US20180116784A1

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Publication number: US20180116784A1
Application number: US15/337,596
Authority: US
Inventors: Michio Takayama; Takamitsu Sakamoto; Ken Fujisaki
Original assignee: Olympus Corp
Current assignee: Olympus Corp
Priority date: 2016-10-28
Filing date: 2016-10-28
Publication date: 2018-05-03
Also published as: US11439425B2; US20200078041A1

Abstract

A surgical procedure of preparing bone holes to dispose an implanted tendon to a femur when performing reconstruction of a ligament in a knee joint, includes: forming a first bone hole in the femur; and applying ultrasonic vibration from a treatment portion of an ultrasonic treatment instrument to the femur, thereby cutting and expanding the first bone hole from the inside of the knee joint to the first bone hole of the femur along a predetermined depth, and forming a second bone hole having a polygonal shape, an approximately polygonal shape, an elliptical shape or an approximately elliptical shape to receive the implanted tendon.

Description

BACKGROUND OF THE INVENTION1. Field of the Invention

This invention relates to a surgical procedure of a knee joint which is performed under an arthroscope.

2. Description of the Related Art

In a case where a surgeon performs reconstruction of a ligament in a knee joint, it is known that an outer shape of a cross section of an implanted tendon which is perpendicular to a longitudinal axis thereof, is a polygonal shape such as a rectangular shape, an elliptical shape, or an approximately polygonal shape close to the elliptical shape.

BRIEF SUMMARY OF THE INVENTION

According to one aspect of the present invention, a surgical procedure of preparing bone holes to dispose an implanted tendon to a femur when performing reconstruction of a ligament in a knee joint, includes: forming a first bone hole in the femur; and applying ultrasonic vibration from a treatment portion of an ultrasonic treatment instrument to the femur, thereby cutting and expanding the first bone hole from the inside of the knee joint to the first bone hole of the femur along a predetermined depth, and forming a second bone hole having a polygonal shape, an approximately polygonal shape, an elliptical shape or an approximately elliptical shape to receive the implanted tendon.

Advantages of the invention will be set forth in the description which follows, and in part will be obvious from the description, or may be learned by practice of the invention. The advantages of the invention may be realized and obtained by means of the instrumentalities and combinations particularly pointed out hereinafter.

BRIEF DESCRIPTION OF THE DRAWINGS

The accompanying drawings, which are incorporated in and constitute apart of the specification, illustrate embodiments of the invention, and together with the general description given above and the detailed description of the embodiments given below, serve to explain the principles of the invention.

FIG. 1 is a schematic view showing a treatment system for use in a surgical treatment of a knee joint;

FIG. 2 is a schematic view showing one example of an ultrasonic treatment unit for use in the system shown inFIG. 1;

FIG. 3A is a schematic view showing an ultrasonic probe of a treatment instrument shown inFIG. 2;

FIG. 3B is a cross-sectional view showing a state where the ultrasonic probe shown inFIG. 3A is cut along the3B-3B line perpendicular to a longitudinal axis inFIG. 3A;

FIG. 3C is a schematic view showing a state where the ultrasonic probe shown inFIG. 3A is seen from a direction indicated by an arrow3C inFIG. 3A;

FIG. 3D is a cross-sectional view showing a modification of the ultrasonic probe shown inFIG. 3A and cut along the3B-3B line perpendicular to the longitudinal axis inFIG. 3A;

FIG. 3E is a schematic view showing a modification of the ultrasonic probe shown inFIG. 3A and seen from the direction indicated by the arrow3C inFIG. 3A;

FIG. 4A is a schematic partial cross-sectional view showing a state where a hole is formed in a bone with the ultrasonic probe shown inFIG. 3A;

FIG. 4B is a schematic perspective view showing a concave hole formed in a desired orientation at a desired position of a footprint region of an anterior cruciate ligament with the ultrasonic probe shown inFIG. 4A;

FIG. 5A is a schematic perspective view showing a modification of a treatment portion of the ultrasonic probe shown inFIG. 3A;

FIG. 5B is a schematic perspective view showing a modification of the treatment portion of the ultrasonic probe shown inFIG. 3A;

FIG. 6A is a schematic perspective view showing a modification of the treatment portion of the ultrasonic probe shown inFIG. 3A;

FIG. 6B is a schematic perspective view showing a modification of the treatment portion of the ultrasonic probe shown inFIG. 3A;

FIG. 6C is a schematic perspective view showing a modification of the treatment portion of the ultrasonic probe shown inFIG. 3A;

FIG. 7 is a schematic view of an implanted tendon which includes an STG tendon for use in reconstruction of the anterior cruciate ligament;

FIG. 8A is a schematic view showing a procedure of the reconstruction of the anterior cruciate ligament and showing a state where a through hole (a drilled hole) is formed from the inside of the knee joint to the footprint region of the anterior cruciate ligament of a femur of the knee joint with a drill;

FIG. 8B is a schematic view showing a state where a concave hole is formed from the inside of the joint to the through hole of the femur in the state shown inFIG. 8A with the probe of the ultrasonic treatment instrument;

FIG. 8C is a schematic view showing a state where a through hole (a drilled hole) is formed from the inside of the knee joint to a footprint region of an anterior cruciate ligament of a tibia of the knee joint in the state shown inFIG. 8B with the drill;

FIG. 8D is a schematic view showing a state where a concave hole is formed from the inside of the joint to the through hole of the tibia in the state shown inFIG. 8C with the probe of the ultrasonic treatment instrument;

FIG. 8E is a schematic view showing a state where the implanted tendon including the STG tendon shown inFIG. 7 is fixed to the femur and the tibia;

FIG. 9 is a schematic view of an implanted tendon which includes a BTB tendon for use in the reconstruction of the anterior cruciate ligament;

FIG. 10A is a schematic view showing a procedure of the reconstruction of the anterior cruciate ligament and showing a state where a through hole (a drilled hole) is formed from the inside of the knee joint to the footprint region of the anterior cruciate ligament of the femur of the knee joint with the drill;

FIG. 10B is a schematic view showing a state where a concave hole is formed from the inside of the joint at a position including the through hole of the femur in the state shown inFIG. 10A with the probe of the ultrasonic treatment instrument;

FIG. 10C is a schematic view showing a state where a concave hole is formed from the inside of the joint at a position that is adjacent to the concave hole of the femur in the state shown inFIG. 10B and that includes the through hole of the femur with the probe of the ultrasonic treatment instrument;

FIG. 10D is a schematic view showing a state where a through hole (a drilled hole) is formed from the inside of the knee joint to the footprint region of the anterior cruciate ligament of the tibia of the knee joint in the state shown inFIG. 10C with the drill;

FIG. 10E is a schematic view showing a state where a concave hole is formed from the inside of the joint at a position including the through hole of the tibia in the state shown inFIG. 10D with the probe of the ultrasonic treatment instrument;

FIG. 10F is a schematic view showing a state where a concave hole is formed from the inside of the joint at a position that is adjacent to the concave hole of the tibia in the state shown inFIG. 10E and that includes the through hole of the tibia with the probe of the ultrasonic treatment instrument;

FIG. 10G is a schematic view showing a state where the implanted tendon including the BTB tendon shown inFIG. 9 is fixed to the femur and the tibia;

FIG. 11A is a schematic view showing a procedure of the reconstruction of the anterior cruciate ligament and showing a state where a through hole (a drilled hole) is formed from the inside of the knee joint to the footprint region of the anterior cruciate ligament of the femur of the knee joint with the drill;

FIG. 11B is a schematic view showing a state where concave holes are formed from the inside of the joint at a position including, in a middle, the through hole of the femur in the state shown inFIG. 11A with the probe of the ultrasonic treatment instrument;

FIG. 11C is a schematic view showing a state where concave holes are formed from the inside of the knee joint to the footprint region of the anterior cruciate ligament of the tibia of the knee joint shown inFIG. 11B with the probe of the ultrasonic treatment instrument;

FIG. 11D is a schematic view showing a state where the implanted tendon including the BTB tendon shown inFIG. 9 is fixed to the tibia with screws;

FIG. 12A is a schematic view showing a procedure of the reconstruction of the anterior cruciate ligament and showing a state where a through hole is formed from the outside of the femur toward the footprint region of the anterior cruciate ligament of the femur of the knee joint;

FIG. 12B is a schematic view showing a state where a cortical bone on an outer side of the femur is removed with the drill to the through hole of the femur in the state shown inFIG. 12A;

FIG. 12C is a schematic view showing a state where a through hole is formed from the outside of the femur of the knee joint in the state shown inFIG. 12B to the footprint region of the anterior cruciate ligament with the ultrasonic treatment instrument;

FIG. 12D is a schematic view showing a state where a through hole is formed from the outside of the tibia toward the footprint region of the anterior cruciate ligament of the tibia of the knee joint;

FIG. 12E is a schematic view showing a state where a through hole is formed from the outside of the tibia of the knee joint in the state shown inFIG. 12D to the footprint region of the anterior cruciate ligament with the ultrasonic treatment instrument;

FIG. 12F is a schematic view showing a state where the implanted tendon including the STG tendon shown inFIG. 7 is fixed to the femur and the tibia;

FIG. 13A is a schematic view showing a procedure of the reconstruction of the anterior cruciate ligament and showing a state where a through hole is formed from the outside of the tibia toward the footprint region of the anterior cruciate ligament of the tibia of the knee joint;

FIG. 13B is a schematic view showing a state where a through hole is formed in an outer side of the femur continuously with the through hole of the tibia in the state shown inFIG. 13A through the footprint region of the anterior cruciate ligament of the femur;

FIG. 13C is a schematic view showing a state where a through hole is formed from the outside of the tibia of the knee joint in the state shown inFIG. 13B to the footprint region of the anterior cruciate ligament with the ultrasonic treatment instrument;

FIG. 13D is a schematic view showing a state where a concave hole is formed continuously with the through hole of the tibia in the state shown inFIG. 13C to the footprint region of the anterior cruciate ligament of the femur of the knee joint; and

FIG. 13E is a schematic view showing a state where the implanted tendon including the STG tendon shown inFIG. 7 is fixed to the femur and the tibia.

DETAILED DESCRIPTION OF THE INVENTION

Embodiments of this invention will be described with reference to the drawings.

When a knee joint100 is treated, for example, atreatment system10 shown inFIG. 1 is used. Thetreatment system10 includes anarthroscope device12, atreatment device14, and anirrigation device16.

Thearthroscope device12 includes anarthroscope22 to observe an inner part of the knee joint100, i.e., the inside of ajoint cavity110 of a patient, anarthroscope controller24 that performs image processing on the basis of a subject image imaged by thearthroscope22, and amonitor26 that displays the image generated by the image processing in thearthroscope controller24. Thearthroscope22 is inserted into thejoint cavity110 of the knee joint100 through afirst portal102 by a skin cutting portion via which the inner part of theknee joint100 of the patient communicates with an outer side of skin. A position of thefirst portal102 is not uniform but is suitably determined in accordance with a patient's condition. It is also preferable that an unshown cannula is disposed to thefirst portal102 and thearthroscope22 is inserted into thejoint cavity110 of the knee joint100 via the cannula. Additionally, it is drawn that thearthroscope22 and a later-describedtreatment instrument52 of thetreatment device14 are disposed to face each other inFIG. 1, but the arthroscope and the treatment instrument are arranged in a suitable positional relation in accordance with a position of a treatment object, or the like.

Thetreatment device14 includes afirst treatment unit30, asecond treatment unit32, acontroller34, and switches36aand36b. The

switches

36aand36bare shown as hand switches inFIG. 1, but may be foot switches.

Thecontroller34 suitably supplies energy (electric power) to thefirst treatment unit30 in accordance with an operation of theswitch36ato form a hole in a bone B. Thefirst treatment unit30 is, for example, a drill.

Thecontroller34 suitably supplies energy (electric power) to a later-describedultrasonic transducer unit54 of thesecond treatment unit32 in accordance with an operation of theswitch36bto transmit ultrasonic vibration to atreatment portion74 of a later-describedprobe66 of thesecond treatment unit32. Thetreatment portion74 of theprobe66 is inserted into thejoint cavity110 of the knee joint100 through asecond portal104 by a skin cutting portion via which the inner part of the joint100 of the patient communicates with the outer side of skin. A position of thesecond portal104 is not uniform but is suitably determined in accordance with the patient's condition. It is also preferable that an unshown cannula is disposed to thesecond portal104 and thetreatment portion74 of theprobe66 is inserted into thejoint cavity110 of the knee joint100 via the cannula. Theswitch36bmaintains, for example, a driven state of a later-describedultrasonic transducer56bin a state where the switch is pressed to be operated, and when the pressed state is released, the driven state of theultrasonic transducer56bis released.

Here, it is described that oneswitch36bis disposed, but the switches may be disposed. An amplitude of theultrasonic transducer56bcan suitably be set by thecontroller34. In consequence, a frequency of the ultrasonic vibration to be output from the later-describedultrasonic transducer56bis the same, but by the operation of theswitch36b, the amplitude may vary. Therefore, it is also preferable that theswitch36bcan switch the amplitude of theultrasonic transducer56bto states such as two large and small states.

Additionally, although not shown in the drawing, it is also preferable that as thetreatment device14, there is used another treatment unit that dissects a later-described region to which an anterior cruciate ligament adheres. In this way, in thetreatment device14, treatment units are suitably used.

Theirrigation device16 includes aliquid source42 that contains an irrigation liquid such as physiological saline, anirrigation pump unit44, aliquid supply tube46 whose one end is connected to theliquid source42, aliquid discharge tube48, and asuction bottle50 connected to one end of theliquid discharge tube48. Thesuction bottle50 is connected to a suction source attached to a wall of an operating room. In theirrigation pump unit44, the irrigation liquid can be supplied from theliquid source42 by a liquid supply pump44a. Additionally, in theirrigation pump unit44, suction/suction stop of the irrigation liquid in thejoint cavity110 of the knee joint100 to thesuction bottle50 can be switched by opening/closing a pinchingvalve44bas a liquid discharge valve.

The other end of theliquid supply tube46 which is a liquid supply tube path is connected to thearthroscope22. In consequence, the irrigation liquid can be supplied into thejoint cavity110 of the joint100 via thearthroscope22. The other end of theliquid discharge tube48 which is a liquid discharge tube path is connected to thearthroscope22. In consequence, the irrigation liquid can be discharged from thejoint cavity110 of the joint100 via thearthroscope22. Additionally, needless to say, the other end of theliquid discharge tube48 may be connected to thetreatment instrument52, so that the irrigation liquid can be discharged from the joint100. It is to be noted that the irrigation liquid can be supplied and discharged through another portal.

As shown inFIG. 2, thesecond treatment unit32 has theultrasonic treatment instrument52 and theultrasonic transducer unit54. It is preferable that theultrasonic transducer unit54 is attachable to and detachable from theultrasonic treatment instrument52, but the unit may be integrated with the ultrasonic treatment instrument. Theultrasonic transducer unit54 has a housing (a transducer case)56a, the bolt-clamped Langevin-type transducer56b, and a connectingportion56cat a proximal end of the later-describedultrasonic probe66. The connectingportion56cis formed at a distal end of thetransducer56b. It is preferable that the connectingportion56cprojects along a central axis C of theultrasonic transducer unit54 toward a distal side of thehousing56a. Acable56dhaving one end connected to thetransducer56band the other end connected to thecontroller34 extends out from a proximal end of thehousing56aof theultrasonic transducer unit54. Thetransducer56band the connectingportion56cform an integrated vibratingbody58.

Thehousing56asupports a supportedportion58aof the vibratingbody58. Theultrasonic transducer unit54 is known and thus a detailed description is omitted. In a state where vibration is generated in thetransducer56b, the connectingportion56cand a proximal end of thetransducer56bconstitute antinodes of the vibration. It is to be noted that although not shown inFIG. 2, theswitch36bis preferably disposed in thehousing56aof theultrasonic transducer unit54 or in a later-describedhousing62 of theultrasonic treatment instrument52.

Theultrasonic treatment instrument52 includes the housing (a handle)62, a tubular body (an outer tube)64 extending out from thehousing62 along the central axis C, and theultrasonic probe66 inserted into thetubular body64. Here, in theultrasonic treatment instrument52, a side on which thehousing62 is positioned relative to thetubular body64 is defined as a proximal side (an arrow C1 side), and a side opposite to the proximal side is defined as a distal side (an arrow C2 side). Thetubular body64 is attached to thehousing62 from the distal side. Furthermore, theultrasonic treatment instrument52 has the later-describedtreatment portion74 in a portion on the distal side to thetubular body64.

Thehousing62 and thetubular body64 of theultrasonic treatment instrument52 are made of a material having insulating properties. Thehousing56aof theultrasonic transducer unit54 is attachably/detachably connected to thehousing62 of theultrasonic treatment instrument52. It is also preferable that thehousing62 of theultrasonic treatment instrument52 and thehousing56aof theultrasonic transducer unit54 are integrated.

A rotary knob (not shown) of a rotary operating member may be attached to thehousing62 of thetreatment instrument52. The rotary knob is rotatable relative to thehousing62 in a periaxial direction of the central axis of thetubular body64. By the rotation of the rotary knob, thehousing56aof theultrasonic transducer unit54, thetubular body64, the later-describedtreatment portion74 and a probemain body portion72 rotate together relative to thehousing62 in the periaxial direction of the central axis C of the probemain body portion72.

Outer peripheral surfaces of thehousing62 and thetubular body64 of theultrasonic treatment instrument52 have insulating properties. Theultrasonic probe66 is made of a material that is capable of transmitting the ultrasonic vibration, e.g., a metal material such as a titanium alloy material. At the proximal end of theprobe66, there is fixed the connectingportion56cof theultrasonic transducer unit54 that is fixed to thehousing62. It is preferable that a total length of theprobe66 is, for example, an integer multiple of a half-wave length based on a resonance frequency of thetransducer56b. The total length of theprobe66 is not limited to the integer multiple of the half-wave length based on the resonance frequency of thetransducer56b, and is suitably adjusted in accordance with the material, an amplitude enlargement ratio, or the like. Therefore, the total length of theprobe66 may be an approximate integer multiple of the half-wave length based on the resonance frequency of thetransducer56b. In the vibratingbody58 and theprobe66, materials or lengths thereof are suitably set to vibrate as a whole at the resonance frequency of thetransducer56band a frequency in an output of thecontroller34.

As shown inFIG. 2 andFIG. 3A, theultrasonic probe66 includes the probemain body portion72, and includes thetreatment portion74 that is disposed on the distal side of the probemain body portion72 and that is capable of forming a hole in a bone of a treatment object by the ultrasonic vibration. The ultrasonic vibration generated in theultrasonic transducer56bis transmitted to the probemain body portion72 via the connectingportion56cof the vibratingbody58. The ultrasonic vibration generated in theultrasonic transducer56bis transmitted to thetreatment portion74 via the connectingportion56cand the probemain body portion72.

It is preferable that the probemain body portion72 is formed straight. It is preferable that thetreatment portion74 extends straight out from a distal end of the probemain body portion72 on the distal side, but thetreatment portion74 may suitably be bent in consideration of visibility of thetreatment portion74 to thearthroscope22. Therefore, the central axis C of the probemain body portion72 may match a longitudinal axis L of thetreatment portion74 or may be different therefrom.

Thetreatment portion74 includes a cuttingportion82. As a projection shape when the proximal side is seen from the distal side along the longitudinal axis L of thetreatment portion74, the cuttingportion82 has a polygonal shape such as a rectangular shape shown inFIG. 3B andFIG. 3C or an elliptical shape (including an approximately elliptical shape) shown inFIG. 3D andFIG. 3E. The projection shape may be an approximately polygonal shape close to the elliptical shape. The polygonal shape may be a regular polygon. The projection shape may be an approximately polygonal shaped rectangle having round corners, or an approximately elliptical shape such as a track shape of an athletic field. For this reason, the projection shape is formed into a suitable shape such as the polygonal shape such as the approximately polygonal shape, the elliptical shape, or the approximately elliptical shape.

As shown inFIG. 4A, the cuttingportion82 of thetreatment portion74 is moved so that thetreatment portion74 applies a force F to a bone B on the distal side along the longitudinal axis L in a state where the ultrasonic vibration is transmitted to the probemain body portion72. Because of this, theprobe66 is moved straight or generally straight to the distal side along the central axis C. At this time, the bone is resected with thetreatment portion74.

The cuttingportion82 includes ablock body86 in a distal portion of thetreatment portion74. Theblock body86 is formed into a block shape to determine an outer shape (a contour of the hole) when the bone B is resected. Theblock body86 has a pillar-shapedportion86a, and aconvex portion86bprojecting out from the pillar-shapedportion86ato the distal side along the longitudinal axis L. The pillar-shapedportion86ais formed into a shape of a pillar such as a polygonal pillar or an elliptical pillar. The pillar-shapedportion86aand theconvex portion86bare integrally formed by cut processing or the like.

A cross section of the pillar-shapedportion86aof theblock body86 of the cuttingportion82 which is perpendicular to the longitudinal axis L is formed into the same shape or approximately the same shape from adistal end87ato aproximal end87balong the longitudinal axis L. An outer peripheral surface of the pillar-shapedportion86ais continuous with the proximal side of thedistal end87aof the pillar-shapedportion86aalong the longitudinal axis L. Therefore, the cross section of the pillar-shapedportion86a, which is perpendicular to the longitudinal axis L, is formed into the same area or approximately the same area from thedistal end87ato theproximal end87b. Thedistal end87aof the pillar-shapedportion86adetermines a maximum outer shape region (the contour of the hole) when the bone B is resected. The outer peripheral surface of the pillar-shapedportion86ahas the same projection shape as the projection shape of the cuttingportion82 when its proximal side is seen from the distal side along the longitudinal axis L of thetreatment portion74. In this way, an outer shape of the cuttingportion82 of thetreatment portion74 is formed in accordance with a shape of the hole to be formed by resecting the bone B (seeFIG. 4B).

A polygonal pillar of the pillar-shapedportion86ais formed into a suitable shape or a shape close to the suitable shape, e.g., a triangular pillar, a quadrangular pillar, a pentangular pillar, a hexagonal pillar or the like. In the pillar-shapedportion86a, distinct corners do not necessarily have to be formed. Furthermore, thedistal end87aof the pillar-shapedportion86adoes not have to be a regular polygon, and is also preferably formed to be flat. Therefore, the hole can be formed into a desire shape by use of theprobe66 according to the present embodiment.

It is preferable that the projection shape of the cuttingportion82 is a polygonal shape such as an approximately rectangular shape shown inFIG. 3B andFIG. 3C, or the elliptical shape shown inFIG. 3D andFIG. 3E. In a case of performing reconstruction of the anterior cruciate ligament by use of a later-described STG tendon212 (seeFIG. 7), an outer shape of a cross section of an implanted tendon which is perpendicular to the longitudinal axis is formed as an approximately rectangular shape of about 4 mm×5 mm. Because of this, in a case where, as one example, the projection shape of the cuttingportion82 is an approximately rectangular shape, it is preferable that a size of the outer shape of the cross section perpendicular to the longitudinal axis L is, for example, about 4 mm×5 mm.

Theconvex portion86bis formed on the distal side of the pillar-shapedportion86a. Theconvex portion86bprojects out from thedistal end87aof the pillar-shapedportion86ato the distal side along the longitudinal axis L, and is formed into a conical shape or an approximately conical shape based on the projection shape of the cuttingportion82. Atop portion86cof theconvex portion86bof the cuttingportion82 is formed at a suitable position on the distal side along the longitudinal axis L to the pillar-shapedportion86a. Thetop portion86cof theconvex portion86bof the cuttingportion82 is formed in a range of a projection shape of a boundary (thedistal end87aof the pillar-shapedportion86a) between the convex portion of the cuttingportion82 and the pillar-shapedportion86athereof when the proximal side is seen from the distal side along the longitudinal axis L. A line connecting one point of the boundary between theconvex portion86bof the cuttingportion82 and the pillar-shapedportion86aof the cuttingportion82 to thetop portion86cmay be a straight line or a curved line. Therefore, theconvex portion86bof the cuttingportion82 is not limited to the conical shape and may have the approximately conical shape. Furthermore, thetop portion86cdoes not have to be sharpened and may have an obtuse shape.

Here, it is defined that theconvex portion86bof the cuttingportion82 is formed as a quadrangular pyramid shown inFIG. 3C. A contact area between thetop portion86cof theconvex portion86bof the cuttingportion82 and the bone is small in an initial state when the bone is resected. Because of this, the bone can start to be cut in a state where friction between the cuttingportion82 and the bone is decreased.

Here, thetop portion86cat the topmost end of theconvex portion86bof the cuttingportion82 is appropriately sharp. When thetop portion86cis brought into contact with or pressed onto the bone B with suitable force, it is difficult for the top portion to slip to the bone B as compared with the obtuse shape. For this reason, when the ultrasonic vibration is transmitted to theprobe66 in the state where thetop portion86cis brought into contact with or pressed onto the bone B with suitable force, it is difficult for the top portion to slip to the bone B, and for the position to shift in a case where a hole200 (seeFIG. 4A andFIG. 4B) starts to be opened. Therefore, when thetop portion86cis appropriately sharp, it is difficult for the position of thetop portion86cat the topmost end of theconvex portion86bof the cuttingportion82 to shift to the bone B, and it becomes easy to determine a position at which thehole200 is to be formed.

As shown inFIG. 3A toFIG. 3C, thetreatment portion74 includes a dischargingportion84 to discharge cutting debris of the bone resected by the cuttingportion82 from the cuttingportion82 toward the proximal side along the longitudinal axis L. Apart of the dischargingportion84 is disposed in the cuttingportion82. The dischargingportion84 includesconcave portions92 formed in an outer peripheral surface of the cuttingportion82 and ashaft portion94 disposed on the proximal side of the cuttingportion82.

As shown inFIG. 3B, in the outer peripheral surface of the cuttingportion82, there are formed theconcave portions92 of the dischargingportion84 that decreases the contact area between thetreatment portion74 and the bone, and which becomes a discharge path of the cutting debris. Here, each of theconcave portions92 is formed into a wavelike shape having a bottom surface at a position dented to outer peripheral surfaces of the pillar-shapedportion86aand theconvex portion86b. The bottom surface of theconcave portion92 is closer to the central axis C (the longitudinal axis L) than the pillar-shapedportion86a. Theconcave portions92 do not necessarily have to be formed in theconvex portion86b(seeFIG. 5A).

Theshaft portion94 is extended from theblock body86 of the cuttingportion82 to the proximal side along the longitudinal axis L. Theshaft portion94 is interposed between the distal end of the probemain body portion72 and theproximal end87bof theblock body86 of the cuttingportion82. A projection shape of theshaft portion94 when its proximal side is seen from the distal side along the longitudinal axis L falls within a range of a projection shape of theblock body86 of the cuttingportion82.

Theshaft portion94 has a distal portion94athat is continuous with a proximal end of theblock body86. In the distal portion94aof theshaft portion94, a cross-sectional area of a cross section perpendicular to the longitudinal axis L decreases from the distal side toward the proximal side along the longitudinal axis L. Theshaft portion94 also has a range in which the cross-sectional area of the cross section perpendicular to the longitudinal axis L increases from the distal side toward the proximal side, or is maintained to be constant in a range on the proximal side of the distal portion94a. That is, theshaft portion94 has a narrowed range between its distal end and its proximal end. A boundary between the distal portion94aof theshaft portion94 and the proximal end of the block body86 (thedistal end87aof the pillar-shapedportion86a) has a shape to prevent stress concentration in a state where the ultrasonic vibration is transmitted. Therefore, a boundary between the distal portion94aof theshaft portion94 and theproximal end87bof the pillar-shapedportion86aof theblock body86 is smoothly continuous. Note that when thetreatment portion74 is seen from the distal side toward the proximal side along the longitudinal axis L, theshaft portion94 is hidden behind theblock body86 and cannot be observed. Therefore, theshaft portion94 that is continuous with the proximal side of theblock body86 can be a part of the dischargingportion84 to discharge the cutting debris of the bone or a liquid such as an irrigation liquid to the proximal side along the longitudinal axis L.

When thetreatment portion74 is seen from the distal side to the proximal side in a direction indicated by an arrow3C inFIG. 3A, in other words along the longitudinal axis L, outer shapes of theconvex portion86bof the cuttingportion82 and the pillar-shapedportion86athereof are observed as an outer shape of thetreatment portion74 as shown inFIG. 3C. At this time, theconcave portions92 of the dischargingportion84 are formed in the pillar-shapedportion86a, but in an outer edge of thetreatment portion74 inFIG. 3C, the outer peripheral surface of the pillar-shapedportion86aappears at least once between thedistal end87aof the pillar-shapedportion86aand theproximal end87bthereof. Therefore, the cuttingportion82 determines the maximum outer shape region. Accordingly, when the proximal side is seen from the distal side along the longitudinal axis L, the projection shape of the cuttingportion82 forms the shape of the hole when the bone B is resected by using thetreatment instrument52.

Theconcave hole200 of the desired shape has, for example, anopening edge202 of the same shape and size as in the projection shape of the cuttingportion82 of thetreatment portion74 when the proximal side is seen from the distal side along the longitudinal axis L, and the concave hole is dented straight to an inner side in the same shape as the shape of theopening edge202. Therefore, one example of the desired shape of thehole200 is a rectangular shape having a suitable depth.

Next, an operation of thetreatment system10 according to this embodiment will be described. Here, there will be described a case where theconcave hole200 is formed in the bone B by use of theultrasonic probe66 of thesecond treatment unit32 after a through hole or a concave hole is formed in afemur112.

Theultrasonic transducer unit54 is attached to theultrasonic treatment instrument52 to form thesecond treatment unit32. At this time, the proximal end of theultrasonic probe66 is connected to the connectingportion56cof theultrasonic transducer unit54. Here, for the purpose of simplifying the description, it is defined that the central axis C of the probemain body portion72 matches the longitudinal axis L of thetreatment portion74.

When theswitch36bis operated, thecontroller34 supplies energy to theultrasonic transducer56bof the vibratingbody58 fixed to the proximal end of theultrasonic probe66, to generate the ultrasonic vibration in theultrasonic transducer56b. Because of this, the ultrasonic vibration is transmitted to theultrasonic probe66 via the vibratingbody58. This vibration is transmitted from the proximal end of theultrasonic probe66 toward the distal side. At this time, the connectingportion56cat a distal end of the vibratingbody58 and a proximal end of the vibratingbody58 are antinodes of the vibration. One point on the central axis C on an inner side of the supportedportion58ais a node of the vibration. The proximal end of theultrasonic probe66 which is connected to the connectingportion56cof the vibratingbody58 is an antinode of the vibration, and the cuttingportion82 of thetreatment portion74 is an antinode of the vibration.

The cuttingportion82 of thetreatment portion74 is the antinode of the vibration, so the cuttingportion82 is displaced along the longitudinal axis L at a rate (e.g., several thousand m/s) based on the resonance frequency of thetransducer56b. Therefore, when thetreatment instrument52 is moved toward the distal side along the longitudinal axis L (the central axis C) to press thetreatment portion74 onto the bone B in the state where the vibration is transmitted, a region of the bone B which is in contact with thetreatment portion74 is shattered by an operation of the ultrasonic vibration. Therefore, as thetreatment instrument52, i.e., theprobe66 moves toward the distal side along the longitudinal axis L (the central axis C), theconcave hole200 is formed in the bone B along the longitudinal axis L of thetreatment portion74 of theultrasonic probe66.

Here, thetop portion86cat the topmost end of theconvex portion86bof the cuttingportion82 is appropriately sharp. When thetop portion86cis brought into contact with or pressed onto the bone B with suitable force, it is difficult for thetop portion86cto slip to the bone B as compared with the obtuse shape. Because of this, when the ultrasonic vibration is transmitted to theprobe66 in the state where thetop portion86cis brought into contact with or pressed onto the bone B with suitable force, it is difficult for the top portion to slip to the bone B and to shift in the case of starting opening the hole200 (seeFIG. 4A andFIG. 4B). Therefore, when thetop portion86cis suitably sharp, it is difficult for the position of thetop portion86cat the topmost end of theconvex portion86bof the cuttingportion82 to shift to the bone B, and it becomes easy to determine the position where thehole200 is to be formed.

Additionally, in a case where the bone B is present under a cartilage, when thetreatment portion74 of theultrasonic probe66 is pressed onto the cartilage toward the distal side along the longitudinal axis L, a region of the cartilage which is in contact with thetreatment portion74 is excised by the operation of the ultrasonic vibration, and a concave hole is formed in the cartilage.

Theconcave portions92 of the dischargingportion84 are respectively formed in theconvex portion86band the pillar-shapedportion86aof thetreatment portion74 of theultrasonic probe66. Theconcave portions92 of the dischargingportion84 are formed whereby, in the case where theconcave hole200 is formed in the bone B, the contact area between the cuttingportion82 and the bone B is smaller than in a case where theconcave portions92 are not formed. Thus, the friction between the cuttingportion82 and the bone B is decreased to inhibit generation of frictional heat in thetreatment portion74 and the bone B. Also, due to the presence of theconcave portions92, a surface area of the cuttingportion82 increases as compared with the case where theconcave portions92 are not formed. A joint liquid or the irrigation liquid is present in the joint100, and thus in thetreatment portion74, a heat radiation ability improves due to the presence of theconcave portions92, and the treatment portion is suitably cooled. Furthermore, the cutting debris of the bone B is disposed in theconcave portions92. Theconcave portions92 are continuous from thedistal end87aof the pillar-shapedportion86ato theproximal end87bthereof. Because of this, the cutting debris of the bone B, once entering theconcave portions92, moves along theconcave portions92 which are continuous from thedistal end87aof the pillar-shapedportion86ato theproximal end87bthereof. Therefore, the cutting debris of the bone B is easily discharged to the proximal side of thetreatment portion74 through thedistal end87aof the pillar-shapedportion86aand theproximal end87bthereof. Thus, thetreatment portion74 of thetreatment unit32 is capable of forming theconcave hole200 at the suitable rate.

When the proximal side of thetreatment portion74 is seen from the distal side along the longitudinal axis L, theshaft portion94 of the dischargingportion84 cannot be observed due to the presence of the pillar-shapedportion86aof the cuttingportion82. Therefore, when forming theconcave hole200, a space is formed between theproximal end87bof the pillar-shapedportion86a, theshaft portion94, and a lateral surface of thebone hole200. Therefore, the cutting debris of the bone B is discharged from theproximal end87bof the pillar-shapedportion86atoward the space between theshaft portion94 and the lateral surface of thebone hole200.

In this way, the cutting debris of a region of the bone B which is treated with thetreatment portion74 is discharged to the proximal side through theconcave portions92 of the dischargingportion84 along the longitudinal axis L. In particular, the inside of the joint100 is filled with the joint liquid. Furthermore, in the joint100, the irrigation liquid circulates. Because of this, the joint liquid or the irrigation liquid becomes a lubricant to easily discharge the cutting debris of the bone B from the cuttingportion82 to the proximal side along the longitudinal axis L. In the case where theconcave hole200 is formed to the desired depth in the bone B, the pressedswitch36bis released to stop the generation of the ultrasonic vibration. Then, theultrasonic probe66 is moved to the proximal side along the longitudinal axis L.

As shown inFIG. 4B, theconcave hole200 formed in the bone B is formed into the same shape as that of an outer edge of the pillar-shapedportion86aof the cuttingportion82 from theinlet202 of the hole to aninner region204. Aninnermost position206 of theconcave hole200 is formed into the same shape as that of an outer shape of theconvex portion86bincluding thetop portion86c. That is, as shown inFIG. 4A, in a case where the ultrasonic vibration is transmitted to theprobe66 of theultrasonic treatment instrument52 to form theconcave hole200 in the bone B, the shape of the cuttingportion82 of thetreatment portion74 can be copied.

The pillar-shapedportion86aof the cuttingportion82 of theprobe66 maintains a region constituting the maximum outer shape region from thedistal end87ato theproximal end87b, and imparts a certain degree of length along the longitudinal axis L. That is, an outer shape of the pillar-shapedportion86afrom thedistal end87atoward the proximal end has a certain degree of length parallel to the longitudinal axis L. Therefore, when theprobe66 is moved straight along the longitudinal axis L, thehole200 can be formed straight along the longitudinal axis L with the pillar-shapedportion86aof the cuttingportion82.

The ultrasonic vibration is transmitted to theprobe66 of thetreatment unit32 according to this embodiment, and the ultrasonic vibration is applied to a region of the bone B in which the hole is to be formed, whereby the region of the bone B, which is in contact with the cuttingportion82 of thetreatment portion74 at a distal end of theprobe66, is finely shattered and cut. The distal portion of thetreatment portion74 is formed into a convex shape (theconvex portion86b), and additionally, theconcave portions92 of the dischargingportion84 to discharge the cutting debris of the bone B are formed in the cuttingportion82. For this reason, as compared with the cuttingportion82 which does not have theconvex portion86band keeps the projection shape of the pillar-shapedportion86ain an axial direction, the cutting portion having theconvex portion86band theconcave portions92 of the dischargingportion84 can proceed with a hole opening processing earlier.

The cuttingportion82 is moved along the longitudinal axis L, so that the shape of thedistal end87aof the pillar-shapedportion86awhen thetreatment portion74 is seen from the distal side along the longitudinal axis L can be copied to the opening edge of theconcave hole200. Because of this, the projection shape of the cuttingportion82 along the longitudinal axis L is the same as the desired shape of theconcave hole200. The bone B is further dug with the cuttingportion82, so that theconcave hole200 having the desired shape and desired depth can be opened in the bone B.

In addition, the distal portion of thetreatment portion74 is formed into a convex shape (theconvex portion86b), and due to theconcave portions92 of the dischargingportion84, the contact area between the bone B and the cuttingportion82 decreases, whereby the cutting debris is further easily discharged to the proximal side of the cuttingportion82. Therefore, when cutting the bone B, it is possible to inhibit the generation of the frictional heat between thetreatment portion74 and the bone B and to increase a processing rate.

It is to be noted that thetreatment portion74 of theprobe66 of theultrasonic treatment instrument52 is not limited to the treatment portion shown inFIG. 2A, and various shapes such as the shapes shown inFIG. 5A toFIG. 6C are allowed.

In an example shown inFIG. 5A, a shape of theconcave portion92 of the dischargingportion84 of thetreatment portion74 is different from that of the dischargingportion84 of thetreatment portion74 shown inFIG. 2.

In an example shown inFIG. 5B, the dischargingportion84 of thetreatment portion74 is not present.

In an example shown inFIG. 6A, the number of thetop portions86cof thetreatment portion74 is plural (three).

In an example shown inFIG. 6B, the number of thetop portions86cof thetreatment portion74 is plural (two).

In an example shown inFIG. 6C, theconvex portion86bof the cuttingportion82 is formed into a hemispherical shape. It is preferable that a size of theconvex portion86bis the same as or slightly smaller than a hole diameter of a hole (a drilled hole) formed with thedrill30. In thetreatment portion74 of the example shown inFIG. 6C, the ultrasonic vibration is transmitted to theconvex portion86binserted in the drilled hole. Theconvex portion86bis guided to the drilled hole, and by use of the drilled hole as a guide hole, the concave hole200 (seeFIG. 4B) is formed straighter.

A first procedure example will be described with reference toFIG. 7 andFIG. 8A toFIG. 8E.FIG. 8A toFIG. 8E schematically show a state where thefemur112, atibia114, and thejoint cavity110 of the knee joint100 are seen from the anterior side. Arrows inFIG. 8A toFIG. 8D indicate a bone excising direction (a moving direction of theprobe66 along the longitudinal axis L).

Here, an example is described where a semitendinosus tendon or a gracilis tendon that is present on an inner side of the knee is used as the implanted tendon. This implanted tendon is referred to as the STG tendon. As shown inFIG. 7, the STG tendon as the implanted tendon is folded several times to be formed to a suitable length as a part of the implantedtendon210. The implantedtendon210 has theSTG tendon212, asuspension fixture214adisposed at one end of theSTG tendon212 viasuture threads214 and, for example, a pair ofartificial ligaments216 fixed to the other end of theSTG tendon212. Theartificial ligaments216 are prepared in the form of strings made of, for example, polyester or the like. Astring214bwound around thefixture214ais used in taking thefixture214afrom the knee joint100 to the outside of thefemur112 through a later-describedconcave hole222 and a later-described through hole (a drilled hole)220. An outer shape of a cross section of theSTG tendon212, which is perpendicular to a longitudinal axis, is an approximately rectangular shape, an approximately elliptical shape close to a rectangular shape, or the like. Furthermore, the outer shape of theSTG tendon212 has a size of, for example, about 4 mm×5 mm. It is preferable that, among the bone holes220 and222 and abone hole224 which will be described later, a position into which theSTG tendon212 is to be inserted has a size and a shape which conform to the outer shape of theSTG tendon212. Consequently, when the implantedtendon210 is formed, a size of theSTG tendon212 is beforehand measured. It is to be noted that theSTG tendon212 is preferably collected before dissecting a region to which a damaged anterior cruciate ligament adheres.

It is preferable that the implantedtendon210 is disposed in the same region as the region to which the damaged anterior cruciate ligament adheres. Because of this, the region to which the damaged anterior cruciate ligament adheres is dissected by using an unshown treatment unit, to clarify

footprint regions

116 and118 to which the anterior cruciate ligament has adhered. At this time, a suitable ultrasonic treatment instrument, an abrader, or the like are usable. Positions to form the later-described

bone holes

220 and224 to the

footprint regions

116 and118 are determined by marking or the like. A lateral cross section of thetreatment portion74 of thetreatment instrument52 mentioned above is not circular, thus the treatment portion has an orientation. Therefore, orientations of the bone holes220 and224 to be formed in the

footprint regions

116 and118 are also determined. Although not shown in the drawing, thefootprint region116 is present in a lateral wall posterior region of an intercondylar fossa of thefemur112. Furthermore, thefootprint region118 is present on an inner side of an anterior intercondylar area of thetibia114.

Here, a procedure is performed using an inside-out method. To thefemur112, the drill (the first treatment unit)30 is inserted from thesuitable portal104 into thejoint cavity110 of theknee joint100. At this time, a distal end of thedrill30 can be brought directly into contact with thefootprint region116. Therefore, in a case where thebone hole220 is formed, a known guide wire and a known guide are not required. Thus, a central area of a marked region of thefootprint region116 is cut from the inside of the joint100 to the outside of thefemur112 with thedrill30, to form the through hole (the drilled hole)220 shown inFIG. 8A straight to thefemur112. A diameter of thedrill30 is adjusted into such a diameter that thesuspension fixture214a(seeFIG. 7) can be passed from ajoint cavity110 side through a cortical bone on an outer side of thefemur112. Thedrill30 is pulled out from the portal104 after the throughhole220 is formed.

Next, as shown inFIG. 8B, the bone hole (the concave hole)222 into which the implantedtendon210 is inserted is formed by using theultrasonic treatment instrument52 shown inFIG. 2. After the implantedtendon210 is prepared, thetreatment portion74 of theprobe66 of theultrasonic treatment instrument52 is attached to the opening edge of thebone hole220 formed with thedrill30 in the joint100. At this time, it is preferable that the vicinity of a distal end of the cuttingportion82 of thetreatment instrument52 which includes thetop portion86cof theconvex portion86bis present in the drilledhole220.

A projection shape of thetreatment portion74 of theultrasonic treatment instrument52, when its proximal side is observed from the distal side along the longitudinal axis L, is formed in a size to cover the opening edge of thebone hole220. Thus, the cross section of the pillar-shapedportion86aof thetreatment portion74 of theultrasonic treatment instrument52 which is perpendicular to the longitudinal axis L has the same size and shape or about the same size and shape from thedistal end87ato theproximal end87b. For this reason, in the state where the ultrasonic vibration is transmitted to theprobe66, the approximately rectangular parallelepiped concave hole (a second bone hole)222 similar to the concave hole shown inFIG. 4B is formed in a predetermined orientation in the marked region of thefootprint region116 shown inFIG. 4B. That is, in the state where the ultrasonic vibration is transmitted to thetreatment portion74 of theultrasonic treatment instrument52, the ultrasonic vibration is applied from thetreatment portion74 to thefemur112. Consequently, thebone hole220 of thefemur112 is cut from the inside of the knee joint100 along a predetermined depth. As a result, a region of thebone hole220 on a joint100 side is expanded, thereby forming thebone hole222 of a suitable shape to receive the implantedtendon210. A bottom surface of thebone hole222 is continuous with thebone hole220.

At this time, thetop portion86cof theconvex portion86bof the cuttingportion82 of thetreatment instrument52 is inserted in the drilledhole220, and hence during preparation of theconcave hole222, the drilledhole220 can be a guide for thetreatment instrument52. Consequently, a central axis of thebone hole222 matches or substantially matches a central axis of thebone hole220 in the bottom surface of thebone hole222. Therefore, theconcave hole222 is easily formed straight.

Furthermore, also as to thetibia114, a central area of a marked region of thefootprint region118 is cut from the inside of the joint100 to the outside of thetibia114 with thedrill30, to form the through hole (the drilled hole)224 straight to thetibia114 as shown inFIG. 8C. The throughhole224 may be formed to extend from the outside of the joint100 through thefootprint region118 in the joint100. Further, aconcave hole226 shown inFIG. 8D is formed in a predetermined orientation in the marked region of thefootprint region118 of thetibia114 by use of thetreatment instrument52 to which the ultrasonic vibration is transmitted.

Thefixture214aat one end of the implantedtendon210 by theSTG tendon212 is taken out from, for example, thesecond portal104 to the outside of thefemur112 via theconcave hole222 and the drilledhole220 of thefemur112. At this time, the outer shape of theSTG tendon212 is approximately rectangular as described above, thus the implantedtendon210 is disposed in accordance with the orientation of theconcave hole222. On the other hand, the other end of the implantedtendon210 is taken out from thetibia114 via theconcave hole226 and the drilledhole224 of thetibia114. Then, a tensile force of the implantedtendon210 is suitably adjusted in accordance with a bent state of the knee joint100 to fix the other end of the implantedtendon210 to the outer side of thetibia114 with afixture218 such as a staple (a screw may be used) as shown inFIG. 8E.

To these approximately rectangular

concave holes

222 and226, theSTG tendon212 of the approximately rectangular implantedtendon210 is disposed in accordance with the orientation of the

concave holes

222 and226. Thus, a clearance formed between theSTG tendon212 of the implantedtendon210 and theconcave hole222 and a clearance formed between theSTG tendon212 and theconcave hole226 become smaller as much as possible. Furthermore, the clearance between theSTG tendon212 and the bone is small, and thus a space volume to be regenerated as the bone is smaller, facilitating the formation of a ligament by theSTG tendon212. Also, the clearance is decreased, whereby it is possible to decrease an amount of the joint liquid to enter the bone holes222 and226 and to inhibit enlargement of the bone holes222 and226 due to the joint liquid. Furthermore, the

concave holes

222 and226 are formed with thetreatment portion74 of theultrasonic treatment instrument52 having the block-shapedcutting portion82 shown inFIG. 2, whereby the holes are not expanded with a dilator. Therefore, even in patients with low bone density, bone fracturing can be suppressed, so it is easy to perform an operation using the implantedtendon210.

The shape of the

concave holes

222 and226 is copied from the shape of thetreatment portion74 of theprobe66 of theultrasonic treatment instrument52 shown inFIG. 2 andFIG. 3A. Because of this, in a case where the outer shape of the cross section of the pillar-shapedportion86aof thetreatment portion74 of theprobe66 of theultrasonic treatment instrument52 which is perpendicular to the longitudinal axis L is not rectangular but is elliptical, the elliptical concave holes are formed. In a case where the outer shape of the cross section of the pillar-shapedportion86aof thetreatment portion74 of theprobe66 of theultrasonic treatment instrument52, which is perpendicular to the longitudinal axis L, is not rectangular but is suitably polygonal, the concave holes of the polygonal shape are formed. The shape of thetreatment portion74 is selected in accordance with the shape of theSTG tendon212 of the implantedtendon210.

It is to be noted that there has been described an example where the throughhole220 shown inFIG. 8A is formed by using thedrill30 here, but the through hole may be formed by applying the ultrasonic vibration from thetreatment portion74 to thefemur112 in a state where the ultrasonic vibration is transmitted to thetreatment portion74 of theultrasonic treatment instrument52. That is, it is also preferable that the suitable throughhole220 is formed with theultrasonic treatment instrument52.

The anterior cruciate ligament anatomically branches into two fiber bundles, so it is also preferable that two holes are made in each of thefemur112 andtibia114, and that the implantedtendon210 is passed through the respective holes.

According to the first procedure example, it can be considered as follows.

Each of an area of thefootprint region116 of thefemur112 of the anterior cruciate ligament and an area of thefootprint region118 of thetibia114 is small. The outer shape of theSTG tendon212 of the implantedtendon210 is different from a circular shape, and is a rectangular shape, an elliptical shape or the like. For example, when theSTG tendon212 with an outer shape of 5 mm×4 mm=20 mm²is to be inserted into a circular hole, a diameter of the circular hole needs to be about 6.5 mm. In a case where the circular hole is used in this way, about 40% of a region of the circular hole is a space other than a region in which theSTG tendon212 of the implantedtendon210 is disposed. The joint liquid permeates this space, and theSTG tendon212 of the implantedtendon210 may slowly form the ligament.

By suitably selecting thetreatment portion74 of theultrasonic treatment instrument52, the concave hole or the through hole having any shape such as the elliptical shape or the polygonal shape can be formed in a suitable depth. Therefore, when the

concave holes

222 and226 are suitably formed in accordance with the outer shape of theSTG tendon212 as shown inFIG. 8A toFIG. 8E, the space volume between the

concave holes

222 and226 and theSTG tendon212 can be smaller, and an amount of thefemur112 and thetibia114 to be cut can be smaller. In the present embodiment, theultrasonic probe66 is suitably selected in accordance with the outer shape of theSTG tendon212, so that it is possible to suitably form the

concave holes

222 and226 while decreasing the amount of bone to be cut. Thus, theSTG tendon212 is fixed to the suitably formed

concave holes

222 and226, whereby the implantedtendon210 can form the ligament sooner.

That is, the

concave holes

222 and226 can be formed by using theultrasonic treatment instrument52 including thetreatment portion74 having the pillar-shapedportion86aof a rectangular, approximately rectangular, elliptical or approximately elliptical cross section. Therefore, it is possible to form the

concave holes

222 and226 having the same outer shape or approximately the same outer shape as the outer shape of theSTG tendon212 of the implantedtendon210, and it is possible to appropriately bury and fix theSTG tendon212 into the

concave holes

222 and226.

Also, in a case where theconcave hole222 is formed with thetreatment portion74 of theultrasonic treatment instrument52, it is possible to perform a treatment of forming theconcave hole222 in a state where a part of a distal end of thetreatment portion74 is fitted into the previously formed throughhole220. As a result, in a case of using this procedure, it is easy to match the central axis of the previously formed throughhole220 with the central axis of theconcave hole222 to be formed later. Furthermore, when theultrasonic treatment instrument52 is used, it is easier to form the concave hole or the through hole at a desired position as compared with a case where the drill is used. Therefore, in the desired regions of the

footprint regions

116 and118 of the anterior cruciate ligament, it is possible to form the bone holes222 and226 in which theSTG tendon212 of the implantedtendon210 is disposed without projecting, to the greatest extent possible, in a desired orientation. Because of this, in thefemur112, invasion into a peripheral tissue of the

footprint regions

116 and118 of the anterior cruciate ligament is prevented.

As described above, the lateral cross section of the implantedtendon210 varies in vertical×horizontal lengths. In a case where theultrasonic treatment instrument52 shown inFIG. 2 is used, a cross section of each of the

concave holes

222 and226 is, for example, rectangular. For this reason, when the

concave holes

222 and226 are formed in the appropriate orientation, it is easy to optimize the orientation in a state where theSTG tendon212 of the implantedtendon210 is implanted.

In this procedure, the example has been described where the suitable regions of the

footprint regions

116 and118 are marked, but the marking is not necessarily required.

A second procedure example will be described with reference toFIG. 9 andFIG. 10A toFIG. 10G.FIG. 10A toFIG. 10G schematically show a state where thefemur112, thetibia114 and thejoint cavity110 of the knee joint100 are seen from the anterior side. Arrows inFIG. 10A toFIG. 10F indicate a bone excising direction.

Here, the example is described where apatellar tendon232 to which bone fragments232aand232badhere at both ends is used as an implantedtendon230. Onebone fragment232ais a part of a patella (not shown). Thebone fragment232aon a patella side has an approximately triangular pillar shape. Theother bone fragment232bis a part of thetibia114. Thebone fragment232bon atibia114 side is rectangular parallelepiped. An outer shape of each of the bone fragments232aand232bhas a size of, for example, about 10 mm×5 mm. Such an implanted tendon is referred to as the BTB tendon.

As shown inFIG. 9, the implantedtendon230 has theBTB tendon232, asuspension fixture234adisposed in thebone fragment232aat one end of theBTB tendon232 via asuture thread234 and, for example, a pair ofsuture threads236 fixed to thebone fragment232bat the other end of theBTB tendon232. It is to be noted that asuture thread234bwound around thefixture234ais used in taking thefixture234afrom the knee joint100 to the outside of thefemur112 through later-described

concave holes

242aand242band a later-described throughhole240.

It is preferable that the later-described

bone holes

242aand242b, into which thebone fragment232aof theBTB tendon232 is inserted, and later-described

bone holes

246aand246b, into which thebone fragment232bis inserted, have sizes and shapes which conform to an outer shape of theBTB tendon232, respectively.

It is preferable that theBTB tendon232 is collected before dissecting a region to which the damaged anterior cruciate ligament adheres. Thus, a size of the outer shape of each of the bone fragments232aand232bis beforehand measured.

Here, a procedure is performed using the inside-out method. Descriptions of those parts that are the same as in the procedure of theSTG tendon212 are omitted whenever possible.

With thedrill30, the through hole (a drilled hole)240 shown inFIG. 10A is formed straight to thefemur112 through thefootprint region116 of thefemur112. That is, thebone hole240 is cut and formed from the inside of the joint100 toward the outside of thefemur112. To thefemur112, the drill (the first treatment unit)30 is inserted from thesuitable portal104 into thejoint cavity110 of theknee joint100. Further, a diameter of thedrill30 is adjusted into such a diameter that thesuspension fixture234acan be passed from thejoint cavity110 side through a cortical bone on the outer side of the femur. Thedrill30 is pulled out from the portal104 after the throughhole240 is formed.

Next, thetreatment portion74 of theultrasonic treatment instrument52 is attached to a position that shifts from the opening edge of thebone hole240 formed with thedrill30 in the joint100. At this time, the vicinity of the distal end of the cuttingportion82 of thetreatment instrument52 which includes thetop portion86cof theconvex portion86bmay be present on an inner or outer side of the drilledhole240. As shown inFIG. 10B, theconcave hole242ainto which the implantedtendon230 is to be inserted is formed by using theultrasonic treatment instrument52 shown inFIG. 2.

The projection shape of thetreatment portion74 of theultrasonic treatment instrument52 when its proximal side is observed from the distal side along the longitudinal axis L is approximately rectangular. Further, the cross section of the pillar-shapedportion86aof thetreatment portion74 of theultrasonic treatment instrument52 which is perpendicular to the longitudinal axis L has the same size and shape or about the same size and shape from thedistal end87ato theproximal end87b. Consequently, in the state where the ultrasonic vibration is transmitted to theprobe66, the approximately rectangular parallelepiped first concave hole (a second bone hole)242ashown inFIG. 10B is formed similarly to the concave hole shown inFIG. 4B. At this time, the firstconcave hole242ais formed straight.

Further, the secondconcave hole242bshown inFIG. 10C is formed adjacent to the firstconcave hole242awith thesame treatment portion74 of theultrasonic treatment instrument52. At this time, the treatment is performed while thetreatment portion74 of theultrasonic treatment instrument52 is left in the joint100. The firstconcave hole242amust be in communication with the secondconcave hole242b. Therefore, when necessary, a bone tissue between the firstconcave hole242aand the secondconcave hole242bis removed by cutting. In this way, a bone hole of an outer shape required for the

concave holes

242aand242bis formed into a desired size and a desired shape by pressing thetreatment portion74 of theultrasonic treatment instrument52 at a position adjacent to thebone hole242aonce or a number of times. Therefore, an outer shape of 4 mm×5 mm of oneconcave hole242ais continuous with an outer shape of 4 mm×5 mm of anotherconcave hole242b, additionally, the treatment is suitably performed with thetreatment portion74 of theultrasonic treatment instrument52. Because of this, the

concave holes

242aand242bcooperate to form one bone hole (the second bone hole) of an outer shape of 10 mm×5 mm into which thebone fragment232ais insertable.

Also as to thetibia114, a throughhole244 shown inFIG. 10D is formed from the inside of the joint100 to the outside of thetibia114 in thefootprint region118 on thetibia114 side with thedrill30.

As shown inFIG. 10E, theconcave hole246ais formed in thefootprint region118 of thetibia114 by the ultrasonic vibration.

As shown inFIG. 10F, theconcave hole246bthat is continuous with theconcave hole246ais formed in thefootprint region118 of thetibia114. A bone hole of an outer shape required for the

concave holes

246aand246bis formed into a desired size and a desired shape by pressing thetreatment portion74 of theultrasonic treatment instrument52 at a position adjacent to thebone hole246aonce or a number of times. Therefore, an outer shape of 4 mm×5 mm of oneconcave hole246ais continuous with an outer shape of 4 mm×5 mm of anotherconcave hole246b, and further, the treatment is suitably performed with thetreatment portion74 of theultrasonic treatment instrument52. Consequently, the

concave holes

246aand246bcooperate to form one bone hole of an outer shape of 10 mm×5 mm into which thebone fragment232bcan be inserted.

Further, onebone fragment232aof the implantedtendon230 by theBTB tendon232 is inserted from, for example, thesecond portal104 into the

concave holes

242aand242bof thefemur112. At this time, thefixture234ais taken out from thefemur112 via the drilledhole240. The onebone fragment232aof the implantedtendon230 is disposed in accordance with an orientation of the

concave holes

242aand242b. It is to be noted that as described above, an outer shape of the onebone fragment232aof the implantedtendon230 is a triangular pillar shape.

Theother bone fragment232bof the implantedtendon230 is disposed in the

concave holes

246aand246bof thetibia114 to take thesuture threads236 attached to thebone fragment232bto the outside of thetibia114 via the drilledhole244. Further, a tensile force of the implantedtendon230 is suitably adjusted in accordance with the bent state of the knee joint100 to fix thesuture threads236 of the implantedtendon230 to the outer side of thetibia114 with afixture238 such as a staple (a screw may be used) (seeFIG. 10G).

According to the second procedure example, it can be considered as follows.

The outer shape of each of the bone fragments232aand232bat the ends of theBTB tendon232 of the implantedtendon230 is different from a circular shape and is a rectangular parallelepiped shape or an approximately triangular pillar shape. For example, when theBTB tendon232 of 5 mm×10 mm=50 mm²is to be inserted into the circular hole, a diameter of the circular hole needs to be about 11 mm. In this case, a cross-sectional area of the circular hole is about 95 mm²and about a half becomes a space. The joint liquid permeates this space and formation of a ligament by theBTB tendon232 of the implantedtendon230 might become slow.

Consequently, when the

concave holes

242a,242b,246aand246bare suitably formed in accordance with the outer shape of the bone fragments232aand232bof theBTB tendon232 as shown inFIG. 10A toFIG. 10G, it is possible to decrease each of a space volume between the

concave holes

242aand242band thebone fragment232aof theBTB tendon232 and a space volume between the

concave holes

246aand246band thebone fragment232bof theBTB tendon232, and it is possible to decrease an amount of thefemur112 and thetibia114 that is cut. In the present embodiment, theultrasonic probe66 is suitably selected in accordance with the outer shape of the bone fragments232aand232bof theBTB tendon232, so that it is possible to suitably form the

concave holes

242a,242b,246aand246bwhile decreasing the amount of cut bone. Further, the bone fragments232aand232bare fixed to the suitably formed

concave holes

242a,242b,246aand246b, whereby it is possible to more quickly form the ligament by the implantedtendon230.

That is, it is possible to form the

concave holes

242a,242b,246aand246bby use of theultrasonic treatment instrument52 including thetreatment portion74 having the pillar-shapedportion86aof the rectangular, approximately rectangular, elliptical or approximately elliptical cross section. Consequently, it is possible to form the

concave holes

242a,242b,246aand246bhaving the same outer shape or about the same outer shape as the outer shape of the bone fragments232aand232bof theBTB tendon232 of the implantedtendon230, and it is possible to appropriately bury and fix the bone fragments232aand232binto the

concave holes

242a,242b,246aand246b.

Further, when theultrasonic treatment instrument52 is used, it is easier to form a position to form the concave hole or the through hole at a desired position as compared with a case where the drill is used. Consequently, it is possible to form the bone holes242a,242b,246aand246bin which the end portions of the implantedtendon230 are disposed without projecting as much as possible, to the

footprint regions

116 and118 of the anterior cruciate ligament. Consequently, in thefemur112, there is prevented invasion into a peripheral tissue of thefootprint region116 of the anterior cruciate ligament.

Furthermore, as described above, the lateral cross section of the implantedtendon230 varies in vertical×horizontal lengths. In a case where theultrasonic treatment instrument52 shown inFIG. 2 is used, the cross section of each concave hole is, for example, rectangular. Consequently, when the concave holes are formed in the appropriate orientation, it is easy to optimize the orientation in a state where theBTB tendon232 of the implantedtendon230 is implanted.

There will be described another procedure example where the implantedtendon230 having theBTB tendon232 is used with reference toFIG. 11A toFIG. 11D. Arrows inFIG. 11A to FIG.11C indicate a bone excising direction.

A drilledhole250 shown inFIG. 11A is formed from thefootprint region116 of thefemur112 to the outside of thefemur112.

In the state where the ultrasonic vibration is transmitted to thetreatment portion74 of theultrasonic treatment instrument52 shown inFIG. 2,

concave holes

252aand252bwhich communicate with the drilledhole250 as shown inFIG. 11B are formed from the inside of thejoint cavity110 toward the outside of thefemur112.

Concave holes

254aand254bshown inFIG. 11C are formed from the inside of thejoint cavity110 toward the outside of thetibia114 in thefootprint region118 of thetibia114 while thetreatment portion74 of theultrasonic treatment instrument52 shown inFIG. 2 is left in thejoint cavity110 as it is.

For example, onebone fragment232aof theBTB tendon232 is inserted tom thesecond portal104 into the

concave holes

252aand252bof thefemur112. At this time, thefixture234ais taken out from thefemur112 via the drilledhole250. On the other hand, theother bone fragment232bof theBTB tendon232 is disposed in the

concave holes

254aand254bof thetibia114 to fix thebone fragment232bto the

concave holes

254aand254bwith ascrew238a(seeFIG. 11D).

A third procedure example will be described with reference toFIG. 12A toFIG. 12F.FIG. 12A toFIG. 12F schematically show a state where thefemur112, thetibia114 and thejoint cavity110 of the knee joint100 are seen from the anterior side. Arrows inFIG. 12A toFIG. 12E indicate a bone excising direction. Here, a case of using an STG tendon is described.

A guide wire (e.g., a diameter of 2.5 mm) for the drill is inserted from the outside of thefemur112 toward thefootprint region116 of thefemur112 by use of an unshown known guide. That is, by an outside-in method, abone hole260 shown inFIG. 12A is formed from the outside of thefemur112 toward the inside of the joint100. At this time, it is preferable to pass the guide wire through thefootprint region116 of thefemur112.

Thedrill30 guided along the guide wire is passed through the cortical bone on a surface side in the vicinity of the outside of thefemur112, to form aconcave hole262 shown inFIG. 12B. Theconcave hole262 is circular. Further, thedrill30 and the guide wire are removed. At this time, the throughhole260 having the diameter of 2.5 mm is formed by the guide wire.

A throughhole264 shown inFIG. 12C is formed from the outside of thefemur112 toward the knee joint100 side by use of theultrasonic treatment instrument52 including thetreatment portion74 having, for example, the shape shown inFIG. 2. The throughhole264 has the same rectangular cross section or about the same rectangular cross section as the outer shape of theSTG tendon212 of the implantedtendon210.

It is also preferable that the throughhole264 is formed with thetreatment portion74 of one ofFIG. 5A toFIG. 6C. The cortical bone of an outer surface of thefemur112 is very hard, and hence there is the fear that much time is taken in cutting the bone with theultrasonic treatment instrument52. On the other hand, the cortical bone is already removed by theconcave hole262 formed with thedrill30. Consequently, it is easy to cut a cancellous bone with theultrasonic treatment instrument52.

It is to be noted that, for example, thetreatment portion74 of theultrasonic treatment instrument52 is strengthened to increase an amplitude of thetreatment portion74, whereby in place of the cutting of the cortical bone with thedrill30, both the cutting of the cortical bone and the cutting of the cancellous bone can be performed once with theultrasonic treatment instrument52.

The guide wire (e.g., the diameter of 2.5 mm) for the drill is inserted from the outside of thetibia114 toward thefootprint region118 of thetibia114 by use of the known guide, to form a throughhole266 shown inFIG. 12D. With thedrill30 guided from the outside of thetibia114 toward thefootprint region118 of thetibia114 along the guide wire, a throughhole268 extending from the outside of thetibia114 through thefootprint region118 of thetibia114 is formed as shown inFIG. 12E. The throughhole268 is circular. It is to be noted that the rectangular throughhole268 is preferably formed with thetreatment instrument52 shown inFIG. 2 in place of thedrill30.

Further, for example, thestring214bwound around thefixture214ais taken out from thefemur112 through the throughhole268 of thetibia114 and the throughhole264 of thefemur112, and thefixture214ais taken out from thefemur112. At this time, as described above, the outer shape of theSTG tendon212 is approximately rectangular, and hence theSTG tendon212 is disposed in thefemur112 in accordance with an orientation of the throughhole264. Further, when necessary, thestring214bis cut or removed from thefixture214a.

On the other hand, theartificial ligaments216 at the other end of the implantedtendon210 is held on the outer side of thetibia114. Further, the tensile force of the implantedtendon210 is suitably adjusted in accordance with the bent state of the knee joint100 to fix theartificial ligaments216 of the implantedtendon210 to the outer side of thetibia114 with thefixture218, e.g., a staple or the like.

Depending on the patient, there might be a case where the patient cannot take a deeply bent body position. Even in such a case, thebone hole264 can be formed to thefemur112 in this manner by the outside-in method.

It is to be noted that there has been described the case where theSTG tendon212 shown inFIG. 7 is used as the implanted tendon here, but the BTB tendon232 (seeFIG. 9) is also usable as the implanted tendon.

A fourth procedure example will be described with reference toFIG. 13A toFIG. 13E.FIG. 13A toFIG. 13E schematically show a state where thefemur112, thetibia114 and thejoint cavity110 of the knee joint100 are seen from the anterior side. Arrows inFIG. 13A toFIG. 13D indicate a bone excising direction.

Here, there is simply described a transtibial method of forming a bone hole (a concave hole)278 in thefemur112 via abone hole276 formed in thetibia114.

The guide wire for the drill is inserted from the outside of thetibia114 toward thefootprint region118 of thetibia114 by use of the known guide. As shown inFIG. 13A, awire hole272 is formed. Furthermore, a through hole (a concave hole may be formed)274 is formed from thefootprint region118 of thetibia114 through thefootprint region116 of thefemur112 toward the outside of thefemur112 with the guide wire for the drill as shown inFIG. 13B. Afterward, the guide wire is removed.

In a state where the ultrasonic vibration is generated in thetransducer56bof theultrasonic treatment instrument52, thetreatment portion74 is pushed from the outside of thetibia114 toward the footprint region along theguide hole272 of thetibia114. Consequently, the throughhole276 shown inFIG. 13C is formed.

Furthermore, abone hole278 shown inFIG. 13D is formed from thefootprint region118 of thetibia114 toward the outside of thefemur112 through thefootprint region116 of thefemur112 along theguide hole274 with thetreatment portion74 of theultrasonic treatment instrument52. Thebone hole278 has an approximately rectangular cross section.

Further, thefixture214aat one end of the implantedtendon210 by theSTG tendon212 is taken out from thefemur112 through, for example, the knee joint100 from the outside of thetibia114. At this time, the outer shape of theSTG tendon212 is approximately rectangular as described above, and hence theSTG tendon212 is disposed in accordance with an orientation of theconcave hole278. On the other hand, the other end of theSTG tendon212 maintains a state where the end is disposed on the outer side of thetibia114. Further, the tensile force of the implantedtendon210 is suitably adjusted in accordance with the bent state of the knee joint100 to fix the other end of the implantedtendon210 to the outer side of thetibia114 with thefixture218, e.g., the staple or the like (seeFIG. 13E).

Thebone hole278 is formed in thefemur112 through thetibia114, and hence thebone hole278 can be formed without deeply bending theknee joint100. Furthermore, the guide wire and thetreatment portion74 of theultrasonic treatment instrument52 can directly abut on thefootprint region116 of the anterior cruciate ligament in thefemur112, and hence it is possible to securely form the bone hole in thefootprint region116 of thefemur112.

Hitherto, the examples of the procedure of reconstructing the anterior cruciate ligament have been described, but it is possible to similarly perform the procedure on a posterior cruciate ligament, thereby reconstructing the ligament.

Additional advantages and modifications will readily occur to those skilled in the art. Therefore, the invention in its broader aspects is not limited to the specific details and representative embodiments shown and described herein. Accordingly, various modifications may be made without departing from the spirit or scope of the general inventive concept as defined by the appended claims and their equivalents.

Claims

What is claimed is:

1. A surgical procedure of preparing bone holes to dispose an implanted tendon to a femur when performing reconstruction of a ligament in a knee joint, comprising:

forming a first bone hole in the femur; and

applying ultrasonic vibration from a treatment portion of an ultrasonic treatment instrument to the femur, thereby cutting and expanding the first bone hole from the inside of the knee joint to the first bone hole of the femur along a predetermined depth, and forming a second bone hole having a polygonal shape, an approximately polygonal shape, an elliptical shape or an approximately elliptical shape to receive the implanted tendon.

2. The procedure according toclaim 1, wherein a bottom surface of the second bone hole is continuous with the first bone hole.

3. The procedure according toclaim 2, wherein the second bone hole is formed so that a central axis of the second bone hole matches or substantially matches a central axis of the first bone hole in the bottom surface of the second bone hole.

4. The procedure according toclaim 1, wherein:

when the treatment portion of the ultrasonic treatment instrument which forms the second bone hole is projected from a distal side to a proximal side along a longitudinal axis of the treatment portion of the ultrasonic treatment instrument, its projection shape is the polygonal shape, the approximately polygonal shape, the elliptical shape or the approximately elliptical shape, and

the second bone hole is formed into a desired size and a desired shape by pressing the treatment portion of the ultrasonic treatment instrument to the first bone hole once or a number of times.

5. The procedure according toclaim 1, wherein the first bone hole is a through hole.

6. The procedure according toclaim 5, wherein:

the implanted tendon is received in the second bone hole from the knee joint toward the outside of the femur,

the first bone hole and the second bone are to guide a fixture that fixes the implanted tendon from the inside of the knee joint to the outside of the femur, and

the first bone hole is formed in a size to pass the fixture to the outside of the femur so that the fixture is supported on the outside of the femur.

7. The procedure according toclaim 1, wherein the first bone hole is a concave hole.

8. The procedure according toclaim 1, wherein:

the second bone hole is formed into the polygonal shape, the approximately polygonal shape, the elliptical shape or the approximately elliptical shape by moving the treatment portion along the longitudinal axis.

9. The procedure according toclaim 1, wherein the first bone hole is formed by applying the ultrasonic vibration from the treatment portion to the femur in a state where the ultrasonic vibration is transmitted to the treatment portion of the ultrasonic treatment instrument.

10. The procedure according toclaim 1, wherein the first bone hole is formed with a drill.

11. The procedure according toclaim 1, wherein the second bone hole is formed as a concave hole or a through hole having a polygonal shape, an approximately polygonal shape, an elliptical shape or an approximately elliptical shape to receive one of bone fragments which are present at both ends of a patellar tendon, from the inside of the knee joint toward the outside of the femur along a predetermined depth, by applying the ultrasonic vibration from the treatment portion to the femur in a state where the ultrasonic vibration is transmitted to the treatment portion of the ultrasonic treatment instrument.

12. The procedure according toclaim 11, wherein:

13. The procedure according toclaim 11, wherein the second bone hole is formed into a desired size and a desired shape by pressing the treatment portion of the ultrasonic treatment instrument at a position adjacent to the bone hole once or a number of times.

14. A procedure of fixing one of bone fragments which are present at both ends of a patellar tendon to a femur when performing reconstruction of a ligament in a knee joint, comprising:

applying ultrasonic vibration from a treatment portion of an ultrasonic treatment instrument to the femur in a state where the ultrasonic vibration is transmitted to the treatment portion thereof, thereby forming a concave hole or a through hole as a first bone hole having a polygonal shape, an approximately polygonal shape, an elliptical shape or an approximately elliptical shape to receive the one bone fragment of the patellar tendon from the inside of the knee joint toward the outside of the femur along a predetermined depth; and

fixing the one bone fragment to the femur in a state where the one bone fragment is received to the first bone hole.