US20180153698A1 - Joint fusion instrumentation and methods - Google Patents

Abstract

Systems and methods for joint preparation and fusion are disclosed. The system includes a cutting device having a handle, and rigid blade member. The blade member may include cutting edges on first and second sides, and may be curved in one or more planes. The blade member may be deployed to project outside of an outer tube, and the cutting device may be rotated to create a circular cavity. In a method of use, a cannula provides access to a procedure site such as a joint. A pathway to the joint is created, and the cutting device is inserted and deployed to undercut a cavity in the joint. A fusion device may be implanted across the joint to provide compression and fuse the joint. The system may also include instrumentation for creating access to a joint, bone graft insertion and implant insertion.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
• This application is a continuation of:
• Pending U.S. patent application Ser. No. 15/137,848, filed on Apr. 25, 2016, Attorney's Docket No. IMDS-56, entitled JOINT FUSION INSTRUMENTATION AND METHODS.
• The foregoing is incorporated by reference herein as though set forth in its entirety.
STATEMENT REGARDING PRIOR DISCLOSURES BY THE INVENTOR OR A JOINT INVENTOR
• William W. Cross III is the inventor of the subject matter of U.S. patent application Ser. No. 14/790,480, filed on Jul. 2, 2015 and entitled SACROILIAC JOINT FUSION SCREW AND METHOD, published as U.S. Patent Application Publication no. US2016/0000488A1. William W. Cross III is an inventor of the subject matter of the present disclosure. The above-identified patent application publication is incorporated herein by reference.
BACKGROUND OF THE INVENTION
• The present invention relates to instrumentation and methods for the creation of a cavity in a bone or joint. More specifically, the invention relates to instrumentation and methods for creating a cavity in a joint between a sacrum and an ilium, and implants, instrumentation and methods for fusing a sacroiliac joint.
• The sacroiliac (SI) joints are formed by the connection of the sacrum and the right and left iliac bones. While most of the spinal vertebrae are mobile, the sacrum is made up of five vertebrae that are fused together and do not move. The iliac bones are the two large bones that make up the pelvis. As a result, the SI joints connect the spine to the pelvis, and form the largest axial joints in the body. The sacrum and the iliac bones are held together and supported by a complex collection of strong ligaments. There is relatively little motion at the SI joints; there are normally less than 4 degrees of rotation and 2 mm of translation at these joints. Most of the motion in the area of the pelvis occurs either at the hips or the lumbar spine. These joints support the entire weight of the upper body when it is erect, placing a large amount of stress across them. This can lead to wearing of the cartilage of the SI joints. Some causes of degeneration and/or pain in the SI joints include osteoarthritis, pregnancy, leg length discrepancy, gout, rheumatoid arthritis, psoriatic arthritis, reactive arthritis, and ankylosing spondylitis.
• Treatment options have been limited to conservative care involving physical therapy and joint injections or traditional open SI joint arthrodesis surgery until recently. Open arthrodesis procedures reported in the literature require relatively large incisions, significant bone harvesting, and lengthy hospital stays; moreover, they may require non-weight bearing for several months.
• The systems and methods for sacroiliac joint fusion disclosed here can be used to provide SI joint arthrodesis in a minimally invasive procedure. SI joint fusion using the systems and methods disclosed herein may provide advantages which can include a small incision, relatively short operating time with fewer steps, minimal blood loss, and a relatively short period of postoperative immobilization. For example, the steps disclosed herein for creating a cavity in the joint, filling it with graft material, and inserting a fusion device, may all be accomplished through a single access cannula in a single procedure. The size and configuration of the cutting instrument allows insertion into a bone or joint through a relatively narrow pathway, and creation of an undercut cavity within the bone or joint. Due to the shape and rigid construction of the blade disclosed herein and its assembly within the cutting instrument, the bone cutting instrument disclosed herein may create a cleaner cavity in a relatively short time, without the need to switch out blade members or employ multiple cutting instruments.
BRIEF DESCRIPTION OF THE DRAWINGS
• Various embodiments of the present invention will now be discussed with reference to the appended drawings. It is appreciated that these drawings depict only typical embodiments of the invention and are therefore not to be considered limiting of its scope.
• FIG. 1 illustrates a cross-sectional view of a natural sacroiliac joint and a cavity extending across the joint, the cavity filled with bone graft material, and the joint fused by a fusion device and a supplementary screw;
• FIG. 2A illustrates a front view of a cutter which may be used to create the cavity ofFIG. 1, the cutter having a blade in a retracted configuration;FIG. 2B is a side view of the cutter ofFIG. 2A, the side view rotated 90 degrees from the front view;FIG. 2C is a side view of the cutter ofFIG. 2A, with the blade in an extended configuration;
• FIG. 3 is a partially exploded view of the cutter ofFIG. 2A, the cutter including a handle assembly, a blade assembly, and an outer tube;
• FIG. 4A is a front view of a blade shaft of the cutter ofFIG. 2A;FIG. 4B is a side view of the blade shaft ofFIG. 4A;FIG. 4C is a cross-sectional view of the blade shaft ofFIG. 4B, taken along line A-A inFIG. 4B;
• FIG. 5A is a partially exploded side view of one end of a blade shaft assembly for the cutter ofFIG. 2A, the assembly having a blade shaft, a blade holder, and a blade;FIG. 5B is a partially exploded back view of the blade shaft assembly ofFIG. 5A;
• FIG. 6A is a perspective view of the blade ofFIG. 5A;FIG. 6B is a front view of the blade ofFIG. 5A;FIG. 6C is a back view of the blade ofFIG. 5A;FIG. 6D is a cross-sectional view of the blade ofFIG. 5A taken along line E-E ofFIG. 5A;
• FIG. 7A is a longitudinal side cross-sectional view of a shaft portion of the cutter ofFIG. 2A with the blade in the retracted configuration;FIG. 7B is a longitudinal side cross-sectional view of the shaft portion of the cutter ofFIG. 2A with the blade in the extended configuration;
• FIG. 8A is a perspective view of another embodiment of a blade for the cutter ofFIG. 2A;FIG. 8B is a cross-sectional view of the blade ofFIG. 8A taken approximately along line B-B ofFIG. 8A;
• FIG. 9A is a perspective view of another embodiment of a blade for the cutter ofFIG. 2A;FIG. 9B is a cross-sectional view of the blade ofFIG. 9A taken approximately along line C-C ofFIG. 9A;
• FIG. 10 is a view of a guide wire inserted to cross a joint of a first bone and a second bone at a procedure site, and a set of dilators mounted over the guide wire; inFIGS. 10-22 the first and second bones and the joint are depicted in cross-section in order to view the components of the invention in situ;
• FIG. 11 is a view of the guide wire and dilators ofFIG. 10, with a cannula inserted over the guide wire and dilators and docked into the first bone;
• FIG. 12 is a view of the cannula ofFIG. 11, with an impactor mounted on an end of the cannula;
• FIG. 13 is a view of the cannula ofFIG. 11, with an support struts attached to the cannula;
• FIG. 14A is a view of the cannula ofFIG. 11, with a sleeve partially received in a bore of the cannula;FIG. 14B is a longitudinal cross-sectional view of the cannula, guide wire and sleeve ofFIG. 14A;
• FIG. 15 is a view of the cannula and sleeve ofFIG. 14A, with a drill inserted through the cannula and sleeve, and a passageway drilled across the joint;
• FIG. 16A is a view of the cannula and sleeve ofFIG. 14A, with the cutter ofFIG. 2C inserted into the cannula and sleeve, the cutter blade in the extended configuration, and a circular cavity cut into the first bone and second bone across the joint;FIG. 16B is a close-up view of the distal end of the sleeve and cutter ofFIG. 16A, also showing a cutting radius r of the cutter and a diameter d of the cavity;FIG. 16C is a cross-sectional view of the cutter shaft portion, cannula and sleeve ofFIG. 16A cutting a cavity in a sacro-iliac joint;
• FIG. 17 is a view of the cannula, sleeve and cavity ofFIG. 16A, with a suction tool inserted through the cannula and sleeve and into the cavity;
• FIG. 18 is a view of the cannula, sleeve and cavity ofFIG. 16A, with a graft funnel mounted in the cannula, a tamp inserted through the graft funnel, and bone graft material in the cavity;
• FIG. 19 is a view of the cannula, sleeve, cavity and bone graft material ofFIG. 18, with a drill inserted through the cannula and sleeve, and another passageway drilled across the joint deeper into the second bone;
• FIG. 20 is a view of the cannula, sleeve, cavity, bone graft material and passageway ofFIG. 19, with a guide wire installed though the passageway and into the second bone and a length gauge mounted on the cannula;
• FIG. 21 is a view of the cannula, sleeve, cavity, bone graft material, guide wire passageway and ofFIG. 19, with the fusion device ofFIG. 1 implanted in the first bone and second bone, across the joint;
• FIG. 22 is a view of the joint and fusion device ofFIG. 21, with a guide brace mounted over the guide wire and the supplementary screw inserted in the first bone and second bone, across the joint;
• FIG. 23A is a side view of the fusion device ofFIG. 1;FIG. 23B is a perspective view of the fusion device ofFIG. 1;FIG. 23C is a cross-sectional view of the fusion device ofFIG. 1, taken along line F-F inFIG. 23A;FIG. 23D is an exploded view of the fusion device ofFIG. 1;
• FIG. 24 is a perspective view of the cannula ofFIG. 11;
• FIG. 25 is a perspective view of the sleeve ofFIG. 14A;
• FIG. 26 is a perspective view of the length gauge ofFIG. 20;
• FIG. 27 is a perspective view of the graft funnel ofFIG. 18;
• FIG. 28 is a perspective view of the tamp ofFIG. 18;
• FIG. 29 is a perspective view of an alternate embodiment of a fusion device screw-type fastener;
• FIG. 30 is a perspective view of another alternate embodiment of a fusion device screw-type fastener;
• FIG. 31 is a perspective view of another alternate embodiment of a fusion device screw-type fastener;
• FIG. 32 is a perspective view of another alternate embodiment of a fusion device screw-type fastener;
• FIG. 33 is a perspective view of another alternate embodiment of a fusion device screw-type fastener;
• FIG. 34 is a perspective view of another alternate embodiment of a fusion device nail-type fastener;
• FIG. 35 is a perspective view of another alternate embodiment of a fusion device nail-type fastener;
• FIG. 36 is a perspective view of another alternate embodiment of a fusion device nail-type fastener; and
• FIG. 37 is a perspective view of another alternate embodiment of a fusion device nail-type fastener.
DETAILED DESCRIPTION OF THE EMBODIMENTS
• The present invention relates specifically to systems and methods for fusion of a sacroiliac joint, and more generally to systems and methods for creating a cavity in a bone or joint. Those of skill in the art will recognize that the following description is merely illustrative of the principles of the invention, which may be applied in various ways to provide many different alternative embodiments. This description is made for the purpose of illustrating the general principles of this invention and is not meant to limit the inventive concepts in the appended claims.
• The terms “front”, “side”, “back”, “upper” and “lower” are used herein to identify a relative frame of reference to a particular device or an individual element of a device. In alternate embodiments the front or upper side of a device or element may be established on any desired side of the device or element.
• According to a first aspect of the disclosure, a system for fusing a joint between a first bone portion and a second bone portion includes: a cannula having a distal end and proximal end, and a cannula bore extending therebetween, the cannula having an inner diameter; a sleeve having a distal end and a proximal end and a sleeve bore extending therebetween, the sleeve at least partially receivable in the bore of the cannula; a cutting instrument insertable into the sleeve bore, the cutting instrument having a longitudinal axis, and comprising a handle, an actuation mechanism, and a blade assembly extending distally from the handle; wherein the blade assembly comprises a blade body having a proximal end, a distal end and first and second opposing sides extending therebetween, the first side having a first curved cutting edge, wherein upon actuation of the actuation mechanism the blade assembly is movable between a retracted configuration in which the blade body extends along the longitudinal axis and an extended configuration in which the blade body is projected away from the longitudinal device axis; wherein the blade body is sized to pass through the sleeve bore; and an implant having a first end and a second end and a bone engagement portion, wherein the implant is sized to pass through the cannula bore and engage the first and second bone portions to fuse the joint.
• Embodiments of this aspect of the disclosure may include one or more of the following features: The blade body moves along a curved path as the blade assembly is moved into the extended configuration. The blade assembly further includes a blade shaft coaxial with the longitudinal axis, and the blade body is pivotably connected to the blade shaft. The blade assembly further includes a blade holder, wherein the blade holder is removably attachable to the blade shaft, and wherein the blade body is pivotably attached to the blade holder. The cutting instrument further comprises an outer tube extending distally from the handle, wherein the blade assembly is receivable in the outer tube. The outer tube includes a curved guide surface within the outer tube, wherein the curved guide surface directly contacts and urges the blade body along the curved path when the blade assembly is moved into the extended configuration. The outer tube comprises a window, wherein when the blade assembly is in the retracted configuration, the blade body is inside the window, and when the blade assembly is in the extended configuration, the blade body projects out of the window. Actuation of the adjustment mechanism when the sleeve is engaged with the cannula varies the length between the sleeve proximal end and the cannula distal end along a continuum. A cutting radius of the cutting instrument is the distance from the blade distal end to the longitudinal axis, perpendicular to the longitudinal axis. The blade body second side has a second curved cutting edge opposite the first curved cutting edge and the blade body is curved in a first plane between the blade body proximal and distal ends. The blade body comprises a void open to the blade body first side and the blade body second side.
• According to a second aspect of the disclosure, a system for fusing a joint between a first bone portion and a second bone portion includes a guide wire having a distal end and proximal end; a cannula having a distal end and proximal end, and a cannula bore extending therebetween, the cannula bore insertable over the guide wire, the cannula bore defining a cannula central longitudinal axis; a sleeve having a distal end and a proximal end and a sleeve bore extending therebetween, the sleeve at least partially receivable in the bore of the cannula and adjustably engageable with the cannula; an adjustment mechanism, wherein actuation of the adjustment mechanism when the sleeve is engaged with the cannula varies the length between the sleeve proximal end and the cannula distal end along a continuum; a cutting instrument actuable to excise a cavity in the joint, the cutting instrument comprising a handle and a blade assembly extending distally from the handle, wherein the blade assembly comprises a blade body having a proximal end and a distal end and first and second opposing sides extending therebetween, the first side having a first cutting edge, the cutting instrument having an instrument cutting radius; wherein the blade assembly is movable between a retracted configuration and an extended configuration, wherein the instrument cutting radius in the retracted configuration is less than instrument cutting radius in the extended configuration; a graft insertion instrument at least partially receivable in the bore of the cannula; an implant insertion instrument at least partially receivable in the bore of the cannula; and an implant having a first end and a second end and a bone engagement portion, wherein the implant is sized to pass through the cannula bore and engage the first and second bone portions to fuse the joint.
• Embodiments of this aspect of the disclosure may include one or more of the following features: A gauge engageable with the cannula, wherein the gauge is configured to measure the distance between the guide wire distal end and the cannula distal end. An outer tube extending distally from the handle, wherein the blade assembly is captured in the outer tube. At least one stabilizing element having a proximal end and a distal end, wherein the stabilizing element proximal end is removably attachable to the cannula and the distal end extends distally oblique to the cannula central longitudinal axis when the stabilizing element is attached to the cannula. At least one drill having a drill bit insertable through the cannula bore. A sleeve having a proximal end and a distal end and a sleeve bore extending therebetween, the sleeve at least partially receivable in the cannula bore. An adjustment mechanism, wherein the adjustment mechanism is actuable to control the length between the sleeve proximal end and the cannula distal end when the sleeve is received in the cannula bore.
• According to a third aspect of the disclosure, a method for fusing a joint between a first bone portion and a second bone portion, the method includes inserting an access cannula toward the joint, the access cannula having a distal end and a proximal end and a cannula bore extending therebetween; affixing the distal end of the access cannula to the first bone portion adjacent the joint, the bore of the access cannula providing access to the first bone portion; inserting a sleeve at least partially into the access cannula bore, the sleeve having a distal end and a proximal end and a sleeve bore extending therebetween; inserting a cutting instrument to extend through the sleeve bore toward the joint, the cutting instrument having a longitudinal axis and comprising a handle, an actuation mechanism, and a blade assembly extending distally from the handle; wherein the blade assembly comprises a blade body having a proximal end, a distal end and first and second opposing sides extending therebetween, the first side having a first curved cutting edge; actuating the actuation mechanism to move the blade assembly from a retracted configuration in which the blade body extends along the longitudinal axis to an extended configuration in which the blade body is projected away from the longitudinal device axis; rotating the cutting instrument about the longitudinal axis to urge the blade body first curved cutting edge to excise a cavity in the joint; inserting a fusion device through the cannula bore and across the joint, the implant having a first end and a second end and a bone engagement portion, the fusion device crossing the cavity and the joint; and engaging the fusion device to the first bone portion and the second bone portion.
• Embodiments of this aspect of the disclosure may include one or more of the following features: Moving the blade body along a curved path as the blade assembly is moved into the extended configuration. Pivotably connecting the blade body to a blade shaft of the blade assembly, wherein the blade shaft is coaxial with the longitudinal axis. The blade assembly further comprises a blade holder, and the method further includes pivotably attaching the blade body to the blade holder and removably attaching the blade holder to the blade shaft. The cutting instrument further includes an outer tube extending distally from the handle, and the method further includes receiving the blade assembly in the outer tube. The outer tube includes a curved guide surface within the outer tube, and the method further includes moving the blade body into contact with the curved guide surface to urge the blade body along the curved path. The outer tube includes a window, and the method further includes moving the blade body from a position inside the window to project out of the window. The cutting instrument further includes an adjustment mechanism, and the method further includes actuating the adjustment mechanism to vary the length between the sleeve proximal end and the cannula distal end. The blade body second side has a second curved cutting edge opposite the first curved cutting edge and the blade body is curved in a first plane between the blade body proximal and distal ends, and the method further includes rotating the cutting instrument in at least one of a clockwise and a counter-clockwise direction about the longitudinal axis to excise the cavity in the joint.
• FIG. 1 illustrates a natural sacroiliac joint fused by methods of the invention. Thesacroiliac joint2 comprises the meeting of asacrum5 and anilium6. According to methods of the invention disclosed herein, acavity20 is created between thesacrum5 and theilium6, and may be filled withbone graft material15. Afusion device550 is implanted across the joint2 to provide compression and fuse the joint. The fusion device may be sized to extend through theilium6, across the joint2 andcavity20, and into thesacrum5, extending through thecortical bone4, the sacral ala7, and into thesacral vertebrae9 of thesacrum5. It is appreciated that the instrumentation and methods disclosed herein may also be applied to provide fusion in any other joint, or to provide fusion between two or more bones or bone portions.
• FIGS. 2-9B disclose a cutting instrument, herein referred to as acutter100, which may be used to create thecavity20 in thejoint2. In other embodiments of the method,cutter100 may applied to create a cavity within a bone or bones, and/or across a joint. Referring toFIGS. 2A-2C,cutter100 outwardly comprises ahandle portion102, a shaft portion104, and ablade portion106. In use by a practitioner, thehandle portion102 may be gripped and moved to direct the shaft andblade portions104,106 to a specific area such as a bone or joint, and manipulated to deploy a blade to create a cavity in the bone or joint. The cutter comprises aproximal end110 and adistal end112 with a cutter centrallongitudinal axis114 extending therebetween.
• Referring toFIGS. 2A-3, thehandle portion102 comprises ahandle120 and aknob122, and has adistal end124 and aproximal end126. The shaft portion104 comprises an outer tubular member orouter tube134 which extends distally from thehandle portion102 and terminates at thedistal end112. Housed within theouter tube134, and handle120 is ablade shaft140. Theblade shaft140 extends from theproximal end110 of the cutter, through theknob122, handle120 andouter tube134. At a distal end of theblade shaft140, ablade150 is modularly and pivotably connected to theblade shaft140 via ablade retainer142. The blade may also be referred to as a cutting member, or a decorticator. In alternative embodiments, the blade may be monolithic with the blade shaft or may be permanently attached to the blade shaft.
• Referring toFIG. 2A, handle120 includes a handleouter surface260 which can includegripping features262 andindicia264.Indicator windows266 allow viewing ofmarkings176 from either side of thehandle120. Similarly, theknob122 includes a knobouter surface270 which can includegripping features272 and indicia.
• Referring toFIGS. 4A, 4B and 4C, additional detail of theblade shaft140 is shown.Blade shaft140 extends between aproximal end160 and adistal end162 along a shaft centrallongitudinal axis164. When theblade shaft140 is assembled with the outer tube and handle, the shaft centrallongitudinal axis164 is coaxial with the cutter centrallongitudinal axis114. In an embodiment, theblade shaft140 may be cannulated throughout, having acentral bore165. The blade shaft can include aproximal handle portion180, ashaft182, and adistal attachment portion184. The blade shaft may include anengagement feature166 which engages with theknob122, forming an actuation mechanism which controls extension and retraction of theblade150.
• As seen inFIGS. 4A and 4C, thehandle portion180 of theblade shaft140 includes alongitudinal section183 which is generally rectangular in cross-section. The rectangular section engages with thehandle120 to prevent rotation of theblade shaft140 relative to thehandle120. Indicia, which may take the form of themarkings176, are present on the blade shaft and positioned to be visible through a window in thehandle120, allowing a practitioner to determine the diameter of the cavity being excised by theblade150. At thedistal end162 of theblade shaft140, anattachment feature178 protrudes distally allowing for attachment of theblade holder142. Theattachment feature178 is shaped as aboss186 having an undercut188 and paired angled projections orears190 to retain theblade holder142. In another embodiment, the blade holder may connect to the blade shaft in another connection mechanism, or may be permanently connected. In another embodiment, theblade150 may be directly connected to theblade shaft140.
• With reference toFIGS. 2A and 3,outer tube134 includes atubular body280 extending between aproximal end282 and adistal end284. Thedistal end284 of thetubular body280 terminates in adistal end face290. Adjacent thedistal end284 is anotch292 which may be viewed fluoroscopically to ascertain the position of thedistal end112 of thecutter100 during a procedure. Ablade window294 functions as an opening to allow theblade150 to protrude out of the tubular member for cutting procedures. A rampedsurface296 opposite and interior to theblade window294 guides theblade150 as it is urged out of thewindow294, guiding the blade to project laterally relative to thecutter axis114. When theblade150 is fully projected away from the cutterlongitudinal axis114 and out thewindow294, the rampedsurface296 functions as a stop to prevent further distal movement of theblade150 and hold it rigid relative to thecutter100.
• The connections between theblade shaft140,blade holder142 andblade150 are illustrated inFIGS. 5A and 5B. In the embodiment depicted,blade holder142 may be snapped on and off ofblade shaft140.Blade holder142 includes a first orshaft end300 and a second orblade end302. Theshaft end300 is U-shaped, comprising a pair ofconnected sidewalls304,306 separated by agap308 shaped to receive theblade shaft boss186. Each sidewall terminates in a tab305,307. When the blade holder is snapped on to theblade shaft140, theboss186 is received in thegap308, and tabs305,307 are engaged under the angled projections, or ears,190.
• Theblade end302 includes areceiver boss310 having abore312, the bore extending perpendicular to the longitudinal axis of theblade holder142. Theblade end302 terminates in a curved or rampedsurface316 sloping to an apex314. When thecutter100 is properly assembled and theblade150 is fully extended out of the blade window, as seen for example inFIG. 7B, the rampedsurface316 provides structural support and rigidity, and provides a physical stop to rotation of the blade relative to itsholder142 during cutting steps, and a physical stop to movement of theblade150 relative to thecutter100 during cutting steps. A pin or may pivotably connect theblade150 to theblade holder142 via extending through thebore312. In another embodiment, another pivotable connection may connect theblade150 to theblade holder142 or directly to theblade shaft140.
• Referring toFIGS. 6A-6D, theblade150 includes a proximal orattachment end330, adistal end332, and acurved blade body334 extending therebetween along a blade length. Theattachment end330 includes first andsecond extensions336,338 which project proximally from theblade body334, and include bores to receive a connecting pin. Thebody extensions336,338 are separated by agap339 shaped to receive thereceiver boss310. Thecurved blade body334 may be reduced in its width relative to the first andsecond extensions336,338, as seen inFIGS. 6B and 6C.
• Theblade body334 is shaped as a loop, looping from theextensions336,338 at ablade front side340 on a bladefirst leg341, forming a U-shapedterminal curve342 at thedistal end332, back to theextensions336,338 at a blade backside344 on a bladesecond leg343. Theblade150 may also be described as lasso-shaped or banana-shaped. Acurved void346 extends from theextensions336,338 to theterminal curve342, separating the bladefirst leg341 from the bladesecond leg343. Thecurved void346 provides passage for bone fragments and other materials moved by or encountered by theblade150 during use. A bladefirst side348 extends between thefirst extension336 and thedistal end332, and a bladesecond side350 extends between thesecond extension338 and thedistal end332, opposite the bladefirst side348. Thus, the bladefirst side348 includes portions of both the first andsecond legs341,343, as does the bladesecond side350. The first andsecond legs341,343 may be parallel to one another, separated by the width of thevoid346.
• A furrow orblade relief352 is recessed into the blade body, theblade relief352 continuous from theblade front side340 onfirst leg341 onto the blade backside344 on thesecond leg343. Opposite theblade relief352 is a rounded ridge353, which is also continuous from thefirst leg341 on to thesecond leg343, and forms the boundary of thecurved void346. Put another way, theblade front side340 and the blade backside344 each include a concave curvature along their respective lengths, the concave curvature centered along the midline of the blade length to reduce the contact area at the cutting surface and thus reduce the drag forces on the blade. Opposite the concave curvature is a convex curvature. The bladefirst side348 terminates laterally in afirst cutting edge356, and the bladesecond side350 terminates laterally in asecond cutting edge358 which projects opposite from the first cutting edge. Thus, a curved cutting edge having an open ended U shape is formed on either side of theblade150, enabling cutting to occur whether thecutter100 is rotated clockwise or counter-clockwise. Theblade150 is bilaterally symmetrical relative to a longitudinally extending midline, generally demarcated by the center of theblade relief352, between thefirst side348 and thesecond side350. A first slopedsurface360 slopes from thefirst cutting edge356 to the ridge353, and a secondsloped surface362 slopes from thesecond cutting edge358 to the ridge353. The sloped surfaces360,362 may facilitate movement of severed material toward thevoid346 and away from the cutting edge to prevent clogging during operation of thecutter100. In another embodiment of the invention, the blade body may include a single cutting edge, enabling unidirectional cutting when thecutter100 is rotated in one direction. In another embodiment of the invention, rotation of thecutter100 may be limited to a single direction.
• Viewed in cross-section as inFIG. 6D, theblade legs341,343 are each generally V-shaped. The cutting edges356,358 form the opposing lateral tips of the V, and theblade relief352 and ridge353 form the bottom of the V. Because the blade is looped, a cross-section of the entire blade to include both blade legs results in twin V shapes which are back-to-back, or facing away from one another, and separated by thevoid346, as seen inFIG. 6D. It is also noted that eachleg341,343 is curved in at least two planes: from thefirst side348 to thesecond side350, and from theproximal end330 to thedistal end332. The shape of each leg may be described as an elongated hyperbolic paraboloid, or as an elongated saddle shape. The blade relief provided by the shape of the blade reduces friction as the blade is rotated during a cutting procedure.
• In the embodiment shown, theblade150 is a monolithic entity composed of a rigid material, in order to provide sufficient rigidity during cutting processes to cleanly cut through softer tissues such as cartilage, and harder materials such as cancellous bone, and particularly, cortical bone. The blades disclosed herein may be composed of stainless steel. Theblade150 may be provided in a variety of sizes, varying in length, width, curvature, and/or thickness. A practitioner may select the appropriate sized blade for the patient and attach the blade to thecutter100.
• Theblade shaft140,blade holder142 andblade150 form ablade assembly155. Theblade assembly155 is modular and may be inserted and removed from thecutter100 as needed, for example to change blades. Theblade150 andblade holder142 may be provided in a variety of shapes, lengths, widths, curvatures and/or angles in order to create the desired size and shape of cavity when the cutter is deployed. By way of non-limiting example, the radius of curvature between the proximal330 and distal332 ends of theblade150 vary, as may the radius of curvature between the first and second cutting edges356,358, in different embodiments of the blade. The length of theblade150 from proximal330 and distal332 ends may vary, as may the depth between thefront side340 and theback side344, and/or the width between the between thefirst side348 and thesecond side350. Theblade holder142 may be provided in a variety of lengths, and the angle of the rampedsurface314 may vary.
• FIGS. 7A and 7B are cross-sectional views of the shaft104 andblade106 portions ofcutter100. During assembly of the cutter, theouter tube134 may be attached to thehandle portion102 to form a housing assembly145. Theblade150 may be attached to theblade holder142; in some embodiments the blade and blade holder may be provided pre-assembled. Theblade holder142 is snapped to theblade shaft140 as described herein. Theblade assembly155 can be inserted into the housing assembly145 in a proximal to distal approach, with theblade150 leading throughknob122 and handle120. The indicia on theblade shaft140 and on thehandle120 can provide guidance as to the proper orientation of the blade shaft about itslongitudinal axis164 as theblade assembly155 is inserted. When theblade assembly155 is fully inserted and in the retracted or stowed configuration, theblade150 rests insideblade window294 at the distal end of the housing assembly145, and theblade150 is generally longitudinally aligned to extend along thecutter axis114.
• To employ thecutter100 at a procedure site, the cutterdistal end290 is positioned at the site. To extend theblade150 from the stowed configuration, torque may be applied toknob122 to rotate it in a first direction such as clockwise, wherein theknob122 engages theengagement feature166 ofblade shaft140 to translate theblade assembly155 distally along thedevice axis114. As theblade assembly155 moves distally, theblade150 is projected laterally away fromdevice axis114 and out ofwindow294, biased by contact with rampedsurface296, which functions as a curved guide surface during blade extension. The bladedistal end332 moves alongcurved guide path370 as the blade exits the window. Theindicia176 are visible through thehandle window266 and may indicate the current cutting diameter of the instrument. When a desired cutting diameter is displayed, rotation of the knob is ceased, and to perform a cutting step theentire cutter100 may be rotated about itslongitudinal axis114 by applying torque to the handle, allowing the leadingcutting edge356 or358 to cut through the bone or other material surrounding the exposedblade150. The cutting step may form a circular cavity in the procedure site. After the cutting step, theknob122 may again be actuated to further extend the blade laterally out thewindow294, and the cutting step may be repeated. Extension and retraction of the blade may be ceased at any point along thecurved path370.
• It is noted that during the cutting step, theblade150 is essentially immobilized relative to thecutter100; independent movement of theblade250 is prevented. If theblade150 is less than fully extended, theblade150 is rigidly held between the bone or joint being cut and the rampedsurface296; rotational movement of theblade150 in concert with rotational movement of thecutter100 is permitted but movement of theblade150, including pivotal, axial and rotational, relative to theshaft140 andcutter100 is prevented. When theblade150 is fully extended, theblade150 is rigidly held between the opposingcurved surfaces316 and296 in a locked position; rotational movement of theblade150 in concert with rotational movement of thecutter100 is permitted but movement of theblade150, including pivotal, axial and rotational, relative to theshaft140 andcutter100 is prevented.
• When fully extended, the longitudinal curvature ofblade150 may match the curvature ofguide path370. By way of example, in the embodiment depicted inFIG. 7B, the concave curvature of the rampedsurface296 matches the convex curvature of the bladesecond leg343 andblade holder142 when theblade150 is fully extended out of the blade window, to provide structural support and rigidity, and to provide a physical stop to independent movement of theblade150 relative to theshaft140 andcutter100. The blade extension and cutting steps may be repeated as desired to create a cavity of a selected diameter at the procedure site. When cutting is completed, theknob122 may be turned in a second direction such as counter-clockwise to translate theblade shaft140 proximally and retract theblade150 into thewindow294, and the cutter may be withdrawn from the procedure site. Optionally, thecutter100 may be inserted axially deeper into the procedure site and redeployed to deepen the circular cavity or create another cavity. Optionally, thecutter100 may be rotated less than 360° to create a cavity that is less than a full circle.
• Thecutter100 described herein may be used in a procedure to fuse a sacro-iliac joint. In a procedure, thecutter100 may be deployed to create a cavity in the cartilage at the joint between the sacrum and the ilium, and/or in the hard cortical bone matter of the sacrum and/or ilium. Bone graft material may be inserted into the cavity, and a fusion device may be implanted across the joint to compress and fuse the joint.
• Referring toFIGS. 8A-9B, alternative embodiments of a blade forcutter100 are shown.FIGS. 8A and 8B disclose ablade200 having a proximal or attachment end201, and a distal or workingend202, and acurved blade body204 extending therebetween along a blade length. An attachment portion203 is proximate the proximal end201. The description of the features of the attachment end ofblade150 also applies toblades200 and250. Theblade body204 is shaped as a loop, looping from attachment end201 at ablade front side206 on a bladefirst leg208, forming a U-shapedterminal curve210 at thedistal end202, back to the attachment end201 at a blade backside212 on a bladesecond leg214. Theblade200 may also be described as lasso-shaped or banana-shaped. Acurved void216 extends from the attachment portion203 to theterminal curve210, separating the bladefirst leg208 from the bladesecond leg214. Thecurved void216 provides passage for bone fragments and other materials moved by or encountered by theblade200 during use. A bladefirst side218 extends between the attachment end201 and thedistal end202, and a bladesecond side220 extends between the attachment end201 and thedistal end202, opposite the bladefirst side218.
• Theblade body204 is flat on a continuousouter surface222 formed by thefront side206 offirst leg208, around theterminal curve210, and theback side212 ofsecond leg214. The bladefirst side218 terminates laterally in a first cutting edge246, and the bladesecond side220 terminates laterally in asecond cutting edge226 which projects opposite from the first cutting edge. Thus, a curved cutting edge having an open ended U shape is formed on either side of theblade200, enabling cutting to occur whether thecutter100 is rotated clockwise or counter-clockwise. Theblade200 is bilaterally symmetrical relative to a longitudinally extending midline, generally demarcated by the midline center of the continuousouter surface222, between thefirst side218 and thesecond side220. In cross-section as inFIG. 8B, thefirst leg208 andsecond leg214 are generally triangular, resulting in twin triangular shapes which are apex-to-apex, or facing away from one another, and separated by thevoid216. The other features ofblade150 also apply toblade200, including the void, and the sloped surfaces extending from the cutting edges toward the void.
• FIGS. 9A-9B disclose another alternate embodiment of a blade for use withcutter100. The description, form and features ofblade150 apply toblade250, with the exception of the cutting edges.Blade250 includes first252 and second254 cutting edges which are broken up by scallops orserrations256. Theserrations256 may vary in size along different portions of theblade250, and may extend inward as far as the longitudinally extending midline of the blade. When deployed incutter100, theserrations256 may facilitate cutting through hard cortical bone material.
• A method of fusing a joint is set forth below. It is appreciated that although the method described is for a sacro-iliac joint, the method can be applied to any joint, or to fusion of any two bones or bone portions. In addition, the instruments and/or methods described herein may be applied to other procedures, including at least: intramedullary osteotomies for limb-lengthening, derotation, and/or malunion procedures; spinal disc space joint preparation for arthrodesis, arthroplasty and/or other procedures; and subtalar joint preparation for ankle fusion. Thecutter100 may be advantageously used to cut both soft cancellous bone and hard cortical bone.
• Referring toFIGS. 10-27, systems and methods for preparing a joint space and implanting a fusion implant are shown. The method may include one or more of the following steps described below. It is understood that in certain embodiments of the method, the steps may or may not be performed in the order set forth below, one or more of the steps may be omitted, one or more of the steps may be repeated, and/or additional steps may be performed. In other embodiments of the invention, the systems and methods described herein may be used to fuse two bone portions, or two bones.
• FIGS. 10-22 include a stylized cross-sectional depiction of a meeting of anilium6 and asacrum5 at a sacro-iliac joint2. At thejoint2, the portion of the ilium depicted may include primarily hard cortical bone. Thesacrum5 is depicted as having three strata; hard corticalsacral bone4, the sacral ala7 and the sacralvertebral body9. It is appreciated that the natural joint2 between theilium6 andsacrum5 undulates, as do the strata of thesacrum5, with the natural anatomy of the bones; in the figures they are depicted as straight lines for clarity.
• Referring toFIG. 10, in a step a guide wire is introduced into a procedure site, in the example shown a sacro-iliac joint2 between asacrum5 and anilium6. In the embodiment shown, the guide wire is introduced through the ilium, and into the joint space, so that the tip of the guide wire is in the joint space. The guide wire may comprise a guide line, guide pin, k-wire, or another guiding line known in the art. The guide wire may create anaccess passageway8 through skin, muscle and other tissues from outside the patient to the sacro-iliac joint. In one embodiment, a first guide wire comprising a 2 mm k-wire may be introduced, removed, and a largerdiameter guide wire400 is introduced through theaccess passageway8 created by the first guide wire. The guide wire may be positioned so that atip402 of the largerdiameter guide wire400 protrudes through theilium6 across the joint2 and into thebone4 of thesacrum5. In one embodiment, theguide wire400 may be a 3.2 mm k-wire. Following introduction of theguide wire400, in another step one or morecannulated dilators404,406,408 may be sequentially introduced over aproximal end401 of theguide wire400 toward the procedure site, to further increase the diameter of theaccess passageway8. In the example shown, three dilators are introduced sequentially, in ascending diameter size, over theguide wire400. Each dilator may be inserted concentrically over the guide wire and previous dilator(s) until a distal end of the dilator, for example distal end410 ofdilator408 contacts theilium6. In another embodiment of the method, one or more steps of the method may be performed without utilizing guide wires. In another embodiment of the method, a computerized navigation system may be used to guide the instrumentation and steps of the system.
• Referring toFIGS. 11, 14A, and 24, in another step anaccess cannula420 is introduced over theguide wire400 and dilator(s). Theaccess cannula420 includes aproximal end422 and adistal end424, with aperipheral wall426 extending therebetween, surrounding aninternal bore425. Thecannula420 may include one or more distally projectingteeth428 which may protrude into theilium6 to dock the cannula to the ilium and stabilize the position of the cannula. Thecannula420 may further include one ormore brackets430 or other attachment features to connect to stabilizing elements such as wires or struts. Thebrackets430 may be specifically shaped and/or angled to hold the stabilizing elements in a desired alignment. A portion of theperipheral wall426 includesinternal threading432, and one ormore access ports434 may be formed in theperipheral wall426. Upon introduction into the procedure site, theteeth428 may protrude several millimeters into the ilium, but in the embodiment shown, preferably do not extend into thejoint2.
• Referring toFIG. 12, in another step animpactor440 may be connected to theproximal end422 of thecannula420 to drive theteeth428 into the ilium and more securely fix the cannula in place. A mallet or other tool (not shown) may be used to apply axial force to theimpactor440.
• Referring toFIG. 13, following the docking of the cannula into the ilium, in another step one or more stabilizingguide wires444 may be connected to thebrackets430 and introduced into theilium6, to further stabilize the position of thecannula420 for subsequent steps of the method. When thecannula420 is satisfactorily positioned and stabilized, the dilator(s)404,406,408 may be proximally withdrawn from the cannula, over theguide wire400.
• Referring toFIGS. 14A, 14B and 25, in another step asleeve450 is introduced over theguide wire400 and into the proximal end of thecannula420. Thesleeve450 includes aproximal end452, adistal end454 and asleeve body456 surrounding alongitudinal sleeve bore455. Arim458 encircles thesleeve body456, and a portion of the sleeve body includesexternal threading460 for engagement with theaccess cannula420, forming an adjustment mechanism with the cannula. Thesleeve body456 may include aproximal section462, aneck464 and adistal section466. The diameter of the sleeve bore455 may decrease from theproximal section462 to thedistal section466, tapering in theneck464. Aflange469 projects outwardly from thedistal section466 and may stabilize the distal section with respect to theaccess cannula420.
• Thesleeve450 may includeindicia468 so that as thesleeve450 is engaged with theaccess cannula420, a precise distance to the cannuladistal end424, and thus the procedure site, may be achieved. The combined axial length of thesleeve450 andcannula420 may be adjusted along a continuum by rotation of thesleeve450. This adjustability allows precise placement of thecutter blade150 at the joint2, and may prevent over-insertion of thecutter100 or other instrumentation. At least one ball detent may be received in acannula access port434, and interact with agroove463 formed on the exterior of thesleeve body450 to provide tactile indication of the extent of the sleeve rotation. The reduced inner diameter of the sleevedistal section466 may precisely target instrumentation such ascutter100 toward the procedure site.
• Referring toFIG. 15, in another step adrill470 is introduced over theguide wire400 and through the sleeve bore455 and cannula bore425. Afirst passageway18 is drilled through theilium6, across the joint2, and into the sacrum, and replaces theaccess passageway8. After the drilling step, theguide wire400 may be withdrawn from theaccess cannula420. Suction may be applied to remove material from thefirst passageway18.
• Referring toFIGS. 16A and 16B, in another step thecutter100 is introduced, with the shaft portion104 inserted through thesleeve450,cannula420, andfirst passageway18. The cutterdistal end112 may contact thesacrum5, and theblade150 withinblade window294 are positioned past, or distal to, thedistal end424 of thecannula420. During the introduction step, theblade150 is in the retracted configuration, so that it is contained within a diameter envelope of theouter tube134. The handledistal end124 may contact therim458 of the sleeve, limiting the insertion depth of thecutter100. Thesleeve450 may be rotated as needed to adjust the depth of the cutterdistal end112. Fluoroscopy may be utilized as desired to visualizenotch292 andblade window294, allowing precise placement ofcutter100 relative to the joint2 at the procedure site.
• When the cutter shaft104 andblade106 portions are at the desired location, and theblade portion106 is distal to the cannuladistal end424, in one ormore steps knob122 is rotated to deploy thecutter blade150 laterally. During initial deployment, only a small portion of theblade150 may project laterally out of the blade window, the bladedistal end332 extending to a first deployed distance r, measured as the distance from the cutterlongitudinal axis114 to the bladedistal end332, perpendicular to theaxis114. The deployed distance represents the radius of a circle which may be cut by the cutter blade. The practitioner may check the deployed distance by reading theindicia176 visible in theindicator window266. In embodiments of the device, theindicia176 indicate the diameter of a circular cavity cut by the device. In embodiments of the device, the diameter cut by thecutting device100 may range from 2 mm to 70 mm, and the cutting radius or deployed distance r may range from 1 mm to 35 mm.Blades150 of varying lengths may be provided to attain the range of cutting diameters disclosed herein.
• In another step, torque is applied to thehandle120 to rotate theentire cutter100 about its longitudinal axis, thus sweeping theblade150 in a circular path to perform a first cut. Thecutting edge356 or358 at the leading side of theblade150 cuts into the surrounding bone and/or other tissue. Fragments of the bone and/or tissues are severed from the joint and are urged toward thevoid346, the leading slopedsurface360 or362 facilitating movement of the tissue fragments away from the cutting edge and toward thevoid346. Theblade150 cuts a cavity having a diameter determined by the distance between the cutter longitudinal axis and the bladedistal end332 at its deployed distance, or r. After the first cut, theknob122 may again be rotated relative to thehandle120 to further extend the blade laterally to a second deployed distance. Theentire cutter100 may be rotated again to perform a second cut of a larger diameter, thus increasing the diameter of the cavity. These steps may be repeated as needed until the desireddiameter cavity20 is created.FIG. 7B illustrates theblade150 at a fully deployed or fully extended configuration. At the fully extended configuration, theblade150 is held essentially immobile relative to thecutter100 by contact with the opposingcurved surfaces296 and316, which act as stops to lock the blade in its extended position. At less than the fully extended configuration, theextended blade150 is held rigid by contact with the rampedsurface296 and contact with the bone or other tissue against which the blade is deployed.
• Referring toFIG. 17, in one or more steps suction may be deployed in between cutting steps, or at other points during the procedures described herein, as needed to clear debris from the cavity and/or instrument. To deploy suction, thecutter100 or other instrument may be withdrawn from thecannula420. Asuction tool470 may be inserted, until anopening472 of thesuction tool470 is at a desired location in thecannula420 orcavity20, orpathway18. Thesuction tool470 may be connected to a suction source, and suction is applied until the debris is removed. Fluid may be applied during the suction process. In other embodiments, means for suction may be integrated intocutter100, eliminating the need for a separate suction tool.
• After thecavity20 of a desired or selected diameter is created, bone graft material and/or other substances may be introduced into the cavity. With reference toFIGS. 18 and 27, agraft funnel480 may be used to guide bone graft material into thecavity20. The graft funnel includes afunnel portion482 and aconduit484. A pair ofopenings483 on opposite sides at the distal end of theconduit484 allow movement of the graft material out of the conduit. Aplug485 in the distal end of the conduit includes guide surfaces that divert the graft material out of the opposingopenings483. In a graft insertion step, the graft funnel may be inserted to extend through thesleeve450 andcannula420 with the distal end of theconduit484 opening into thecavity20.Graft material15 is inserted into thefunnel portion482. A tamp486 may be used to push the graft material distally through theconduit484 toward theplug485, out theside openings483 and into thecavity20. The tamp may include ahandle487, ashaft488 and a distal tampface489. In another embodiment, a tamping member with a solid distal tamp face may be coupled to theblade holder142 of thecutter100 and deployed by rotation of theknob122 to push the graft material through theconduit484 and into thecavity20. During a graft insertion step, thefunnel480 may be selectively rotated to ensure that graft material exits theopenings483 into all or selected parts of thecavity20.
• Referring toFIG. 19, in another step of the method a tunnel may be drilled through the packed bone graft and across the cavity to prepare for insertion of a fusion device. Prior to drilling the hole, a dilator such asdilator404 may be reintroduced into throughsleeve450 intocannula420, to provide a guide for a guide wire. Theguide wire400 may also be reintroduced, and inserted through theilium6, thecavity20 andgraft15, and into thesacrum5, extending through the hardcortical layer4, the sacral ala7 and into thevertebral body9. Adrill490 is introduced over theguide wire400 to drill asecond passageway28 also extending through the bone graft and cavity and into thesacrum5, to provide a passage for the fusion screw implant. In another embodiment of the method, bothpassageways18 and28 may be drilled prior to cutting thegraft cavity20 with thecutter100.
• As shown inFIGS. 20 and 26, in another step of the method alength gauge510 can be used to determine the proper length for a fusion implant.Length gauge510 includes asupport member512 having adistal end514, aproximal end516, and a bore515; and further includes agauge518 and setscrew520. Setscrew520 may include a ball detent. Thegauge518 is partially cannulated, having ablind bore519 shaped to receive theproximal end401 ofguide wire400, the blind bore having anend surface521. Thegauge518 also includes a blind groove22. When assembled for use, thegauge518 is received in bore515 of thesupport member512. Setscrew520 extends through an opening in thesupport member512 and into thegroove522. To measure for proper implant length, thescrew length gauge510 is mounted on tocannula420, with thedistal end514 of thesupport member512 resting on theproximal end422 of the cannula. Theguide wire400proximal end401 is received in theblind bore519 of thegauge518. Thegauge518 may be adjusted until theend surface521 of theblind bore519 rests on theproximal end401 of theguide wire400. The proper implant length may then be indicated byindicia524 on thegauge518, read where thegauge518 intersects the support memberproximal end516.
• As shown inFIGS. 1, and 21-23D, in another step of the method a properlysized fusion implant550 may be implanted into theprepared cavity20, crossing the cavity and joint2 and engaging thesacrum5 andilium6. Thefusion implant550 includes ascrew member552 and awasher member554. Thescrew member552 includes ahead566 and atip568 with ascrew body564 extending therebetween. Engagement features567, for example a hex feature as seen inFIGS. 23B and 23C, are present in thehead556 for connection with insertion and/or removal instrumentation. Thescrew member552 may include a bore orlumen551 extending along its lengthwise dimension to allow for introduction over theguide wire400, and may include one or more fenestrations, orapertures556 which open intolumen551 for graft packing and bone through-growth. A self-tapping threadedengagement zone558 is distal to alag zone560. Anannular lip559 projecting from thescrew body564 may provide resistance to unintentional screw withdrawal, and may provide additional compression when theimplant550 is inserted across a joint. Thescrew member552 may includeinternal threads562 or other features for engagement with implantation and/or removal instrumentation. Upon implantation, theengagement zone558 may be embedded in thesacrum5, extending into thevertebral body9; and thelag zone560 may cross theilium6, joint2,cavity20, and extend into thesacrum5. Thewasher554 abuts theilium6. Thescrew member552 may be sized so that thelag zone560 is positioned to extend through the ilium and theengagement zone558 extends into the sacralvertebral body9 upon implantation, permitting engagement in the highest quality available bone.
• Thewasher554 includes anupper side570, alower side572, and asemispherical capsule553 positioned between the upper and lower sides. Thesemispherical capsule553 may be concavely curved, and circumscribes abore555. When properly assembled with thescrew member552, thesemispherical capsule553 may retain thehead566 of thescrew member552, and thescrew body554 protrudes distally from thebore555. Thehead566 may be recessed below theupper side570 of the screw. The semispherical connection between thehead566 and thewasher member554 permits polyaxial orientation of thescrew member552 relative to thewasher member554. In an embodiment, the washer/screw connection permits +/−18 degrees of angulation of the screw member relative to a central longitudinal axis defined by the washer bore555. Theimplant550 may include one or more surface finishes to promote engagement with bone. For example, the threadedengagement zone558 may be grit-blasted and/or include a hydroxyapatite coating or a non-hydroxyapatite coating.
• In a method of implantation, animplant inserter530 may be used in a step to place and engage thefusion implant550 in the prepared site, as shown inFIG. 21. Theinserter530 includes ahandle portion532, ashaft portion534 and anengagement tip536. Some or all of theinserter530 may be cannulated. Theengagement tip536 may include features to engage with thehead566 to enable insertion and rotation of thescrew member552. Theinserter530 may further include a ratchet system or other mechanisms for implant rotation or deployment. In a method of use, thescrew member552 may be coupled with thewasher member554, with thehead560 received in thewasher capsule553 and thescrew body564 protruding distally. Theimplant550 may be placed over theproximal end401 of theguide wire400, with thescrew member tip568 extending distally toward the joint or procedure site. Theinserter engagement tip536 is coupled to theimplant550, and the inserter may be moved to urge theimplant550 distally along theguide wire400 toward the prepared site. As theimplant550 crosses the joint2 and thecavity20 and intopassageway28, the threadedengagement zone558 may engage in thesacrum5. Theinserter530 may be rotated or otherwise deployed to rotate theimplant550 and secure it in the bone. Once thewasher member554 abuts theilium6, theimplant550 may be further rotated to provide compressive force across thejoint2. In the fully inserted and secured position such as shown inFIGS. 1, 21 and 22, theapertures556 are aligned with and open to the joint2 and thecavity20, allowing for graft distribution into and through theimplant550, and bone through-growth.
• With regard toFIG. 22, in another step of the method a secondary orauxiliary screw580 may be deployed to extend across the joint2 to further stabilize the joint.Auxiliary screw580 may be fully threaded and self-tapping. Aguide brace590 may be mounted overguide wire400 to assist in determining a trajectory forauxiliary screw580. Theguide brace590 includes abracket592, which may be angled. Aguide wire596 is guided through thebracket592 and into the procedure site, at an oblique angle relative to the longitudinal axis of theimplant550 andguide wire400. Theauxiliary screw580 is introduced overguide wire596 along the trajectory and through theilium6 and into thesacrum5, crossing thejoint2. In another embodiment of the method, more than onefusion implant550 may be implanted. In other embodiments of the method, noauxiliary screw580 may be deployed, or multiple auxiliary screws may be deployed. In other embodiments of the method, anauxiliary screw580 may be implanted to extend parallel to theprimary fusion implant550, and a guide brace with a parallel bracket may be used.
• FIGS. 29-37 disclose alternate embodiments of fastener members which may be included in a fusion implant such asimplant550. Any of the fastener members may be coupled withwasher member554 to form a fusion implant, or may be combined with other washer members, or may be used individually. Any of the fastener members disclosed herein may include surface roughening, grit-blasting, or coatings on all or a portion of the fastener member to promote bone engagement. Any of the fastener members may be cannulated, and may include fenestrations or windows for graft distribution or bone ingrowth.
• Referring toFIGS. 29-33, alternate embodiments of screw-type fastener members are disclosed.Fastener member600 includeshead602,tip603, threadedportion604,lag portion606, andannular grooves608.Fastener member600 is a combination fastener, the threadedportion604 having a double lead tip transitioning to a single lead toward thehead602. The thread diameter of the threadedportion604 may taper moving from thelag portion606 toward thetip603.Fastener member610 includeshead612,tip613, threadedportion614,lag portion616, andannular grooves618.Fastener member610 is a double lead screw with dual threads of increasing height moving from thetip613 toward thehead612.Fastener member620 includeshead622,tip623, threadedportion624,lag portion626, andannular grooves628.Fastener member620 is a single lead screw having tall threads to support cancellous bone.Fastener member630 includeshead632,tip633, threadedportion634,lag portion636, andannular grooves638.Fastener member630 is a double lead screw having dual height threads which provide additional joint compression when themember630 is implanted across a joint.Fastener member640 includeshead642,tip643, threadedportion644,lag portion646, andannular grooves648.Fastener member640 includes double lead threading which may allow faster installation than fasteners with single lead threading. Theannular grooves608,618,628,638,648 are tapered towards the respective fastener head to provide resistance to fastener withdrawal. The annular grooves may also function as compression bands to grab bone and provide added compression across a joint as they are driven into bone. Thelag portions606,616,626,636,646 may be proportioned to accommodate the width of a bone they are implanted in, such as an ilium.
• Referring toFIGS. 34-37, alternate embodiments of nail-type fastener members are disclosed.Fastener members650,660,670 and680 may be used as supplementary or auxiliary implant to a fusion device such as550, to provide additional compression across a joint, and resistance to joint rotation.Fastener member650 includes ahead652 andtip654 withspiral shaft656 extending therebetween. Thespiral shaft656 includes a fast hexagonal spiral which provides compression across the joint.Fastener member660 includes ahead662 andtip664 withspiral shaft666 extending therebetween. Thespiral shaft666 includes a slow hexagonal spiral which provides compression across the joint.Fastener member670 includes ahead672 andtip674 withspiral shaft676 extending therebetween. Thespiral shaft676 includes a slow square spiral which provides compression across the joint.Fastener member680 includes ahead682 andtip684 withshaft686 extending therebetween. Theshaft686 comprises annular grooves which taper toward thehead682, and which provide compression across the joint and resistance to withdrawal.
• The present invention may be embodied in other specific forms without departing from its spirit or essential characteristics. Above are described various alternative examples of systems and methods for joint fusion and for creating a cavity within a bone or joint. It is appreciated that various features of the above-described examples can be mixed and matched to form a variety of other combinations and alternatives. Not every instrument described herein may be used in a procedure such as a joint fusion. For example, in a method of fusing a joint, the steps of using the cutter instrument may be optional. In other embodiments of the method, the sleeve and/or cannula may be optional. The instruments described herein may be used in other procedures not described herein. As such, the described embodiments are to be considered in all respects only as illustrative and not restrictive. The scope of the invention is, therefore, indicated by the appended claims rather than by the foregoing description. All changes which come within the meaning and range of equivalency of the claims are to be embraced within their scope.

Claims (20)

1. A cannula system comprising:

a cannula comprising a proximal end, a distal end, a peripheral wall extending between the proximal and distal ends, and a cannula bore surrounded by the peripheral wall; and

a stabilizing element comprising a proximal end and a distal end;

wherein the stabilizing element is removably attachable to the cannula.

2. The cannula system ofclaim 1, wherein the proximal end of the stabilizing element is removably attachable to the proximal end of the cannula.

3. The cannula system ofclaim 2, wherein the proximal end of the cannula comprises a first bracket, wherein the proximal end of the stabilizing element is removably attachable to the first bracket.

4. The cannula system ofclaim 3, wherein the first bracket extends outwardly from an exterior surface of the peripheral wall of the cannula.

5. The cannula system ofclaim 4, wherein the cannula comprises a second bracket that extends outwardly from the exterior surface of the peripheral wall of the cannula distal to the first bracket, wherein the stabilizing element is removably attachable to the second bracket.

6. The cannula system ofclaim 5, wherein the cannula bore defines a cannula central longitudinal axis, wherein when the stabilizing element is attached to the first and second brackets, the stabilizing element extends oblique to the cannula central longitudinal axis.

7. The cannula system ofclaim 1, wherein the cannula bore defines a cannula central longitudinal axis, wherein when the stabilizing element is attached to the cannula, the stabilizing element extends oblique to the cannula central longitudinal axis.

8. The cannula system ofclaim 7, wherein when the stabilizing element is attached to the cannula, the distal end of the stabilizing element extends distally oblique to the cannula central longitudinal axis.

9. A cannula system comprising:

a cannula comprising a proximal end, a distal end, and a cannula bore extending between the proximal and distal ends; and

a stabilizing element comprising a proximal end and a distal end;

wherein the proximal end of the stabilizing element is removably attachable to the cannula.

10. The cannula system ofclaim 9, wherein the proximal end of the stabilizing element is removably attachable to the proximal end of the cannula.

11. The cannula system ofclaim 10, wherein the proximal end of the cannula comprises a first bracket, wherein the proximal end of the stabilizing element is removably attachable to the first bracket.

12. The cannula system ofclaim 11, wherein the first bracket extends outwardly from an exterior surface of a peripheral wall of the cannula, wherein the peripheral wall extends between the proximal and distal ends of the cannula and surrounds the cannula bore.

13. The cannula system ofclaim 12, wherein the cannula comprises a second bracket that extends outwardly from the exterior surface of the peripheral wall of the cannula distal to the first bracket, wherein the stabilizing element is removably attachable to the second bracket.

14. The cannula system ofclaim 13, wherein the cannula bore defines a cannula central longitudinal axis, wherein when the stabilizing element is attached to the first and second brackets, the stabilizing element extends oblique to the cannula central longitudinal axis.

15. The cannula system ofclaim 9, wherein the cannula bore defines a cannula central longitudinal axis, wherein when the stabilizing element is attached to the cannula, the stabilizing element extends oblique to the cannula central longitudinal axis.

16. The cannula system ofclaim 15, wherein when the stabilizing element is attached to the cannula, the distal end of the stabilizing element extends distally oblique to the cannula central longitudinal axis.

17. A cannula system comprising:

a cannula comprising a proximal end, a distal end, and a cannula bore extending between the proximal and distal ends; and

a stabilizing element comprising a proximal end and a distal end;

wherein the stabilizing element is removably attachable to the cannula;

wherein when the stabilizing element is attached to the cannula, the stabilizing element extends beside the cannula.

18. The cannula system ofclaim 17, wherein the proximal end of the stabilizing element is removably attachable to the proximal end of the cannula.

19. The cannula system ofclaim 18, wherein the cannula bore defines a cannula central longitudinal axis, wherein the proximal end of the cannula comprises a first bracket and a second bracket, wherein the first and second brackets extend outwardly from an exterior surface of a peripheral wall of the cannula, wherein the second bracket is distal to the first bracket, wherein the proximal end of the stabilizing element is removably attachable to the first bracket, wherein the stabilizing element is removably attachable to the second bracket, wherein when the stabilizing element is attached to the first and second brackets, the stabilizing element extends oblique to the cannula central longitudinal axis.

20. The cannula system ofclaim 17, wherein the cannula bore defines a cannula central longitudinal axis, wherein when the stabilizing element is attached to the cannula, the distal end of the stabilizing element extends distally oblique to the cannula central longitudinal axis.

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