection point106 may also include an offset105. The guide balls allow thetool100 to rotate about the first and second reference markers or K-wires throughout the range of motion of the joint even when the reference markers are not exactly parallel.
• Thesecond connection point106 is secured to aflexible ribbon108 which is longitudinally movable on thetool100. Theflexible ribbon108 acts as a gauge to monitor the relative motion of the reference markers while moving the joint through a predetermined range of motion. Thus, thesecond connection point106 moves longitudinally on theverification tool100 as the joint is moved through a range of motion. Theverification tool100 is used to determine whether the first and second reference markers move in a desired kinematic pattern with respect to one another throughout the predetermined range of motion. As discussed above, the desired kinematic pattern may be a pattern where the reference markers move apart as the joint moves from extension to flexion. If the desired kinematic pattern is not achieved, one of the reference markers is relocated. The verification tool may then be used to check the new position.
• Other configurations of theverification tool100 are also contemplated in which the motion between the first and second connection points104,106 is accommodated and verified in other manners. For example, atelescoping verification tool100 may be used including bars or identifying bands on a portion of the telescoping parts.
• In one approach to a surgical method, an initial step in treatment involves identifying a patient's Blumensaat's line, which is a radiographic and structural feature of a femur. Using Blumensaat's line as an anatomical radiographic landmark, an acceptable region and target area can be identified for placement of a center of rotation of a femoral socket just anterior and/or proximal of the center of rotation of the femur. As shown inFIG. 4, areference marker104 or K-wire is positioned in the femur under fluoroscopy or another imaging technique. The placement of thefemoral reference marker104 can be done manually without the assistance of a placement tool. Alternatively, abullseye tool guide200 or other placement tool may be used to insert thereference marker104 at a desired target area.
• Thebullseye tool200 shown inFIGS. 6A and 6B is employed as a guide through which a K-wire130 is inserted into the femur either through the patient's skin or after making a small incision. It is to be noted that anatomical and/or radiographic landmarks (e.g., center of Blumensaat's line, inferior and posterior regions of the femoral condyles) can aid in manually positioning a K-wire in the target region or location, with or without the bullseye instrument. The bullseye tool is used for locating a center of rotation of the femoral socket by locating an anatomical reference location, such as the center of Blumensaat's line, and locating the center of rotation of the implant a predetermined distance and direction from the anatomical reference location.
• When using thebullseye tool200, the bullseye tool is placed with acenter pin202 of the bullseye tool on the midpoint of Blumensaat's line. The tool is rotated until twowings204 of the tool (with radiopaque markers) are parallel to Blumensaat's line. Vertically spaced apartradiopaque rings206 are arranged in the center portion of thebullseye tool200 and when these rings are aligned (concentric) in a the bullseye tool is perpendicular to the fluoroscopic view and properly aligned to insert areference marker130 perpendicular to the lateral view. In this position, the K-wire orreference marker130 is placed through ahole208 in thetool200 to locate the center of rotation of the femoral socket of theenergy absorbing device60. Thehole208, a shown, has a trajectory which is parallel to the direction of imaging when the concentric rings are aligned. However, other trajectories of thereference marker130 may be achieved by varying the trajectory of the hole in thebullseye tool200.
• The location of thehole208 in thebullseye tool200 is designed to be just anterior and proximal of the midpoint of Blumensaat's line when the tool is positioned as described above. Since it has been shown that the midpoint of Blumensaat's line is a good radiographic approximation of a center of rotation of the femur, the location of thereference marker130 anterior and proximal of this midpoint of Blumensaat's line has been shown to be a starting point for finding a location of the center of rotation of the femoral articulation and achieving a desired kinematic pattern where the reference markers move apart as the joint moves from extension to flexion.
• As shown inFIG. 4, theverification tool100 is inserted through a tissue tunnel between first and second incisions in the leg on opposite sides of the knee joint. The tool is placed onto thefirst reference marker130 positioned in the femur and a second substantiallyparallel reference marker132 is placed through theconnection point106 of the tool into the tibia. The distance between thefirst connection point104 and thesecond connection point106 on theverification tool100 is selected to provide the desired spacing for mounting bases to the bones to accommodate theenergy absorbing member60. Although theverification tool100 has been described as operating partly beneath the patient's skin within a tissue tunnel, it should be understood that in some cases the verification tool may be entirely underneath or entirely outside of the patient's skin.
• Theverification tool100 includes one or more bars, bands, grids or other markings, such as the 45° and 90°bars120 shown inFIG. 3 as well as apointer122. The 45° bar shows the range of acceptable locations of thepointer122 when the joint is at 45° of flexion, while the 90° bar shows the range of acceptable locations of the pointer when the joint is at 90° of flexion. The bars are merely shown by way of example as one or more other bars may also be used. The bars are merely a simplified way of determining if there is not enough or too much space between the reference markers as the joint is articulated. If there is not enough or too much spacing between the reference markers, this in an indication that one or both of the reference markers should be moved to achieve the best function of theenergy absorbing device50.
• In one embodiment of the invention, the location of the femoral reference marker is verified by placing the verification tool on thefemoral reference marker130 as shown inFIG. 4 and inserting thetibial reference marker132 through theconnection point106. When placing thetibial reference marker132, thepointer122 should be pointing at the zeromark126. To simulate stance or loaded extension, the knee should be located in extension and any medial laxity in the joint should be removed by pulling the tibia medially to close the medial joint space during placement of thetibial reference marker132. In the event that the knee joint was not in full extension or the medial joint space was partially open during placement of the tibial reference marker, theverification tool100 can be readjusted to the zeromark126 after correcting the knee position. To verify the femoral reference marker location, the knee is flexed through a range of motion while the location of thepointer122 with reference to thebars120 on theverification tool100 is observed. For example, when the knee is moved from extension through 45° of flexion with the medial joint space closed the pointer position should be within the 45° bar. In addition, when the knee is moved from extension through 90° of flexion with varus, valgus, internal and external rotations, the pointer position should be within the 90° bar. If this verification is successful, theverification tool100 can be removed and thefemoral reference marker104 is confirmed to be at the desired location for the center of rotation of thefemoral articulation66. If the pointer moved outside of the bars during the prescribed motion, the femoral reference marker location should be adjusted as described below. This verification is performed under direct visualization.
• The following guidelines can be used to move thefemoral reference marker130 if the criterion of theverification tool100 are not met. If the pointer never enters either the 45° or 90° bar during the verification steps or if the pointer travels outside the bounds of either of the 45° or 90° bars during the specified flexion angles, a new reference marker should be inserted at a location displaced a short distance from theoriginal reference marker130. In the case of the pointer never entering either the 45° or 90° bar during the verification steps, the new reference marker should be inserted in a region which is distal and/or anterior to the original marker a distance of about 1-2 mm. If the pointer travels outside the bounds of either of the 45° or 90° bars (moves completely past the bars) during the verification steps, a new reference marker should be inserted in a region which is posterior to the original marker. The originalfemoral reference marker130 is then removed and the verification step is repeated with the new relocated reference marker. Thetibial reference marker106 does not need to be moved as theverification tool100 can be readjusted to the zero position after the newfemoral reference marker104 is inserted.
• In the event that multipleenergy absorbing devices50 are available, i.e. different sizes, the verification tool may include additional markings or may come in different sizes.
• Although theverification tool100 has been illustrated as using the visual analog reference of thepointer122 and thebars120, it should be understood that other methods may alternatively or additionally be used for verification feedback. For example, theverification tool100 can include visual, auditory, tactile, and/or digital feedback.
• Once an acceptable position of thereference marker130 is verified theenergy absorbing device50 is implanted across the joint by locating thebases52,54 on the bones employing the instruments and methods which will be described below. Particularly, thefemoral base52 is located at a preferred location with respect to the location of thereference marker130 to locate the center of rotation of thefemoral articulation66 at the location of the reference marker.
• To assist in location of the femoral base152, afemoral placement guide300 shown inFIGS. 7A,7B and8 is temporarily attached to the femoral base152. To ensure that the femoral base152 stays at a correct location during attachment to the bone, thefemoral placement guide300 is configured to temporarily attach to the base and later be removed after attachment is complete. Theplacement guide300 is attached to a selected femoral base152 by a guide knob312 (FIG. 8) which fits into the largedistal hole314 of theguide300 and threads into abone screw hole330 of the base. Theplacement guide300 includes aproximal guide hole310 into which a K-wire or other elongated member can be inserted for positioning. The placement guide also includes ahole316 with an offset318 for receiving thereference130 which was placed in the previous steps. The configuration of thehole316 and offset318 is designed to locate the femoral base152 at a position where when theabsorber60 is attached to the femoral base, the absorberfemoral articulation66 will be located to achieve the desired kinematics. Specifically, the location of thehole316 with respect to the base152 corresponds to the location of thefemoral articulation66 with respect to the base when theabsorber60 is attached to the base. Additionally, the offset318 corresponds to a desired offset of the absorberfemoral articulation66 from the bone. A height of the offset318 is preferably at least 2 mm to provide sufficient clearance between the ball and socket articulation of the absorber and the bone when the absorber is connected to the base.
• As shown inFIG. 9, thefemoral base52 with the attachedplacement guide300 are placed onto the femur by sliding theplacement guide hole316 over the previously placedreference marker130. A proper position of thefemoral base52 can be determined by placing a guide wire into theguide wire hole310 of theplacement guide300. The guide wire should extend generally perpendicular to the tibial plateau and generally parallel to the medial femoral condyle. Thefemoral base52 is held in place by inserting one or more, and preferably two or more, K-wires322 through the available K-wire holes320 in the femoral base. These K-wires322 will hold thefemoral base52 in place during placement of the bone screws332 through the bone screw holes330. The bone screws may include combinations of unicortical cancellous compression screws, locking screws, and bicortical compression screws. The screws may be placed before or after removal of theplacement guide300 from thebase52. Preferably, the placement guide is removable from the base52 by removing theguide knob312 after the base is secured to the bone by bone screws.FIG. 10 illustrates the placement of thefemoral base52 after theplacement guide300 has been removed. Once thefemoral base52 is secured to the bone, the base is ready for attachment of theabsorber60 and securing of thetibial base54.
• Thefemoral base52 can be provided in different shapes and/or sizes as well as versions for left and right knees. Thefemoral placement guide300 can be provided in versions which coordinate with the different bases. In addition, in the event that different absorber configurations are available, theplacement guide300 can be provided in different versions to accommodate the absorbers.
• In addition to or as an alternative to thefemoral placement guide300, trial bases can be used to located a desired orientation and position of thefemoral base52. For example, a trial base in the form of a one piece member having a shape of the combination of the base and placement guide shown inFIG. 8 can be used to determine and mark a position for the placement of the base. In the case of a trial base, the trial can include the offset to determine correct spacing of the articulation from the bone and can include the guide wire hole to aid in determining angular position with respect to the joint surfaces.
• In one embodiment, once thefemoral base52 has been secured to the bone theabsorber60 with the attachedtibial base54 is inserted through a tissue tunnel between the skin and bone of the patient and thesocket66 of the absorber is connected to thefemoral base52. Methods and instruments for connecting theabsorber sockets66,68 to thebases52,54 are shown and described in further detail in US Patent Publication No. 2009/0014016. Such connection of the sockets to the bases may be by taper locks, locking pins, locking screws and the like. Once theabsorber60 has been connected to thefemoral base52, the system is ready for attachment of thetibial base54 to the tibia of the patient.
• To assist in proper alignment and positioning of theabsorber60 and positioning of thetibial base54, anabsorber positioning collar400 is shown inFIGS. 11A and 11B. Setting the trajectory of thefemoral bearing66 is important to achieve desired motion of the absorber relative to the motions of the knee and the implantable system. If the bearing resides in an inappropriate plane then one of the ball/sockets can have insufficient motion in at least one direction. Theabsorber positioning collar400 includes ahandle410, a femoralbase receiving recess412, and a femoralsocket receiving recess414. Thepositioning collar400 also includes an optional K-wire hole420 for temporarily securing the positioning collar in place. Theabsorber positioning collar400 is designed to be temporarily located between thefemoral base54 and thefemoral socket66 to aid in positioning. Thecollar400 sets the absorber position relative to the implantedbase52. Since anatomies vary, thecollar400 may be configured to fix the absorber position or to allow some limited range of angles of the absorber with respect to the base. For example, where a total range of motion of the articulation is greater than 100 degrees, the motion may be limited by thecollar400 for purposes of initial positioning to less than 45 degrees, and preferably about 20 degrees or less.
• In addition to setting the absorber angular position, thecollar400 can include one or more features for setting a desired range of offset distances between the absorber and the underlying bone.
• As shown inFIG. 12, theabsorber positioning collar400 is placed onto thefemoral socket66 of theabsorber60 with therecesses412,414 receiving the distal end of the femoral base and the femoral socket, respectively. Thepositioning collar400 temporarily limits motion of the femoral socket to a reduced range of motion which corresponds to acceptable positions of the absorber at full extension. When the knee is placed in full extension and the medio-lateral laxity of the joint is removed by applying varus stress on the knee, the absorber is in a proper position. Thetibial base54 can then be fixed to the anteriomedial surface of the tibia by initially stabilizing with K-wires followed by screw fixation in a manner similar to that used to secure thefemoral base52. In one embodiment, an additional temporary tibial collar may also be used to limit the available range of motion of the tibial articulation during implantation.
• The terms “spring” and “absorber” are used throughout the description but these terms are contemplated to include other energy absorbing and compliant structures to accomplish the functions of the invention as described in more detail herein.
• While screws are used to fix the femoral andtibial bases52,54 to the bone, those skilled in the art will appreciate that any fastening members known or developed in the art may be used to accomplish desired affixation. Although thebases52,54 depicted include four to five openings and screws, it is contemplated that other embodiments of the bases may have any number of openings for screws.
• FIGS. 13A-13C show afemoral trial500 according to an aspect of the present invention. Thefemoral trial500 functions as a tool for selecting one base from among a plurality of bases having different base geometries for an implant at a joint, such as when the femoral base is provided in two or more versions to accommodate different patient anatomies, such as the 40°, 45°, and 50° base shapes disclosed in U.S. patent application Ser. No. 12/755,335, which is incorporated by reference in its entirety. Thetrial500 comprises atool body501 having abone contacting surface503 with a shape generally corresponding to the shape of bone contacting surfaces of the plurality of bases from which the one base is to be selected. It will be appreciated that the principles associated with the femoral trial are applicable to other joints and joint components, as well.
• Abottom surface503 of thebody501 conforms generally to the shape of the bone to which it is desired to attach a base. Atop surface505 of thebody501 that faces away from the bone may be generally flat or of any other convenient shape for grasping and manipulating the tool.
• Aguide opening507 is provided on thetool body501 and extends through the tool body. Theopening507 is sized to be received over a reference marker, such as a K-wire which has been placed into the bone. Theguide opening507 hasindicia509 adjacent to the opening and corresponding to at least some of the plurality of bases. Theguide opening507 is generally conical, with awide end511 of the cone being disposed on a side of thetool body501 opposite thebottom surface503 of the tool body intended to face the bone. Theindicia509 are disposed on thetool body501 at thewide end511 of the cone of theguide opening507. Theguide opening507 extends through thetool body501. In the embodiment ofFIGS. 13A-13C, theindecia509 are located on projecting portions513 that include twoshafts513aand513bbetween which the generally conical opening extends.
• During a procedure of placing an energy absorbing device, thetool body501 is positioned on a bone of the joint in a desired alignment with the bone. In the case of thefemoral trial500, an elongated wire reference marker130 (FIG. 9) is installed in the bone so as to extend generally perpendicular to the tibial plateau and generally parallel to the medial femoral condyle extends through the guide opening. Thetool body501 is positioned so that a long axis515 (FIG.13B) of the tool body is aligned parallel to an extended tibial axis and so that the trial base fits on the femur geometry in a fashion so that it is stable on the femur, and the reference marker extends through theguide opening507.
• Thereference marker130 extending through theguide opening507 will then be disposed in a position relative to theindicia509 that indicates which base is to be selected from among the plurality of bases. For example, the embodiment ofFIGS. 13A-13C is intended to facilitate selection of one of the 40°, 45°, and 50° base shapes disclosed in U.S. patent application Ser. No. 12/755,335. In the example ofFIG. 13B, theindicia509 is in the form of markings that read “40°” and “50°”. If thereference marker130 is centered in the cone of theguide opening507 and not touching either side, then a 45° base is indicated. If thereference marker130 touches the side of the cone marked with the “40°”indicia509, then a 40° base is indicated. If thereference marker130 touches the side of the cone marked with the “50°”indicia509, then a 50° base is indicated.
• FIGS. 14A-14B show a base600,FIGS. 15A-15B show aplacement guide700,FIG. 16 shows alocking pin800 of asystem900, shown inFIGS. 17A-17B, for placing an energy absorbing device at a joint, such as a knee joint. Thesystem900 is designed for use in placing a femoral base of an energy absorbing device on a patient's femur, however, it will be appreciated that the principles associated with the system are applicable to other joints and joint components, as well. Thesystem900 is particularly suited for use in connection with placement of a femoral base of the type that is designed to be placed with an end of the base offset from the bone surface in order to accommodate an articulating portion of the implant in manner disclosed in U.S. patent application Ser. No. 12/755,335, which is incorporated by reference.
• Thebase600, shown by itself inFIGS. 14A-14B, is configured to be secured to the bone adjacent the joint and has abody601 including aninner surface603 facing the bone and conforming generally the shape of the bone, and anouter surface605 facing away from the bone. Thebody601 further includes a first placementguide mounting surface607 and afirst connector component609.
• Theplacement guide700, shown by itself inFIGS. 15A-15B, can be formed of, e.g., molded plastic, and includes a second placementguide mounting surface701, asecond connector component703 adapted to mate with thefirst connector component609, and an offsetmember705. Theplacement guide700 is attachable to the base600 in an attached position, seen inFIGS. 17A-17B, such that the first and second placementguide mounting surfaces607 and701 abut when the first andsecond connector components609 and703 mate. Theplacement guide700 is designed to be removable from the base600 after the base has been secured to the bone so that socket components (not shown inFIGS. 14A-17B) can be attached to the base. After the sockets are attached to the base, an absorber (not shown inFIGS. 14A-17B) having balls for being received in the sockets to form ball and socket joints can be attached to the base on the first placementguide mounting surface607.
• The offsetmember705 has a first and asecond end707 and709. The first end of the offsetmember705 is configured to contact the bone when theplacement guide700 is in the attached position and thebase600 is in a position at which it is to be secured to the bone. The offsetmember705 further comprises alongitudinal opening711 and is configured such that a reference marker130 (FIG. 9) fixed to the bone is adapted to extend through the longitudinal opening when theplacement guide700 is in the attached position and thebase600 is in a position at which it is to be secured to the bone. Thereference marker130 is typically in the form of a wire installed in the bone so as to extend generally perpendicular to the tibial plateau and generally parallel to the medial femoral condyle.
• Theplacement guide700 may be designed to be attachable to the base600 in only one attached position. For example, theplacement guide700 may be shaped so that it fits betweenarms611 extending from the first placementguide mounting surface607 that prevent rotation of the placement guide relative to thebase600.
• Theplacement guide700 further comprises anelongate member713 having a proximal guide hole (not shown) similar to theproximal guide hole310 discussed in connection with the embodiment shown inFIGS. 7A-9. Theelongate member713 extends from theguide700 in a direction towards an opposite bone of the joint and is thus configured for facilitating orientation of the base on the bone when theplacement guide700 is in the attached position and thebase600 is in a position at which it is to be secured to the bone.
• Theplacement guide700 further includes alocking arm715 adapted to engage with thebase600 for locking the placement guide in the attached position. The lockingarm715 extends from themain body717 of theplacement guide700 in an opposite direction relative to the second placementguide mounting surface701 from the direction of the location of the offsetmember705. The lockingarm715 extends around anengagement portion613 of thebase600 and, while in this locking position, prevents removal of theplacement guide700 from the base. The lockingarms715 is flexible or breakable so that it can be moved from locking position and removal of theplacement guide700 from thebase600 is possible. A removable pin800 (shown by itself inFIG. 16) engages thelocking arm715 to prevent unlocking of theplacement guide700 from the attached position and extends throughopenings719 and721 in the locking arm and thesecond connector component703 and through anopening615 in theengagement portion613 of the base.
• Thesystem900 is used to position thebase600 for an implant at a joint by inserting afirst reference marker130 into a first bone of the joint so that one end of the first reference marker is inserted into the bone and the other end of the first reference marker is free. Thesystem900 in the form of a preassembled combination of abase600 and aplacement guide700 is positioned on the bone of the joint so that thefirst reference marker130 extends through thelongitudinal opening711 in the offset705, which functions as a first guide hole. A second elongated reference marker such as a wire (not shown) is extended through the proximal guide hole in theelongate member713 and into the bone of the joint while orienting thesystem900 comprising thebase600 and placement guide700 combination, together with the second reference marker, so that, when the second reference marker is inserted into the bone, the second reference marker extends in a predetermined relation to the first bone and a second bone of the joint. As described in connection with the attachment of the base52 inFIG. 9, the second reference marker may be a guide wire that extends generally perpendicular to the tibial plateau and generally parallel to the medial femoral condyle. After securing the base600 to the bone via bone screws through bone screw holes617, theplacement guide700 is detached from the base600 by removing thepin800 and moving thelocking arm715 from the locking position to an unlocked position.
• The various embodiments described above are provided by way of illustration only and should not be construed to limit the claimed invention. Those skilled in the art will readily recognize various modifications and changes that may be made to the claimed invention without following the example embodiments and applications illustrated and described herein, and without departing from the true spirit and scope of the claimed invention, which is set forth in the following claims. In that regard, various features from certain of the disclosed embodiments can be incorporated into other of the disclosed embodiments to provide desired structure.

Claims (44)

1. A method of implanting a device at a joint comprising:

inserting a first reference marker into a first bone of the joint;

inserting a second reference marker into a second bone of the joint;

connecting the first and second reference markers to a verification tool;

moving the joint through a predetermined range of motion and utilizing the verification tool to determine whether the first and second reference markers move in a desired kinematic pattern with respect to one another throughout the predetermined range of motion;

relocating one of the reference markers if the desired kinematic pattern is not achieved; and

implanting the device across the joint.

2. The method ofclaim 1, wherein the device is an energy absorbing device.

3. The method ofclaim 1, wherein the first and second reference markers are temporary markers which are removed when the device is implanted.

4. The method ofclaim 1, wherein the desired kinematic pattern includes motion of the first and second reference markers away from one another as the joint is moved through the predetermined range of motion from extension to flexion.

5. The method ofclaim 3, wherein joint is a knee joint.

6. The method ofclaim 1, wherein the first and second markers comprise elongated members having an end configured for inserting into bone and a free end, and wherein the verification tool has openings for receiving the free ends of the elongated members.

7. The method ofclaim 1, wherein the verification tool includes an indicator which indicates whether the first and second reference markers move in a desired kinematic pattern.

8. The method ofclaim 5, wherein the second marker is inserted into the second bone through the opening in the verification tool.

9. The method ofclaim 1, wherein the verification tool is configured to measure a distance between the first and second reference markers while the joint is moved through the predetermined range of motion.

10. The method ofclaim 1, wherein the first and second markers are K-wires and are inserted along substantially parallel paths.

11. The method ofclaim 1, wherein the joint is a knee and the first marker is positioned on a femur relative to a midpoint of Blumensaat's line.

12. A verification tool for verification of a location for implantation of an extra-articular energy absorbing device at a joint, the tool comprising:

a tool body;

a first connection member on the tool body, the first connection member configured to be connected to a first reference marker located in a first bone, the first connection member allowing rotation of the tool with respect to the first bone;

a second connection member on the tool body, the second connection member configured to be connected to a second reference marker located in a second bone, the second connection member allowing rotation of the tool with respect to the second bone, wherein at least one of the first and second connection members is movable with respect to the tool body; and

a gauge configured to provide a user with information about the location of at least one of the first and second reference markers as the joint is articulated.

13. The tool ofclaim 12, wherein the at least on of the first and second connection members is movable with respect to the tool body solely in one dimension.

14. The tool ofclaim 12, further comprising an indicator configured to determine whether the first and second reference markers move in a desired kinematic pattern.

15. The tool ofclaim 14, wherein the indicator is a visual indicator.

16. The tool ofclaim 14, wherein the desired kinematic pattern is a pattern in which the first and second reference markers move apart as the joint moves from extension to about 45 degrees of flexion.

17. A system for placing an energy absorbing device at a joint comprising:

a base configured to be secured to a bone adjacent a joint;

a placement guide removably attachable to the base, wherein the placement guide includes an offset member one end of which is connected to the placement guide and an opposite end of which is configured to contact the bone.

18. The system ofclaim 17, wherein the placement guide is removable from the base after the base has been secured to the bone.

19. The system ofclaim 17, wherein the offset member is configured to slide over a reference wire fixed to the bone.

20. The system ofclaim 17, wherein the offset member is pivotable with respect to the base when the placement guide is attached to the base.

21. The system ofclaim 17, wherein the placement guide further comprises an elongate member extending from the guide in a direction towards an opposite bone of the joint and configured for orienting the base on the bone.

22. A tool for locating a center of rotation for an implantable articulating joint device, the tool comprising:

a tool body having at least one radiographic marker configured for locating an anatomical reference location on a bone; and

means for marking a target location for an implantable articulating joint device at a predetermined distance and direction away from the anatomical reference location.

23. The tool ofclaim 22, wherein the anatomical reference location is on a femur at the center of Blumensaat's line.

24. The tool ofclaim 22, wherein the radiographic marker comprises concentric radiopaque circles.

25. The tool ofclaim 22, wherein the means for marking is an opening configured to receive a marker which is inserted into the bone.

26. The tool ofclaim 22, wherein the target location is a center of rotation for the implantable articulating joint device.

27. A method for locating a center of rotation for an implantable articulating joint device, the method comprising:

locating an anatomical reference location on a bone with a tool having radiopaque markers; and

marking a target location for an implantable articulating joint device at a predetermined distance and direction away from the anatomical reference location by inserting a marker through an opening in the tool.

28. The method ofclaim 27, wherein the target location is a center of rotation for the implantable articulating joint device and further comprising implanting the articulating joint device.

29. A method of implanting an energy absorbing device at a joint comprising:

securing a first base member to a bone on a first side of a joint;

affixing an absorber to the first base member, the absorber having at least one articulation;

temporarily restraining the articulation of the absorber to a limited range of motion less the a full range of motion of the articulation with a removable restraint;

positioning and securing a second base member to a bone on a second side of the joint while the articulation of the absorber is temporarily restrained; and

removing the restraint.

30. The method ofclaim 29, wherein the restraint is a positioning collar arranged to be placed between the first base and the absorber to limit articulation of the absorber.

31. A system for placing an energy absorbing device at a joint comprising:

a base configured to be secured to a bone adjacent a joint and including a first placement guide mounting surface and a first connector component;

a placement guide including a second placement guide mounting surface, a second connector component adapted to mate with the first connector component, and an offset member, the placement guide being attachable to the base in an attached position such that the first and second placement guide mounting surfaces abut when the first and second connector components mate.

32. The system ofclaim 31, wherein the placement guide is removable from the base after the base has been secured to the bone.

33. The system ofclaim 31, wherein the offset member has a first and a second end, the first end of the offset member being configured to contact the bone when the placement guide is in the attached position and the base is in a position at which it is to be secured to the bone.

34. The system ofclaim 31, wherein the offset member comprises a longitudinal opening and is configured such that a reference marker fixed to the bone is adapted to extend through the longitudinal opening.

35. The system ofclaim 31, wherein the placement guide is attachable to the base in only one attached position.

36. The system ofclaim 31, wherein the placement guide further comprises an elongate member extending from the guide in a direction towards an opposite bone of the joint and configured for orienting the base on the bone.

37. The system ofclaim 31, wherein the placement guide includes a locking arm adapted to engage with the base for locking the placement guide in the attached position.

38. The system ofclaim 37, comprising a removable pin adapted to engage the locking arm to prevent unlocking of the placement guide from the attached position.

39. A method for positioning a base for an implant at a joint, comprising:

inserting a first elongated reference marker into a first bone of the joint so that one end of the first reference marker is inserted into the bone and the other end of the first reference marker is free;

placing a preassembled combination of a base and a placement guide on the bone of the joint so that the first reference marker extends through a first guide hole in the placement guide;

inserting a second elongated reference marker through a second guide hole in the placement guide and into the bone of the joint while orienting the combination and the second reference marker so that, when the second reference marker is inserted into the bone, the second reference marker extends in a predetermined relation to the first bone and a second bone of the joint.

40. The method ofclaim 39, comprising detaching the placement guide from the base by moving a locking arm of the placement guide from a locking position in which the locking arm locks the placement guide relative to the base to an unlocked position.

41. A tool for selecting one base from among a plurality of bases having different base geometries for an implant at a joint, comprising:

a tool body having a bone contacting surface shape generally corresponding to a bone contacting surface shape of the plurality of bases from which the one base is to be selected;

a guide opening on the tool body through which an elongated reference marker is adapted to extend;

indicia corresponding to at least some of the plurality of bases,

wherein, when the tool body is positioned on a bone of the joint so that the reference marker extends through the guide opening and the tool body is in a desired alignment with the bone, the reference marker is disposed in a position relative to the indicia that indicates one base is to be selected.

42. The tool ofclaim 41, wherein the guide opening is generally conical, with a wide end of the cone being disposed on a side of the tool body opposite a side of the tool body intended to face the bone.

43. The tool ofclaim 42, wherein the indicia are disposed on the tool body at the wide end of the cone of the guide opening.

44. A method for selecting a base from among a plurality of bases having different base geometries for an implant at a joint, comprising:

inserting an elongated reference marker into a bone of the joint so that one end of the reference marker is inserted into the bone and the other end of the reference marker is free;

positioning a trial so that a surface of the trial is in a desired alignment with the portion of the bone and so that the free end of the reference marker extends through a guide opening on the trial; and

selecting one base from among the plurality bases depending upon a position of the reference marker relative to one or more indicia associated with the guide opening.

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