US20210298766A1 - Surgical instrumentation and methods of use for implanting a prosthesis - Google Patents

Abstract

A method of utilizing a distractor in a joint replacement procedure is provided. The method includes releasably engaging a datum to a datum securement of the distractor and gripping a handle of the distractor in an insertion position. The handle includes a first handle portion and a second handle portion. The method includes disposing a paddle of a tissue engaging portion of the distractor against a tissue surface and adjusting the handle from the insertion position to the distraction position to thereby independently move the paddle with respect to both the second handle portion and the first handle portion such that the paddle remains at a generally constant angle against the tissue surface as the tissue surface is distracted. The paddle is attached directly and exclusively to a distal tip of the second handle portion such that the paddle pivots about an axis transverse to a length of the handle.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
• This application is a continuation of U.S. application Ser. No. 16/017,432 filed Jun. 25, 2018, which is a continuation of U.S. application Ser. No. 15/637,746 filed Jun. 29, 2017, which is a continuation of U.S. application Ser. No. 15/294,307 filed Oct. 14, 2016, which is a continuation of U.S. application Ser. No. 13/001,080, filed Feb. 10, 2012, which is a national phase entry under 35 U.S.C § 371 of International Application No. PCT/US2009/48699 filed Jun. 25, 2009, published in English, which claims the benefit of U.S. Provisional Patent Application No. 61/133,186 filed Jun. 25, 2008 and entitled “Instrumentation for Prosthesis” and U.S. Provisional Patent Application No. 61/178,343 filed May 14, 2009, and entitled “Surgical Instrumentation and Methods of Use for Implanting an Endoprothesis,” the disclosures of which are hereby incorporated by reference herein in their entirety.
BACKGROUND OF THE INVENTION
• The present invention generally relates to surgical instrumentation and methods for such procedures such as, for example, a total joint replacement within a patient.
• Various endoprosthetic devices are known for repairing or replacing joints in a patient. Specifically, it is known to use an endoprosthesis to replace a damaged ankle joint. The ankle joint is a comparatively small joint relative to the weight bearing and torque the joint must withstand. These factors have made the design of total ankle joint replacements technically challenging. Total ankle replacement has been investigated since the 1970's with initially promising results, but the procedure was essentially abandoned in the 1980's due to a high long-term failure rate, both in terms of pain control and improved function. However, researchers have continued to investigate new designs, which can be broadly subdivided into constrained and unconstrained designs. Constrained designs offer the advantage of greater stability, but with decreased mobility and increased stress at the bone implant interface, potentially leading to a greater risk of early loosening and failure. Unconstrained designs provide improved range of motion in multiple planes, but at the expense of stability. Early devices investigated were implanted with cement fixation, which in recent years has given way to cementless designs. One such cementless, non-constrained mobile bearing device that has proven to be successful is a total ankle replacement. An example of the total ankle replacement, shown inFIGS. 1 and 2, is further described in U.S. Pat. No. 6,852,130 and is commercially known as the S.T.A.R.® or the Scandinavian Total Ankle Replacement System.
• Total joint replacements, such as the S.T.A.R.®, have been implanted to repair damaged joints using a combination of cut guides and free hand cutting and shaping to sufficiently prepare the bone contacting the total joint replacement.
• It would be desirable to reduce the amount of measuring, free hand cutting and/or re-mounting of cut guides to the remaining healthy bone structure to efficiently and accurately prepare the resected tissue surface receiving the total joint replacement with repeatable results and minimum bone removal.
BRIEF SUMMARY OF THE INVENTION
• In one embodiment, there is a distractor that includes a handle that is adjustable between an insertion position and a distraction position, a datum securement that is attached to the handle and releasably engagable with a datum, and a tissue engaging portion that is attached to the handle and movable with respect to the datum securement as the handle is adjusted between the insertion position and the distraction position. In another embodiment, the handle includes a first handle portion that extends from the datum securement and a second handle portion that extends from the tissue engaging portion. In another embodiment the second handle portion is pivotable with respect to the first handle portion. In another embodiment, the first handle portion is releasably attached to the second handle portion. In a further embodiment, the first handle portion is generally planar from the distal end to the proximal end. In another embodiment, the second handle has an angular orientation between a distal end and a proximal end. In another embodiment, the second handle portion further comprises a grip portion opposite a tissue engaging portion and an inflection point between the tissue engaging portion and the grip portion wherein the second handle portion is attachable to the first handle portion proximate the inflection point. In another embodiment, the second handle portion includes a distal portion that is generally parallel the first handle portion when the distractor is in the insertion position and is not generally parallel to the first handle portion when the distractor is in the distraction position. In a further embodiment, a ratchet extends between the first handle portion and the second handle portion. In another embodiment, the ratchet is positioned at the proximal end of the distractor. In another embodiment, the ratchet is pivotally attached to the first handle portion. In another embodiment, the ratchet is detachable from the second handle portion. In another embodiment, the tissue engaging portion includes a paddle pivotally attached to the second handle portion. In another embodiment, the paddle is generally parallel with the handle in the insertion position. In another embodiment, the paddle is generally flush with the handle in the insertion position. In another embodiment, at least a portion of the paddle is sized and configured to extend over the datum and between a plurality of projections extending from the datum. In another embodiment, a proximal end of the paddle is heavier than the distal end of the paddle. In another embodiment, the datum securement includes an abutment member, the abutment member engagable with the datum and movable from a secured position to a released position. In a further embodiment, a datum lock is configured to move the datum datum securement from a secured position to a released position. In another embodiment, the datum lock includes a rotatable nut that threadably engages a shaft extending from the datum securement. In another embodiment, the handle further comprises a grip portion having a plurality of indentations separated by columns that are oriented perpendicular to a longitudinal axis of the handle.
• In one embodiment, there is a tissue resection guide for use with a datum that includes a base releasably engagable with the datum and having a first frame fixed relative to the base and the first frame having at least one integral first guide path sized and configured to at least partially capture and guide a first tissue resection tool relative to the first frame. In another embodiment, the base further includes a second frame fixed relative to the base, the second frame having at least one integral second guide path sized and configured to at least partially capture and guide a second tissue resection tool relative to the first frame. In another embodiment, the second frame has an at least partially open sidewall. In another embodiment, the at least partially open sidewall includes two tapered and spaced apart side wall segments. In another embodiment, the base has a bottom surface engagable with the datum and a top surface opposite the bottom surface of the base, the at least one second guide path is at least partially closed proximate the top surface of the base and substantially open proximate the bottom surface of the base. In another embodiment, the at least one first guide path is raised upwardly further from the base in a direction generally normal to the top of the base than the at least one second guide path. In another embodiment, at least one of the first and second frames are angled inwardly toward the base. In another embodiment, the second frame has an angle of inclination relative to the base greater than an angle of inclination between the base and the first frame. In another embodiment, the at least one second guide path and a surface of the datum define a resection plane when the base is engaged with the datum. In another embodiment, the at least one guide path includes an enlarged end. In another embodiment, at least two enlarged ends are on opposite lateral sides of the first frame. In another embodiment, the at least one first guide path includes two substantially parallel longitudinal guide paths. In one embodiment, the two substantially parallel longitudinal guide paths has a longitudinal axis and an enlarged end, and wherein the longitudinal axes of adjacent longitudinal guide paths are spaced apart from one another by a distance that is less than a diameter of one of the enlarged ends. In one embodiment, the at least one first guide path and a surface of the datum define a resection plane along which the tissue resection tool is guided when the base is engaged with the datum. In one embodiment, the base has a bottom surface engagable with the datum and a top surface opposite the bottom surface of the base, the at least one first guide path is at least partially closed proximate the top surface of the base and substantially open proximate the bottom surface of the base. In one embodiment, the at least one first guide path is raised upwardly from the top surface base in a direction generally normal to the top of the base. In one embodiment, the first frame includes at least one viewing window extending through an outer surface of the first frame. In one embodiment, the first frame includes an alignment line intersecting with the at least one viewing window.
• In one embodiment there is a datum engagable with at least one tissue resection guide, the datum includes a bottom surface engagable with a tissue surface, a first side surface that extends upwardly from the bottom surface to define a first acute angle with the bottom surface, a second side surface that extends upwardly from the bottom surface to define a second acute angle with the bottom surface, and a top surface that is connected to the first and second side surfaces and has a securement releasably engagable with the at least one tissue resection guide. In another embodiment, a surface extends upwardly from the bottom surface to define a third acute angle with the bottom surface. In another embodiment, a fourth side surface extends upwardly from the bottom surface to define an obtuse angle with the bottom surface. In another embodiment, a width of the bottom surface measured between the first and fourth side surfaces is smaller than the length of the bottom surface measured between the first and second side surfaces. In another embodiment, the third acute angle is smaller than the first and second acute angles. In another embodiment, a fourth angle between the first side surface and the third side surface is less than a fifth angle between the second side surface and the third side surface. In another embodiment, the third side surface is between the first and second side surfaces. In another embodiment the top surface is generally parallel to the bottom surface. In another embodiment, the securement includes a threaded aperture.
• In one embodiment, there is a method of implanting a prosthesis between first and second bones, the method includes the steps of: resecting tissue from the first bone to expose a first resected tissue surface; resecting tissue from the second bone to expose a second resected tissue surface; attaching a datum to the second resected tissue surface; attaching to the datum a first tissue resection guide configured to guide the first tissue resection tool; further resecting tissue from the second bone with the first tissue resection tool while the first tissue resection tool is guided by the first tissue resection guide to expose a third resected tissue surface; and placing the prosthesis in contact with the first and second resected tissue surfaces to operatively connect the first and second bones. In a further embodiment, the method includes attaching a second tissue resection guide on the datum; and forming a fourth resected tissue surface by further resecting tissue from the second bone using the second tissue resection guide to guide a second tissue resection tool. In another embodiment, the third resected tissue surface is adjacent to a first side of the datum and the fourth resected tissue surface is adjacent to a second side of the datum. In another embodiment, the third resected tissue surface is generally aligned with the first side of the datum and the fourth resected tissue surface is generally aligned with the second side of the datum. In another embodiment, resecting the first bone further includes applying a second tissue resection tool to the first bone along a second tissue resection guide fixed relative to the first bone. In a further embodiment, the method includes determining the position of the second tissue resection guide based upon the position of a spacer guide attached to the second tissue resection guide. In a further embodiment, the method includes fixing the second bone relative to the first bone prior to resecting tissue from the second bone to expose the second resected tissue surface. In a further embodiment, the method includes aligning a feature of the first tissue resection tool with a feature of the first tissue resection guide to achieve a predetermined resection depth. In a further embodiment, the method includes positioning the datum on the second resected tissue surface with a distractor; and moving the first bone away from the second bone with the distractor. In a further embodiment, the method includes placing a window trial over the second resected tissue surface and third resected tissue surfaces to evaluate the size and shape of the second resected tissue surface and the third resected tissue surface. In a further embodiment, the method includes positioning a barrel cut guide against the first resected tissue surface; inserting a drill bit through an aperture in the barrel cut guide; and drilling a cavity into the first bone using the drill bit, the cavity receiving a portion of the prosthesis. In another embodiment, the first bone is the tibia and the second bone is the talus. In another embodiment, the first and second resected tissue surfaces are comprised of bone.
• In one embodiment, there is a tissue resection kit including a datum that is engagable with a tissue surface, and a first tissue resection guide having a first base releasably engagable with the datum and having a first frame fixed relative to the first base, the first frame having at least one integral first guide path sized and configured to at least partially capture and guide a first tissue resection tool relative to the first frame. In another embodiment, the first base includes a third frame fixed relative to the first base, the third frame having at least one integral third guide path sized and configured to at least partially capture and guide a third tissue resection tool relative to the first frame. In another embodiment, the at least one first guide path and a surface of the datum define a resection plane along which the tissue resection tool is guided when the first base is engaged with the datum. In a further embodiment, the tissue resection kit includes a second tissue resection guide having a second base releasably engagable with the datum and having a second frame fixed relative to the second base, the second frame having at least one integral second guide path sized and configured to at least partially capture and guide a second tissue resection tool relative to the second frame. In a further embodiment, the tissue resection kit includes a distractor releasably engagable with the datum. In a further embodiment, the tissue resection kit includes a window trial engagable with the tissue surface, the window trial having the general shape and configuration of a prosthesis and having one or more apertures for viewing the tissue surface.
• In one embodiment there is an alignment guide for attaching one or resection guides to a bone and includes an elongated member having a first end, a second end and a longitudinal axis extending between the first and second ends, a first securement proximate the first end and configured to releasably connect with the bone, an attachment block proximate the second end and having a second securement configured to releasably connect to the bone and a grip tool releasably connectable to the attachment block and generally perpendicular to the attachment block in an engaged position. In a further embodiment, the alignment guide includes an elongated alignment member attached to the elongated member and spaced laterally from and generally parallel to the longitudinal axis.
BRIEF DESCRIPTION OF THE DRAWINGS
• The foregoing summary, as well as the following detailed description of embodiments of the surgical instrumentation and methods of use for implanting a total joint replacement will be better understood when read in conjunction with the appended drawings of exemplary embodiments. It should be understood, however, that the invention is not limited to the precise arrangements and instrumentalities shown.
• In the drawings:
• FIG. 1 is a perspective view of a total joint replacement implanted between first and second bones;
• FIG. 2 is a side, partially cross-section, partially transparent side view of the implanted total joint replacement ofFIG. 1;
• FIG. 3 is a perspective view of an alignment guide in accordance with an exemplary embodiment of the present invention;
• FIG. 4 is a top view of the alignment guide shown inFIG. 3 with the positioning tool removed;
• FIG. 5 is a perspective view of a first tissue resection guide in accordance with an exemplary embodiment of the present invention;
• FIG. 6 is a perspective view of a spacer guide in accordance with an exemplary embodiment of the present invention;
• FIG. 7 is a perspective view of a second tissue resection guide in accordance with an exemplary embodiment of the present invention;
• FIG. 8 is a perspective view of the second tissue resection guide shown inFIG. 7 having a tab extension;
• FIG. 9A is a perspective view of a datum in accordance with an exemplary embodiment of the present invention;
• FIG. 9B is a top plan view of the datum shown inFIG. 9A;
• FIG. 9C is a bottom perspective front view of the datum shown inFIG. 9A;
• FIG. 10A is a perspective view of a distractor in accordance with an exemplary embodiment of the present invention shown in an insertion position and securing the datum ofFIG. 9A;
• FIG. 10B is an enlarged view of a datum lock of the distractor shown inFIG. 10A;
• FIG. 10C an enlarged top view of a paddle of the distractor shown inFIG. 10A being pivoted for demonstrative purposes;
• FIG. 10D a perspective view of the distractor shown inFIG. 10A with the upper handle removed, the ratchet pivoted downwardly and the datum shown in phantom;
• FIG. 10E is a bottom plan view of the distractor shown inFIG. 10D;
• FIG. 11A is a top plan view of a third tissue resection guide in accordance with an exemplary embodiment of the present invention;
• FIG. 11B is a bottom perspective view of the third tissue resection guide shown inFIG. 11A;
• FIG. 12A is a top plan view of a fourth tissue resection guide in accordance with an exemplary embodiment of the present invention;
• FIG. 12B is a front elevational view of the fourth tissue resection guide shown inFIG. 12A;
• FIG. 12C is a side elevational view of the fourth tissue resection guide shown inFIG. 12A;
• FIG. 13 is a perspective view of a window trial in accordance with an exemplary embodiment of the present invention;
• FIG. 14 is a perspective view of a barrel cut guide in accordance with an exemplary embodiment of the present invention;
• FIG. 15 is a perspective view of a fin cutter in accordance with an exemplary embodiment of the present invention;
• FIG. 16 is a perspective view of an incision in an ankle exposing the ankle joint;
• FIG. 17 a side elevational view of a lower leg of a patient with the alignment guide shown inFIG. 3 attached to the first bone;
• FIG. 18 is a top plan view of the alignment guide shown inFIG. 4 attached to the first bone and outlining two resection paths;
• FIG. 19 is a top plan view of the alignment guide shown inFIG. 18 with the first tissue resection guide ofFIG. 5 attached;
• FIG. 20 is a side view of the alignment guide and first tissue resection guide shown inFIG. 19 with the spacer guide ofFIG. 6 attached;
• FIG. 21 is a side view of the alignment guide shown ifFIG. 4 with the second tissue resection guide ofFIG. 8 attached to the alignment guide and the second bone;
• FIG. 22 is a side view of a space evaluator positioned between the first and second resected tissue surfaces;
• FIG. 23 is a perspective view of a sizer on top of the second resected tissue surface;
• FIG. 24 is a perspective view of the distractor shown inFIG. 10A in the insertion position;
• FIG. 25 is a perspective view of the distractor shown inFIG. 10A in the distracted position;
• FIG. 26 is a perspective view of the datum attached to the second resected tissue surface;
• FIG. 27 is a rear perspective view of a second tissue resection tool being guided by the third tissue resection guide shown inFIG. 11A;
• FIG. 28 is a side elevational view of a third tissue resection tool being guided by the third tissue resection guide shown inFIG. 11A;
• FIG. 29 is a front perspective view of the second tissue resection tool being guided by the third tissue resection guide shown inFIG. 11A;
• FIG. 30 is a perspective view of the second resected tissue surface after use of the second and third tissue resection guides shown inFIGS. 8 and 11A respectively;
• FIG. 31 is a perspective view of a fourth tissue resection tool being guided by the fourth tissue resection guide shown inFIG. 12A;
• FIG. 32 is a perspective view of the fourth tissue resection guide shown inFIG. 31 showing the resected surface created by the fourth tissue resection tool;
• FIG. 33 is a perspective view of the resected tissue surfaces after use of the second, third and fourth tissue resection guides shown inFIGS. 8, 11A and 12A respectively;
• FIG. 34 is a perspective view of the window trial shown inFIG. 13 on the resected tissue surfaces shown inFIG. 33; and
• FIG. 35 is a side elevational partially transparent view of the barrel cut guide shown inFIG. 14 and the window trial on the resected tissue surfaces shown inFIG. 34.
DETAILED DESCRIPTION
• Referring to the drawings in detail, wherein like reference numerals indicate like elements throughout, there is shown inFIGS. 1-35 surgical instrumentation and methods of use for installing a prosthesis or endoprosthesis such as, for example, a total joint replacement, generally designated10, between first andsecond bones12,14, in accordance with exemplary embodiments of the present invention.
• Referring toFIGS. 1 and 2, in one embodiment, the totaljoint replacement10 may be an ankle joint and the first andsecond bones12,14 may be the tibia and the talus respectively. Athird bone16, such as the fibula, may also contact the totaljoint replacement10. In one embodiment, the totaljoint replacement10 is a total ankle replacement such as described in U.S. Pat. No. 6,852,130 which is hereby incorporated by reference in its entirety, and is commercially known as the S.T.A.R.® or the Scandinavian Total Ankle Replacement System. However, the present invention may be used for resecting tissue surfaces in implanting any prosthetic device.
• In one an embodiment, the totaljoint replacement10 includes a firstendoprosthetic component18 that engages thefirst bone12 and a secondendoprosthetic component20 that engages thesecond bone14. In one embodiment, the secondendoprosthetic component20 includesprojections20athat are slidable into resectedcavities12ain thefirst bone12. In one embodiment, the totaljoint replacement10 further includes a middleendoprosthetic component22 that is positioned between the first and secondendoprosthetic components18,20 to provide a three piece totaljoint replacement10. The firstendoprosthetic component18 may include arib18afor preventing lateral movement of the middleendoprosthetic component22 relative to the firstendoprosthetic component18. The firstendoprosthetic component18 may also include afin18bfor extending into thesecond bone14 and stabilizing the totaljoint replacement10 relative to thesecond bone14.
• In one embodiment, the firstendoprosthetic component18 has the approximate dimensions set forth in Table 1 below.

• TABLE 1
  First Endoprosthetic Component Dimensions (in mm)

  	XX - Small	X-Small	Small	Medium	Large

  ML Dimension (Width)	28	30	34	36	38
  AP Dimension (Depth)	29	31	35	35	35

• In one embodiment the secondendoprosthetic component20 has the approximate dimensions set forth in Table 2 below.

• TABLE 2
  Second Endoprosthetic Component Dimensions (in mm)

  	X-Small	Small	Medium	Large	X-Large

  ML Dimension (Width)	30	32	32.5	33	33.5
  AP Dimension (Depth)	30	30	35	40	45

• Though further description herein of the first andsecond bones12,14 may refer to thetibia12 andtalus14 and respective anatomical directions, the instrumentation and methods disclosed herein are not limited to thetibia12,talus14,fibula16 and respective anatomical directions. The first, second andthird bones12,14,16 as disclosed herein may be any jointed bones such as the elbow, knee, shoulder or knuckle or a portion thereof that are prepared for the installation or implantation of the totaljoint replacement10 or an endoprosthetic component from any direction. The various instrumentation and methods described below may be used in different orientations depending on the application and reference to anatomical orientation as used herein is for exemplary purposes. Additionally, though aleft ankle24 andfoot26 are shown and described, the various instrumentation and methods described below may be used in conjunction with and/or oriented for use with the right ankle (not shown or illustrated) or another applicable joint.
• Alignment Guide
• Referring to the embodiment ofFIG. 3, analignment guide30 may be used to assist in implanting the totaljoint replacement10. Thealignment guide30 may be used to orient one or more instruments, such as first and second tissue resection guides66,90 relative to thefirst bone12 as described further below. Thealignment guide30 includes afirst end30aand asecond end30d. Thealignment guide30 may include afirst body30bproximate thefirst end30aand asecond body30cproximate thesecond end30d. In one embodiment, the first andsecond bodies30b,30care each comprised of one or more generally cylindrical elongated rods. However, the first andsecond bodies30b,30cmay have any suitable configuration and shape such as a tube that encloses a leg84 (seeFIG. 17). Thealignment guide30 may include apin receiver32. Thepin receiver32 may be proximate thefirst end30a. Thepin receiver32 may include aslot32aand/or a plurality of apertures (not shown) for receiving one ormore pins34 at a plurality of lateral positions. Thepin receiver32 may also move up and down thepin34 as described further below. In one embodiment, thepin receiver32 includes afirst securement36 such as a manually adjustable screw that secures thepin receiver32 to thepin34 and prevents thealignment guide30 from moving relative to thepin32. In one embodiment, thepin32 is a self drilling pin and is approximately 3.2 mm in diameter. However, thepin32 may have any suitable configuration and size.
• Anattachment block38 may be connected to thesecond body30cof thealignment guide30. Theattachment block38 may be configured to secure thesecond end30dof thealignment guide30 to thefirst bone12. Theattachment block38 may serve as a datum for one or more resections as described further below. In one embodiment, thesecond body30cof thealignment guide30 is telescopically connected to thefirst body30bof thealignment guide30. In one an embodiment, thesecond body30cof thealignment guide30 may be fixed with respect to thefirst body30aof thealignment guide30 through use of asecond securement40. Thesecond securement40 may be a manually adjustable screw. Alternatively, the length of thealignment guide30 may be fixed and theattachment block38 may adjust relative to thealignment guide30. Theattachment block38 may include one ormore apertures38aeach for receiving apin42. In one embodiment, thepins42 may be inserted through theattachment block38 at an angle such as an oblique angle as shown inFIG. 3. Thepins42 may be comprised of Kirschner or K-wire. In one embodiment the pins are approximately 2.4 mm in diameter. However, thepins42 may have any suitable configuration and diameter. Though the same reference number is used for theadditional pins42 described below, theadditional pins42 described below may be generally identical or different than thepins42 used to secure theattachment block38 relative to thefirst bone12.
• Theattachment block38 may include one ormore space adjustments48 that may be threadably received in arespective aperture38b. One ormore space adjustments48, such as a manually adjustable screw, may be provided to stabilize theattachment block38 relative to thefirst bone12. Thespace adjustment48 may alternatively or in addition help to position theattachment block38 a distance normal to thefirst bone12 by extending below theattachment block38 an adjustable distance.
• Analignment rod44 is optionally spaced laterally from thealignment guide30 and is configured to be positionable alongside thefirst bone12. In one embodiment, thealignment rod44 is generally parallel with thefirst body30bof thealignment guide30. An X-ray image intensifier, such as a C-arm or other imaging device (not shown), may be used to align thealignment rod44 generally parallel with afeature12fof thefirst bone12. In one embodiment thealignment rod44 is aligned to be generally parallel to the longitudinal axis of thefirst bone12. Thealignment rod44 may be attached to thefirst body30bof thealignment guide30 by an arm44a. A grip member orpositioning tool46 such as a T-grip may releaseably connect or attach to theattachment block38 to assist in orienting theattachment block38 relative to thefirst bone12. In one embodiment, thegrip member46 is generally perpendicular to a longitudinal axis of thealignment guide30 in an engaged position.
• Referring to the embodiment ofFIG. 4, theattachment block38 may include afirst positioning block50. In one embodiment, theattachment block38 is fixed relative to thefirst bone12 and thefirst positioning block50 is movable relative to theattachment block38. In one embodiment, thefirst positioning block50 is adjustable relative to theattachment block38 in first and second directions, e.g. superior and inferior anatomical directions, that are generally parallel to the length of thealignment guide30. Theattachment block38 may include a firstkey adjustment52 that may be configured to set the distance between theattachment block38 and thefirst positioning block50. In one embodiment, the firstkey adjustment52 engages afirst rack54 that extends from thefirst positioning block50 and into theattachment block38. Alternatively, thefirst rack54 may extend from theattachment block38 and extend into thefirst positioning block50. The firstkey adjustment52 may be turned using a tool such as a gear key or screw driver (not shown). Alternatively, thekey adjustment52 may be a manually adjustable screw. Theattachment block38 optionally includes afirst position lock56 that releasably fixes the distance between theattachment block38 and thefirst positioning block50. In one embodiment, thefirst position lock56 is a set screw. However, thefirst position lock56 may be any locking device such as projection extending into the firstkey adjustment52.
• Thefirst positioning block50 may include one ormore pin apertures50aeach for receiving apin42 that extends into thefirst bone12. In one embodiment, thefirst positioning block50 includes a first plurality ofpin apertures50a. The first plurality ofapertures50amay be provided to move thefirst positioning block50 a predetermined distance with respect to the one ormore pins42 for measuring additional resection of thefirst bone12 if necessary as described further below. The first plurality ofpin apertures50amay include afirst pin aperture50bspaced a predetermined distance from asecond pin aperture50cin a direction generally parallel to the length of thealignment guide30, e.g. in an inferior anatomical direction. In one embodiment, athird pin aperture50dis spaced a predetermined distance from thesecond pin aperture50cin a direction generally parallel to the length of thealignment guide30, e.g. in an inferior anatomical direction. The first plurality ofpin apertures50amay includeadditional apertures50a.
• In one embodiment, the first andsecond pin apertures50b,50care spaced from each other a distance equal to the space between the second andthird pin apertures50c,50d. In one embodiment, thefirst positioning block50 includes a second plurality ofpin apertures50a′. The second plurality ofpin apertures50a′ may include first, second andthird pin apertures50b′,50c′,50d′ that each correspond in placement along the first positioning block to respective first, second andthird pin apertures50b,50c,50dof the first plurality ofpin apertures50a. In one embodiment, the predetermined intervals betweenadjacent pin apertures50a,50a′ are each generally 0.5 mm to generally 5 mm such that the positioning block may be moved relative to thepins42 the predetermined distance and 0.5 mm to 5 mm of additional tissue can be resected from the end of thefirst bone12 in one or more additional resections. In one embodiment, the predetermined intervals betweenadjacent pin apertures50aare approximately 2 mm. Alternatively, thefirst positioning block50 is movable relative to thepins42 such as having expanding and contracting ends (not shown) or thepositioning block50 may include a slot (not shown) that releasably engages one ormore pins42 to adjust the position of thefirst positioning block50 relative to thefirst bone12.
• Theattachment block38 may include asecond positioning block58 that is movable relative to the portion of theattachment block38 fixed relative to thefirst bone12. In one embodiment, thesecond positioning block58 is movable relative to thefirst positioning block50. Alternatively, the first and second positioning blocks50,58 are integral. Thesecond positioning block58 may be adjustable relative to theattachment block38 in third and fourth directions, e.g. lateral and medial anatomical directions, that may be generally perpendicular to the length of thealignment guide30. Thefirst positioning block50 may include a secondkey adjustment60 that is used to adjust the position of thesecond positioning block58 relative to theattachment block38.
• In one embodiment, the secondkey adjustment60 engages a second rack (not visible) that extends along thesecond positioning block58. The secondkey adjustment60 may be turned using a tool such as a gear key or screw driver (not shown) to move thesecond positioning block58 relative to thefirst positioning block50. Alternatively, the secondkey adjustment60 may be a manually adjustable screw. The second rack may be alternatively attached to thefirst positioning block50. Thefirst positioning block50 optionally includes asecond position lock62 that releasably fixes the lateral alignment between thesecond positioning block58 and thefirst positioning block50 to prevent unintentional movement between the first and second positioning blocks50,58. In one embodiment, thesecond position lock62 is a set screw. However, thesecond position lock62 may be any locking device such as projection extending into the secondkey adjustment60.
• In one embodiment, thesecond positioning block58 includes first andsecond grooves58a,58bon opposing lateral sides of thesecond positioning block58. The first andsecond grooves58a,58bmay be receive and mate with thepositioning tool46 and additional instrumentation as described below to prevent movement between thesecond positioning block58 and thepositioning tool46 or additional instrumentation. Thepositioning tool46 may be used to assist in positioning theattachment block38 relative to thefirst bone12. Thesecond positioning block58 may include a threadedaperture58dfor securing to additional instrumentation as described below. Thesecond positioning block58 may include one ormore apertures58ceach for viewing thefirst bone12 during positioning of theattachment block38 using a C-arm or other imaging device. In one embodiment, theapertures58cshow up on the imaging device as circular if theattachment block38 is correctly positioned with respect to thefirst bone12 and oval shaped if theattachment block38 is misaligned with respect to thefirst bone12. Theapertures58cmay generally align with where thecavities12a(FIG. 1) are to be drilled.
• First Tissue Resection Guide
• Referring to the embodiment ofFIG. 5, a firsttissue resection guide66 may be provided for resecting thefirst bone12 and exposing a first resectedtissue surface100 as described below. In one embodiment, the first resectedtissue surface100 is bone tissue. In alternative embodiments, the first resectedtissue surface100 is another tissue such as cartilage and/or a combination of different tissue. The firsttissue resection guide66 may removably attach to thesecond positioning block58. The firsttissue resection guide66 may include afastener68 that releasably attaches the first tissue resection guide66 to theaperture58d(seeFIG. 4) in thesecond positioning block58. In one embodiment, thefastener68 is an Allen screw. However, thefastener68 may be any attachment device such as a snap or magnet. The firsttissue resection guide66 may include first andsecond projections66a,66b(seeFIGS. 7 and 8 for thesecond projection66b) that may be received in the first andsecond grooves58a,58b, respectively of thesecond positioning block58. The first andsecond projections66a,66bmay help to prevent the first tissue resection guide66 from moving or rotating with respect to thesecond positioning block58.
• In one embodiment, the firsttissue resection guide66 includes afirst guide path70 for resecting thefirst bone12. Thefirst guide path70 may be aslot70asuch that the guide path captures a tissue resection tool such as a blade (not shown). Theslot70amay be generally rectangular and oriented such the blade is captured and guided in a direction generally perpendicular to the length of thefirst bone12, e.g. the medial and lateral anatomical directions. The blade may be guided at a slight angle relative the longitudinal axis of thefirst bone12 as described further below. Anend surface58eof the second positioning block58 (seeFIG. 4) and thefirst guide path70 may define a resection plane. In an alternative embodiment, thefirst guide path70 is open toward one lateral side (not shown) such that the first tissue resection tool is guided on only one side. Theslot70amay includepin apertures70b,70cat the ends of theslot70afor inserting pins42 (not shown). Thepins42 may be used to protect features of the first andthird bones12,16 such as medial andlateral malleolus12e,16a. Thefirst bone12 may be cut until the first tissue resection tool contacts thepins42. Thepins42 may prevent over or notched cuts in thefirst bone12.
• In one embodiment, the firsttissue resection guide66 includes asecond guide path72. Thesecond guide path72 is optionally provided to guide the tissue resection tool for a second resection. Thesecond guide path72 may be generally perpendicular to theblade guard70. In one embodiment, thesecond guide path72 is open toward one lateral side and defines only one side of a resection plane. In an alternative embodiment, thesecond guide path72 is closed similar to thefirst guide path70 to capture the blade on two opposing sides (not shown).
• The firsttissue resection guide66 may includeindicia74 indicating which foot (i.e. left or right)26 the firsttissue resection guide66 is to be used on. Theindicia74 may also, or in the alternative, indicate a size of the firsttissue resection guide66. The firsttissue resection guide66 may include anindent66con each lateral side of the first tissue resection guide66 to aide in gripping the firsttissue resection guide66 during insertion and removal from thesecond positing block58.
• Spacer Guide
• Referring to the embodiment ofFIG. 6, aspacer guide78 may be provided for positioning the first and second positioning blocks50,58 relative to theattachment block38 and afeature12cof the first bone12 (FIGS. 17-20). Because theattachment block38 may be attached to thefirst bone12 proximate thefeature12c, thespacer guide78 may be used to adjust the first and second positioning blocks50,58 and position theend surface58eof thesecond positioning block58 in the appropriate position. Thespacer guide78 may be used in conjunction with a C-arm or other imaging device to position theend surface58eof thesecond positioning block58 a predetermined distance from thefeature12cof thefirst bone12. In one embodiment, thefeature12cis a superior aspect of the tibial plafond of the tibia (seeFIG. 20).
• Thespacer guide78 may include anextension arm80 extending downwardly from abody78aof thespacer guide78. In one embodiment, theextension arm80 is curved inwardly toward thebody78aduring use of thespacer guide78 such that theextension arm80 curves around the outside of the patient's anatomy,e.g. leg84. However, theextension arm80 may be straight or outwardly curved and have any shape.
• Thespacer guide78 may include a projection or mount82 extending downwardly from thebody78aand spaced laterally from theextension arm80. The mount82 may be configured to snugly fit within theslot70aof thefirst guide path70. Thebody78aoptionally includes agrip78bsuch as an aperture extending through thebody78ato aid in grasping thespacer guide78 between two fingers. Theextension arm80, thebody78aand the mount82 may be generally planar and parallel to one another.
• Theextension arm78 may include one ormore projections86 extending from theextension arm80 and spaced a predetermined distance from the mount82 in order to measure the distance from theslot70aof thefirst guide path70. In one embodiment, theprojections86 are pins. Theprojections86 may extend through theextension arm80 such that theprojections86 extend from either side of theextension arm78 allowing thespacer guide78 to be used on either lateral side of theankle24. In one embodiment, the predetermined distance, i.e. the length of each projection from each side of theextension arm80 is approximately 1 mm to approximately 10 mm. In one embodiment, theprojections86 extend approximately 5 mm from theextension arm80. In one embodiment, there are 6-8projections86. However, their may be any number ofprojections86 having any configuration. Theprojections86 may each include a plurality of distance markings such as ribs or includeprojections86 having different lengths so that multiple predetermined distances can be ascertained using asingle spacer guide78. Alternatively, theextension arm80 and/orbody78amay be curved or spaced from the mount82 in the normal direction from thebody78asuch that theextension arm80 is spaced from the mount82 the predetermined distance in the normal direction from thebody78awithout the need forprojections86. Theextension arm80 may alternatively be adjustable relative to the mount82 such that the predetermined distance may be altered by adjusting a feature or adjusting the orientation of theextension arm80 relative to thebody78a. Theextension arm80 may alternatively have a thickness equal to the predetermined distance from the mount82 for measuring the predetermined distance.
• Second Tissue Resection Guide
• Referring to the embodiment ofFIG. 7, a secondtissue resection guide90 may be provided to resect tissue from thesecond bone14 using, for example, the first tissue resection tool (not shown). The secondtissue resection guide90 may be mounted to thesecond bone14 relative to the placement of theattachment block38. In one embodiment, the secondtissue resection guide90 is configured to mount over the firsttissue resection guide66 such that thesecond bone14 is resected relative to the first resected tissue surface100 (FIG. 21). The secondtissue resection guide90 may include amount92 for securing the second tissue resection guide90 to firsttissue resection guide66. Themount92 may be configured to receive thefastener68 used to secure the first tissue resection guide66 to thesecond positioning block58.
• In one embodiment, atab98 extends downwardly from the second tissue resection guide90 to contact thefirst bone12. Thetab98 may contact the first resectedtissue surface100 of thefirst bone12 to help stabilize the second tissue resection guide90 relative to thefirst bone12. In an alternative embodiment of the secondtissue resection guide90, the secondtissue resection guide90 includes an integral component that is shaped and configured similar to the firsttissue resection guide66 such that after using the firsttissue resection guide90, the firsttissue resection guide66 is removed from thesecond positioning block58 and the second tissue resection guide90 with the integral firsttissue resection guide66 is mountable directly to thesecond positioning block58.
• The secondtissue resection guide90 may include aguide path94 for guiding and capturing a tissue resection tool such as the first tissue resection tool, e.g. a blade (not shown). The secondtissue resection guide90 may be configured to guide a tissue resection tool that is different or the same from the tissue resection tool used with the firsttissue resection guide66. The first tissue resection tool may be used with the second tissue resection guide90 to expose a resected or second surface104 (seeFIG. 22) of thesecond bone14. In one embodiment, the second resectedtissue surface104 is bone. In alternative embodiments, the second resectedtissue surface104 is another tissue such as cartilage and/or a combination of different tissue.
• In one embodiment, the secondtissue resection guide90 may be configured such that one side of theguide path94 is generally flush or parallel with anouter end66d(FIG. 5) of the firsttissue resection guide66 such that theguide path94 and theouter end66dof the firsttissue resection guide66 define a resection plane. In one embodiment, the first and second tissue resection guides66,90 are configured so that when engaged with each other, theguide path94 is spaced from theslot70aof thefirst guide path70 a predetermined distance. In one embodiment, the predetermined distance between theguide path94 and theslot70aof thefirst guide path70 is approximately 1 mm to approximately 8 mm. In one embodiment, the predetermined distance between theguide path94 and theslot70aof thefirst guide path70 is approximately 4 mm. The predetermined distance between theguide path94 and theslot70aof thefirst guide path70 may be generally equal to the thickness of thefirst guide path70. Theguide path94 may include one ormore recesses94aeach for receiving pins (not shown) to adjust the length of theguide path94 and limit the amount that thesecond bone14 is resected.
• The secondtissue resection guide90 may include one or more pin mounts96. The pin mounts96 may be used to supportpins42 that secure the second tissue resection guide90 to the second bone14 (seeFIG. 20). In such an embodiment, thesecond bone14 is held relative to theattachment block38. In an alternative embodiment, theguide path94 may include a generally open side such that the first tissue resection tool is only supported or guided on one side.
• Referring to the embodiment ofFIG. 8, a second tissue resection guide90′ may include atab extension102 that extends further downwardly from thetab98′ such that thetab extension102 is sandwiched between and contacts both the first resectedtissue surface100 and the not yet resectedsecond bone14 when initially in place on the first tissue resection guide66 (seeFIG. 21). In one embodiment, the secondtissue resection guide90 is used for normal to tight joints and the second tissue resection guide90′ with thetab extension102′ is used for lax joints. In one embodiment, thetab extensions102 are approximately 1 mm to approximately 10 mm thick depending on how lax the joint is. In one embodiment, the second tissue resection guides94′ are provided withtab extensions102 in approximately 2 mm, 4 mm or 6 mm thicknesses. In one embodiment, thetab extension102 is generally flat and bulbous shaped such that thetab extension102 sufficiently contacts the first resectedtissue surface100. However, thetab extension102 may be any shape such as rectangular, triangular or square.
• Datum
• Referring to the embodiment ofFIG. 9A-9C, adatum108 may be provided for releasably engaging at least one tissue resection guide as described further below. Thedatum108 may provide a fixed reference point on thesecond bone14 to make one or more resections to thesecond bone14 relative or in reference to thedatum108. Thedatum108 may also include one or more surfaces and/or one or more edges that are aligned with a feature of the tissue resection guide (e.g. a guide path) to form a resection plane an example of which is described in more detail below. Thedatum108 may assist in directly guiding and supporting the various resection tools. In one embodiment, thedatum108 allows for multiple resections adjacent to the datum using two or more resections guides while only attaching one device to thesecond bone14, e.g, thedatum108.
• In one embodiment, thedatum108 is a parallelepiped. However, thedatum108 may be generally shaped and sized such that resections guided at least partially by thedatum108 conform to an upper interior (not shown) of the firstendoprosthetic component18. Though thedatum108 may have planar sides, thedatum108 may alternatively have one or more curved or stepped sides. The shape of thedatum108 may generally correspond to the shape required to fully resect an end of thesecond bone14 using a predetermined number of generally planar resection planes. In one embodiment, thedatum108 includes four generally planar resection planes. The use of thedatum108 may help to minimize the amount of tissue that is resected from thesecond bone14 by reducing recutting, reshaping and over resection caused by free-hand cutting, miss-measurements, measuring off of other cuts and/or misplacement of resection guides.
• In one embodiment, thedatum108 includes first, second, third and forth sides108a,108b,108c,108e. In one embodiment, a bottom108dof thedatum108 is sized and configured to contact a tissue surface (e.g., the second resected tissue surface104). In one embodiment, thedatum108 has at least one side (e.g., one ofsides108a,108b,108c,108e) that is generally in-line or parallel to a resected tissue surface such as a tissue surface (e.g. one ofsurfaces104a,104b,104c,104d) such as in a manner described below after the resections to thesecond bone14 are made. The first second andthird sides108a,108b,108cof thedatum108 may each be angled inwardly such that they each extend at an acute angle from the base or bottom108d(FIG. 9C). In one embodiment, the top of thefourth side108emay extend outwardly such that thefourth side108eextends at an obtuse angle from the bottom108d. The second andthird sides108b,108cmay be angled inwardly toward each other proximate thefirst side108aabout an axis perpendicular to the bottom108dsuch that the second andthird sides108b,108ceach extend from thefourth side108eat an acute angle measured on a plane parallel to the bottom108d. In one embodiment, thefirst side108ais generally ninety degrees from thefourth side108eas measured on a plane parallel to the bottom108d. In one embodiment, thethird side108cis angled inwardly proximate thefirst side108aabout an axis perpendicular to the bottom108d. An angle of inclination defined by the intersection of thethird side108cand a plane normal to the bottom108dmay be greater than an angle of inclination defined by the intersection of thesecond side108band a plane normal to the bottom108das illustrated inFIG. 9B. At least oneside108a,108b,108c,108eof thedatum108 may be sized and configured to at least partially contact and guide a tissue resection tool as described further below. In one embodiment, the first, second, third andfourth sides108a,108b,108c,108eof thedatum108 are posterior, medial, lateral and anterior sides respectively.
• Thedatum108 optionally includes adatum mount110. Thedatum mount110 may include a threadedaperture110a. Thedatum mount110 may include a recessedsection110bfor further engaging at least one tissue resection guide and for receiving adatum securement122 of a distractor120 (see, e.g.,FIG. 10D). The recessedsection110bmay have a generally cube-like shape. However, the recessedsection110bmay have any shape such as pyramid, spherical-like or approximations thereof.
• Thedatum108 may include at least onepin aperture112 for receiving apin42 or ashoulder pin114. Thepin aperture112 may include ashoulder112ato limit depth of the shoulder pins114 (FIG. 25). Thepins114 may be received at an angle relative to the bottom108dsuch that thepins114 extend upwardly from thedatum108 toward thefourth side108eof thedatum108. In one embodiment, thedatum114 includes a pair ofpin apertures120 spaced on medial/lateral sides of thedatum mount110 such that when pinned to the second resectedtissue surface104, thedatum108 does not rotate relative to the second resectedtissue surface104.
• Thedatum108 may includeindicia116 such as a colored polymeric plug that indicates the size and/or shape of thedatum108. In one embodiment, theindicia116 is positioned on a non-tissue contacting surface. In one embodiment, theindicia116 is located on a surface opposite a surface that is a tissue contacting surface such as, for example, the bottom108 in the embodiment illustrated inFIG. 9C.
• Distractor
• FIGS. 10A-10C illustrates one embodiment of adistractor120. Thedistractor120 may be sized and configured to place, orient and/or insert thedatum108 onto a tissue surface, e.g. the second resectedtissue surface104. Thedistractor120 may additionally be used to distract or separate the first resectedtissue surface100 from the second resectedtissue surface104 and provide sufficient space to place thedatum108 and attach resection guides thereto. Thedistractor120 may include ahandle129 and adatum securement122 and atissue engaging portion134 attached to thehandle129. At least a portion of thehandle129 may extend along ahandle axis120a. In one embodiment, thehandle129 includes a first orlower handle130 and a second orupper handle136.
• Thedatum securement122 may be configured to releasably engage thedatum108. Thedatum securement122 may releasably engage thedatum108 in an insertion position (FIG. 10A) and or during positioning of thedatum108 on the second resected tissue surface104 (FIGS. 24 and 25). In one embodiment, thedatum securement122 includes at least oneprojection122a. Theprojection122amay be oriented to project from thedatum securement122 at an angle relative to theaxis120a.Projections122amay be sized, configured and oriented to extend into thedatum mount110 of thedatum108. However, thedatum securement122 may include any suitable device for releasably engaging or securing thedatum108 such as a threaded attachment or a magnet.
• In one embodiment, thedistractor120 includes anabutment member124 proximate thedatum securement122. Theabutment member124 may be fork shaped such that thedatum108 is engaged byends124aon either sides of theprojection122ato provide at least three points of contact with thedatum108 such that thedatum108 is securely held and does not move relative to thedistractor120. However, theabutment member124 may have any suitable shape including one or more surface or point of contact end124a. The ends124aof theabutment member124 may be slanted or otherwise shaped and configured to be generally parallel to thefourth side108eof thedatum108. Theabutment member124 may be slidable relative to alower handle130 extending from thedatum securement122. Theabutment member124 may be slid toward thedatum projection122ato pinch thedatum108 between thedatum projection122aand theabutment member124. Alternatively, thedatum projection122amay be moved relative to theabutment member124. Theabutment member124 may have a recessed or stepped distalbottom surface124b(FIG. 10D) such that theabutment member124 is generally flush or parallel with thebottom surface108dof thedatum108. The remainder of theabutment member124 may be thicker than thedistal bottom surface124bto strengthen theabutment member124.
• In one embodiment, theabutment member124 includes adatum lock126 configured to move thedatum datum securement124 from a secured position to a released position. Thedatum lock126 may include arotatable nut126athat threadably engages a shaft124c. In one embodiment, theshaft126cis integral with theabutment member124. In an alternative embodiment, the shaft124cis integral with thenut126aand the threaded shaft124cextends into theabutment member124. Thedatum securement122 may include a stop128 (FIG. 10E) that engages with theabutment member124 when thedatum108 has been secured with thedistractor120 to prevent over extending theabutment member124 and exerting a pinching force on thedatum108 that may damage thedatum projection122aand/or thedatum108.
• In one embodiment, thelower handle130 extends from thedatum securement122. The lower handle may be generally aligned with thehandle axis120a. Thelower handle130 may include agrip132. In one embodiment, thegrip132 is integral with thelower handle128 and may include a plurality ofindentations132a. Alternatively, thegrip132 may be a separate component and/or have a textured surface.
• Thedistractor122 may include atissue engaging portion134. In one embodiment, theupper handle136 extends from thetissue engaging portion134. Theupper handle136 may include adistal portion136eattached to thetissue engaging portion134 and agrip portion136fattached to thedistal portion136e. Thegrip portion136fof theupper handle136 may include a plurality ofgrips136a. In one embodiment, thegrips136ainclude a plurality indentations136aseparated by columns that are oriented perpendicular to alongitudinal axis120aof thehandle130. Thegrips136amay have any suitable shape such as scalloped or cylindrical.
• Thedistal portion136eand thegrip portion136fmay be joined at an inflection orpivot point136d. In one embodiment, thegrip portion136fof theupper handle136 extends from theinflection point136fat an angle relative to thelower handle130 as shown inFIG. 10A. Thedistal portion136emay be generally parallel with theaxis120ain an insertion position. Theupper handle136 may extend from the inflection point between a range of angles that allows a user to grip the upper andlower handles136,130 with one hand while allowing sufficient movement of thetissue engaging portion134 relative to thedatum108. In one embodiment, theupper handle136 may extend from the inflection point at approximately 30 degrees as shown inFIG. 10A. Theupper handle136 may be convexly shaped away from thelower handle130 so as to make theupper handle136 closer to being parallel with thelower handle130 to make gripping of thedistractor120 easier. In one embodiment, theupper handle136 is pivotable with respect to thelower handle130 such that squeezing the upper andlower handles130,136 together spaces thetissue engaging portion134 from thedatum securement122. In one embodiment, thelower handle130 is releasably attached to theupper handle136. Thelower handle130 may include asocket130athat rotatably supports an axle (not visible) on theupper handle136. In one embodiment, thesocket130ais partially open, e.g. C-shaped, such that theupper handle136 is removable proximally from thelower handle130. The axle of theupper handle136 may be spring biased within thesocket130aby afirst biasing member138. Thefirst biasing member138 may be a cantilever spring. In an alternative embodiment, the lower andupper handles130,136 have a scissor orientation such that thelower handle130 extends from thetissue engaging portion134 and theupper handle136 extends from thedatum securement122.
• In one embodiment, thetissue engaging portion134 includes apaddle140 configured to engage the first resectedtissue surface100. Thepaddle140 may be pivotably attached to theupper handle136 such that thepaddle140 remains at a generally constant angle during separation of the first andsecond bones12,14 to maintain contact with the first resectedtissue surface100 during distraction of the first andsecond bones12,14. In one embodiment, thepaddle140 may remain generally parallel to the second resectedtissue surface100 as thetissue engaging portion134 is pivoted from thedatum securement122. Thepaddle140 andupper handle136 may be pivotable about axes that are generally parallel to one another.
• In one embodiment, a portion of thepaddle140 may be at least partially narrower than the space between thepin apertures112 of thedatum108 such that thepaddle140 can be slid out between the shoulder pins114 after securing thedatum108 to the second resectedtissue surface104. In one embodiment, thepaddle140 includes anenlarged end140a. In one embodiment, theenlarged end140ais wider than the space between thepin apertures112 of thedatum108 to provide, for example, increased surface area for contacting the first resectedtissue surface100 and keeping surrounding tissue clear from the second resectedtissue surface104. Thepaddle140 may also be enlarged toward theenlarged end140ato provide more weight proximal to the axis of rotation such thatpaddle140 tends to lay parallel with the extendingupper handle136 when released. Thepaddle140 may be partially recessed within the extendingupper handle136 such that thepaddle140 is nearly flush and/or parallel with theupper handle136 in the insertion position. In one embodiment, thepaddle140 may include one ormore ribs140c(FIG. 10C) that extends downwardly from thepaddle140 into arecess136bof the upper handle in the insertion position. In one embodiment, theribs140cmay be provided to generally stiffen and minimize bending of theenlarged end140awhile allowing thepaddle140 to be generally flush or parallel with theupper handle136.
• The proximal ends136c,130bof the upper andlower handles136,130 may be connected by aratchet142 such thatdistractor120 can be held in a distracted position (FIG. 25) without a user having to continually squeeze thehandles130,136. Theratchet142 may include a plurality ofteeth142athat engage a projection (not shown) of theupper handle136 and prevent theupper handle136 from returning to the insertion position. Theratchet140 may be spring biased via asecond biasing member144. In one embodiment, thesecond biasing member144 is a cantilever spring secured to thelower handle130.
• In one embodiment, theupper handle136 may be removed from thelower handle130 if distraction of the first and second resected tissue surfaces100,104 is not necessary (e.g. for a lax joint) and/or to disengage and theratchet142 such that theupper handle136 is freely pivotable relative to thelower handle130. Theratchet142 may be disengaged from theupper handle136 by pulling back on the ratchet, removing theupper handle136 from thelower handle130 and pivoting theratchet142 downwardly so that it lies on the lower handle130 (FIG. 10D). Once theratchet142 has been disengaged from theupper handle136, theupper handle136 re-attached to thelower handle130 such that thedistractor120 functions without theratchet142. Theratchet142 optionally includes agrip142bthat extends upwardly past or through theupper handle136 such that theratchet142 may be gripped and pulled rearwardly or proximally to disengage theratchet140 from theupper handle136. In one embodiment, thegrip142bis an indent. Thegrip142bof theratchet142 may receive a portion of thedatum lock126 in the folded position (FIG. 10D) such that theratchet142bmay lie flat against thelower handle130. Alternatively, theratchet142 may have a shorter length than shown such that thedatum lock126 may be used while theratchet142 lies against thelower handle portion130.
• Third Tissue Resection Guide
• Referring to the embodiment ofFIGS. 11A-11B, a thirdtissue resection guide146 may be provided for resecting, for example, thesecond bone14. The thirdtissue resection guide146 may be sized and configured to releasably attach to thetop side108fof thedatum108 and guide one or more tissue resection tools. In one embodiment, the thirdtissue resection guide146 is an anterior/posterior tissue resection guide for resecting thesecond bone14 anterior and posterior to thedatum108. The thirdtissue resection guide146 may be used to resect thesecond bone14 in any direction relative to thedatum108. The thirdtissue resection guide146 includes a base148 that releasably engages thedatum108. The base148 may include adatum projection148athat extends from thebase148 and fits within the recessedsection108dof thedatum108 to prevent the thirdtissue resection guide146 from rotating with respect to thedatum108. Thedatum projection148amay include anaperture148bfor receiving afastener150 configured to secure the thirdtissue resection guide146 to thedatum108. In one embodiment, thefastener150 is an Allen screw. However, thefastener150 may be any securement device such as a snap. The base148 may includepin apertures148cfor fitting over the shoulder pins114 extending from thedatum108. Thepin apertures148cmay be angled away from the base148 such that thepins42 remain out of the way and provide a more stable support from thesecond bone14.
• The thirdtissue resection guide146 may include afirst frame152 attached to thebase148. In one embodiment, thefirst frame152 is integral with thebase148. In one embodiment, thefirst frame152 is adjacent to thefourth side108eof thedatum108 when the thirdtissue resection guide146 is engaged with the datum108 (e.g.,FIG. 28).
• Thefirst frame152 may include or define one or more guide paths (e.g., first andsecond guide paths154,156). In one embodiment, guidepaths154,156 are apertures within a frame (e.g., the first frame152). In one embodiment, theguide paths154,156 are elongate apertures. For example, in one embodiment, theguide paths154,156 are defined by aninner wall152aof a frame (e.g., the first frame152). In the embodiment ofFIG. 11A, for example, theguide paths154,156 are defined by a continuousinner wall152a. In one embodiment, guide paths such asguide path166 is defined a discontinuousinner wall160a. Also as illustrated inFIG. 11A, guide paths, such asguide paths154,156 may extend through a frame (e.g., first frame152) such that there is no restriction to a correctly sized tool passing though such a guide path from one side of a frame to another. As will be illustrated in more detail below, a guide path (such asguide path180cofFIG. 12B may include a closedupper surface180ato restrict the movement of a resection tool when the resection tool is being guided in theguide path180c.
• In one embodiment, the first andsecond guide paths154,156 each include anenlarged end154a,156a. The enlarged ends154a,156a(e.g., of adjacent guide paths) are optionally on opposite lateral sides of thefirst frame152. In one embodiment, theenlarged end154aoffirst guide path154 is proximate the lateral side of theankle24 and theenlarged end156 of thesecond guide path156 is proximate the medial side of theankle24 during use as shown in the embodiment ofFIGS. 28 and 29 such that a resection tool (e.g. a milling bit)168 spinning clockwise tends to pull away from the base148 caused by the contact between the resection tool and thesecond bone14. In one embodiment, the orientation of the enlarged ends145a,156amay be reversed (not shown) for aresection tool168 spinning in a counterclockwise direction. The first andsecond guide paths154,156 may be generally parallel to each other. The first andsecond guide paths154,156 may be generally parallel to the fourth side114eof the datum. In one embodiment, thecenters154b,156bof the first andsecond guide paths154,156 are spaced a distance D.sub.1 that is less than a diameter D.sub.2 of theenlarged end154aof thefirst guide path154. In one embodiment, the spacing of theguide paths154,156 allows for an overlapping resection path as discussed further below. Thecenter154bof thefirst guide path154 may be spaced from thefourth side108eof thedatum108 a distance approximately equal to half of the diameter D.sub.2 of theenlarged end154aof thefirst guide path154 such that the resection path nearly abuts thefourth side108eof thedatum108. Thefirst frame152 may include one or more pin supports158 each configured to receive a pin42 (seeFIG. 27) for further stabilizing the thirdtissue resection guide146 relative to thesecond bone14.
• In one embodiment, each of the first andsecond guide paths154,156 are configured to receive and guide a tissue resection tool such as a secondtissue resection tool168. (SeeFIG. 27). The secondtissue resection tool168 may be a milling bit though the secondtissue resection tool168 may be any tissue resection tool such as a blade. The secondtissue resection tool168 may include anenlarged cutting head168a. In one embodiment, the cuttinghead168afits through the enlarged ends154a,156aof the first andsecond guide paths154,156 respectively but does not fit through the remainder of the first andsecond guide paths154,156. The remainder of the first andsecond guide paths154,156 may be narrowed from the enlarged ends154a,156ato more closely fit another feature of a resection tool such as the diameter of ashaft168bof the secondtissue resection tool168.
• In one embodiment, the secondtissue resection tool168 includes astop168cthat abuts a top surface of thefirst frame152 to limit the distance the secondtissue resection tool168 extends through thefirst frame152 as shown inFIG. 28. In one embodiment, thestop168cis rotatable with respect to theshaft168bthereby significantly reducing the amount that thestop168crotates against and wears the top surface of thefirst frame152.
• The thirdtissue resection guide146 is sized and configured to guide the secondtissue resection tool168 proximate thefourth side108eof thedatum108. In one embodiment, thirdtissue resection guide146 is sized and configured to guide the secondtissue resection tool168 to resect thesecond bone14 and to further expose the second resectedtissue surface104 in a direction away from thefourth side108eof thedatum108. In one embodiment, the further exposed second resectedtissue surface104 is a second resectedtissue surface expansion104b(best illustrated inFIGS. 30 and 33). In one embodiment, the second resectedtissue surface104 is expanded in the anterior direction. The fourthresected tissue surface104bmay be generally normal to thefourth side108eof thedatum108. In one embodiment, eachguide path154,156 is used to expose the fourth resectedtissue surface104b. (SeeFIGS. 28 and 29). The first andsecond guide paths154,156 may be configured to allow for overlapping resections by the secondtissue resection tool168 such that the first andsecond guide paths154,156 create a planar fourth resectedtissue surface104b(SeeFIGS. 28 and 30). Alternatively, thefirst frame152 includes asingle guide path154 or more than twoguide paths154,156.
• With continued reference to the embodiment shown inFIGS. 11A and 11B, the thirdtissue resection guide146 optionally includes asecond frame160 adjacent to thefirst side108aof thedatum108. The thirdtissue resection guide146 may be sized and configured to receive and guide a thirdtissue resection tool170. The thirdtissue resection tool170 may further expose or expand the second resectedtissue surface104 in a direction away from thedatum108. (SeeFIG. 26). In one embodiment, the further exposed second resectedtissue surface104 is a thirdresected tissue surface104a(best illustrated inFIGS. 30 and 33). Referring to the embodiment ofFIG. 27, the thirdtissue resection tool170 may be a blade with a cuttingend170a. The thirdtissue resection tool170 is configured to slide back and forth within theguide path166 such that the cuttingend170aresects tissue and expands the second resectedtissue surface104 to further expose the thirdresected tissue surface104a.
• Thesecond frame160 may include aguide path166. In one embodiment, theguide path166 includes a partiallyopen sidewall160cdefined bysidewall segments162,164. In one embodiment, eachsidewall162,164 extends from thebase148 and wraps around toward each other to define theguide path166.Sidewall162,164 may taper to acenter point162a,164a. In one embodiment, a benefit of an at least partiallyopen sidewall160cincludes permitting a user to view a tissue resection tool within theguide path166. In one embodiment, the partiallyopen sidewall160cpermits viewing of the thirdtissue resection tool170 and/or the thirdresected tissue surface104a(FIG. 27) while the thirdtissue resection tool170 is resecting tissue.
• In one embodiment, aguide path166 is defined byinner walls162b,164b. In one embodiment, afirst side108aof thedatum108 and a feature (e.g. an edge1480 of the base148 are aligned with at least one inner wall of theframe160 when the thirdtissue resection guide146 is engaged with thedatum108.
• In one embodiment, theguide path166 may be generally aligned in a plane with thefirst side108aof thedatum108 when the thirdtissue resection guide146 is engaged with the datum. For example, inFIGS. 27 and 29, the thirdtissue resection guide146 anddatum108 may define a template or resection plane that is aligned with the thirdresected tissue surface104aand in which the thirdtissue resection tool170 is moved along. In one embodiment, the resection plane corresponds to a desired cut surface of a bone to match a feature of the totaljoint replacement10. In one embodiment, the resection plane may be defined by a feature (e.g.,inner wall162b) of thesecond frame160 or by a combination of one or more features of thesecond frame160 and a feature of thebase148. In one embodiment, sidewalls162,164 define a slot withinner edge148fthat is slightly larger than a preselected thickness of thethird resection tool170 and wider than a preselected thickness of thethird resection tool170 to allow thethird resection tool170 to slide from side to side within theguide path166 but small enough to constrain undesirable movement away from thebase178.
• In one embodiment, there are nosidewalls162,164 on thesecond frame160 such that theguide path166 is entirely open toward one side. In such an embodiment, care should be taken not to contact the medial andlateral malleolus12e,16arather than rely on thesidewalls162,164 to stop the secondtissue resection tool170. In one embodiment, thesecond frame160 of the thirdtissue resection guide146 has an entirely closed perimeter wall (not shown). In one embodiment, thethird resection guide146 does not include asecond frame160 and the thirdresected tissue surface104ais exposed by sliding the thirdtissue resection tool170 against thefirst side108aof thedatum108. The thirdtissue resection guide146 may includeindicia172 such as a colored polymeric plug that indicates the size and/or right or leftfoot26.
• Fourth Tissue Resection Guide
• Referring to the embodiment ofFIGS. 12A-12C, a fourthtissue resection guide176 may be provided for resecting thesecond bone14. The fourthtissue resection guide176 is sized and configured to releasably attach to thetop side108fof the datum108 (seeFIGS. 31 and 32). The fourthtissue resection guide176 is also configured to receive and guide one or more resection tools to resect tissue at predetermined orientation and location. In one embodiment, a resection using the fourthtissue resection guide176 is made while fourthtissue resection guide176 is attached to thedatum108 and while thedatum108 is attached to tissue (e.g., the second resected tissue surface104). In one embodiment, the fourthtissue resection guide176 is configured to guide one or more tissue resection tools adjacent to thedatum108. In one embodiment, thefourth resection tool182 is guided adjacent to one or more sides of thedatum108. In one embodiment, thefourth resection tool182 is guided adjacent to different sides of thedatum108 than the sides of thedatum108 that are adjacent to the resections made when the thirdtissue resection guide146 is used as described above. In one embodiment, the fourthtissue resection guide176 is a medial/lateral tissue resection guide for resecting thesecond bone14 medial and lateral to thedatum108. However, the fourthtissue resection guide176 may be used to resect thesecond bone14 in any direction relative to thedatum108.
• The fourthtissue resection guide176 includes a base178 that releasably engages thedatum108. The base178 may include adatum projection178athat extends from thebase178 and fits within the recessedsection108dof thedatum108 to prevent the fourthtissue resection guide176 from rotating with respect to thedatum108. Thedatum projection178amay include anaperture178bfor receiving afastener150 configured to secure the fourthtissue resection guide176 to thedatum108. In one embodiment, thefastener150 is an Allen screw. However, thefastener150 may by any securement device such as a snap or magnet. Thefastener150 may be thesame fastener150 used to secure the thirdtissue resection guide146 to thedatum108. In one embodiment, each of the third and fourth tissue resection guides146,176 may include itsown fastener150. The base178 may includepin apertures178cfor fitting over the shoulder pins114 extending from thedatum108. In one embodiment, the fourthtissue resection guide176 is integral with the thirdtissue resection guide146. The base178 may include one ormore grips178d(seeFIG. 12A) that are configured to engage an insertion tool (not shown) such as forceps. In one embodiment, thegrips178dmay be apertures as shown.
• The fourthtissue resection guide176 may include afirst frame180 attached to the base178 (e.g., such that thefirst frame180 is integral with the base178 or a separate component that is combined with the base178). In one embodiment, thefirst frame180 is adjacent to thesecond side108bof thedatum108 when the fourthtissue resection guide176 is engaged with thedatum108 and is configured to receive and guide a tissue resection tool such as the fourthtissue resection tool182. (SeeFIG. 31).
• Thefirst frame180 may include aguide path180cfor capturing and guiding the fourthtissue resection tool182. In one embodiment, theguide path180cis a generally planar elongated slot. In one embodiment, theguide path180cis defined at least in part by aninner surface180gof thefirst frame180 and anouter surface178gof thebase178. When the fourthtissue resection guide176 is engaged with thedatum108 theguide path180cmay be further defined, at least in part, by thesecond side108bof thedatum108.
• In one embodiment, theguide path180cof thefirst frame180 is at least partially closed proximate a top178fof thebase178 via a closed top180a. In one embodiment, theguide path180cis substantially open proximate the bottom178eof thebase178. In one embodiment, the closed top180aand open bottom of theguide path180cpermit the resection tool to move freely in a direction toward thesecond bone12 but restricts the resection tool in a direction normal to the base178 such that the resection tool may be slid downwardly out of thefourth resection guide176 but not upwardly out of thefourth resection guide176. The closed top180amay be provided so that the fourthtissue resection tool182 can be pivoted up against the closed top180aduring use. The closed top180amay include a roundedinner edge180bto contact the fourthtissue resection tool182 and prevent a pointed contact between thefirst frame180 and the fourthtissue resection tool182. Thefirst frame180 may be open toward the bottom178eof the base178 such that the fourthtissue resection tool182 may extend downwardly past thebase178 and resect thesecond bone14 to further expose a fifth resectedtissue surface104c. Theguide path180cmay be generally parallel to thesecond side108bof thedatum108 when the fourthtissue resection guide176 is engaged with thedatum108. Alternatively, theguide path180cmay be defined solely by thefirst frame180 or solely between thefirst frame180 and thebase178. In one embodiment, theguide path180cof thefirst frame180 is a generally rectangular slot.
• In one embodiment, the fourthtissue resection tool182 is a saw blade. However, the fourthtissue resection tool182 may be any suitable resection device such as any one of the first, second and thirdtissue resection tools168,170 described above (the first tissue resection tool is not shown).
• Thefirst frame180 of the fourthtissue resection guide176 may include at least one viewing window186 extending through anouter side180dof thefirst frame180. In one embodiment, thefirst cut guide180 includes twoviewing windows186a,186b. Theouter side180dof thefirst frame180 may include an alignment feature such as an alignment line188 (best shown inFIG. 31) that extends across or intersects the at least one viewing window186 such that during use the depth of the fourthtissue resection tool182 can be determined by aligning afeature182aof the fourthtissue resection tool182 such as the top edge of the fourthtissue resection tool182 with thealignment line188. (SeeFIG. 31). In one embodiment, thealignment line188 is cut or etched into theouter side180dof thefirst frame180. Alternatively, thealignment line188 may be printed or otherwise affixed to theouter side180dof thefirst cut guide180. Thefirst frame180 may be used to resect or expose the fifth resectedtissue surface104c. (SeeFIGS. 31 and 32).
• Referring toFIGS. 31 and 32, in one embodiment, the fifth resectedtissue surface104cextends medially from the second resectedtissue surface104. In one embodiment, the fifth resectedtissue surface104cis generally parallel with thesecond side108bof thedatum108. In one embodiment, approximately 0.5 mm to approximately 6 mm of tissue may be removed fromsecond bone14 to expose the fifth resectedtissue surface104c. In one embodiment, approximately 2 mm to approximately 3 mm of tissue is removed fromsecond bone14 proximal thesecond side108bof thedatum108. The inferior extending length of the fifth resectedtissue surface104cmay be approximately 5 mm to approximately 15 mm. In one embodiment, the inferior extending length of the medial extension106cis approximately 10 mm.
• The fourthtissue resection guide176 may include asecond frame190 attached to thebase178. In one embodiment, thesecond frame190 is a general mirror image of thefirst frame180. In one embodiment, thesecond frame190 and thefirst frame180 are attached to the base178 in a general symmetrical configuration (see, e.g.,FIGS. 12A and 12B). In one embodiment, thesecond frame190 and thefirst frame180 are oriented to provide guides that facilitate serial medial and lateral resections while the fourthtissue resection guide176 is attached to thedatum108 and thedatum108 is attached to the second bone14 (e.g., without the need to detach and attach a cut guide to thesecond bone14 between medial and lateral resections).
• In one embodiment, thesecond frame190 is adjacent to thethird side108cof thedatum108 when the fourthtissue resection guide176 is engaged with thedatum108 and is configured to receive and guide a tissue resection tool such as the fourth tissue resection tool182 (similar to thefirst frame180 shown inFIG. 31). In one embodiment, thesecond frame190 is integral with the base178 or a separate component that is combined with thebase178. Thesecond frame190 may include aguide path190cfor capturing and/or guiding the fourthtissue resection tool182. In one embodiment, theguide path190cis defined at least in part by aninner surface190gof thefirst frame190 and anouter surface178hof thebase178. When the fourthtissue resection guide176 is engaged with thedatum108. Theguide path180cmay be further defined, at least in part, by athird side108cof thedatum108.
• In one embodiment, theguide path190cof thesecond frame190 is at least partially covered or closed proximate a top178fof thebase178 via a closed top190a. In one embodiment, theguide path190cis substantially open proximate the bottom178eof thebase178. In one embodiment, the closed top190aand open bottom permit the resection tool to move freely in a direction toward thesecond bone12 but restricts the resection tool in a direction normal to the base178 such that the resection tool may be slid downwardly out of thefourth resection guide176 but not upwardly. The closed top190amay be provided so that the fourthtissue resection tool182 can be pivoted up against the closed top190aduring use. The closed top190aof thesecond frame190 may include a roundedinner edge190bto contact the fourthtissue resection tool182 and prevent a pointed contact between thefirst frame190 and the fourthtissue resection tool182. Thesecond frame190 may be open toward the bottom178eof the base178 such that the fourthtissue resection tool182 may extend downwardly past thebase178 and resect thesecond bone14 to further expose a sixthresected tissue surface104d. Theguide path190cmay be generally parallel to thethird side108cof thedatum108 when the fourthtissue resection guide176 is engaged with thedatum108. Alternatively, theguide path190cmay be defined solely by thesecond frame190 or solely between thesecond frame190 and thebase178. In one embodiment, theguide path190cof thesecond frame190 is a generally rectangular slot.
• Thesecond frame190 of the fourthtissue resection guide176 may include at least one viewing window192 extending through anouter side190dof thesecond frame190. In one embodiment, thesecond frame190 includes twoviewing windows192a,192b. Theouter side190dof thesecond frame190 may include an alignment line194 (best shown inFIG. 12A) that extends across the at least one viewing window192 such that during use the depth of the fourthtissue resection tool182 can be determined by aligning afeature182aof the fourthtissue resection tool182 such as the top edge of the fourthtissue resection tool182 with thealignment line194. In one embodiment, thealignment line194 is cut or etched into theouter side180dof thesecond frame190. Alternatively, thealignment line194 may be printed or otherwise affixed to theouter side190dof thesecond frame190. Thesecond frame190 may be used to resect or expose a sixthresected tissue surface104d. (SeeFIG. 32).
• Referring toFIG. 32, in one embodiment, the sixth resectedtissue surface104dextends laterally from the second resectedtissue surface104. In one embodiment, the sixth resectedtissue surface104dis generally parallel with thesecond side108bof thedatum108. Approximately 0.5 mm to approximately 6 mm of tissue may be removed fromsecond bone14 to expose the sixth resectedtissue surface104d. In one embodiment, approximately 2 mm to approximately 3 mm of tissue is removed fromsecond bone14 proximal thethird side108cof thedatum108. The inferior extending length of the sixth resectedtissue surface104dis approximately 10 mm to approximately 25 mm. In one embodiment, the inferior extending length of the sixth resectedtissue surface104dis approximately 17 mm.
• In one embodiment, (e.g., as illustrated inFIG. 12A) thesecond frame190 is angled about an axis that is generally perpendicular to the top178fof the base178 such that thefront edge190eis angled inwardly toward thebase178. In one embodiment, thefirst frame180 is angled about an axis that is generally perpendicular to the top178fof the base178 such that thefront edge180eis angled inwardly toward the base178 (not illustrated). In one embodiment (e.g., as illustrated inFIG. 12B), thefirst frame180 and/orsecond frame190 are angled toward each other such that theclosed tops180a,190aextend inwardly. In one embodiment, the angle of inclination of thefirst frame180 and thesecond frame190 are different. In one embodiment, the angles of inclination of the first andsecond frames180,190 are approximately equal to the angles of inclination of the respective second andthird sides108b,108cof thedatum108.
• In one embodiment, theends180e,190eextend outwardly from thebody178 and generally taper to a point to protect surrounding tissue from the fourthtissue resection tool182. However, theends180e,190eof the first andsecond frames180,190 may have any shape and may or may not extend outwardly further from thebody178. In one embodiment, the top180aof thefirst cut guide180 extends further from the base178 than the top190aof thesecond cut guide190 to allow for a deeper resection proximate thethird side108cof thedatum108 than the resection proximate thesecond side108bof thedatum108. However, the first and second cut guides180,190 may be configured to make a similar depth cut or be oriented to make any desired resections proximate and relative to thedatum108. In one embodiment, the fourthtissue resection tool182 includes vertically extendingteeth182csuch that theteeth182cdo not contact the first or second cut guides180,190 during use.
• Window Trial
• Referring to the embodiment ofFIG. 13, there is shown awindow trial198. Thewindow trial198 may include one or openings200 to evaluate the resectedsecond bone14. Thewindow trial198 may be used to evaluate the second, third, fourth, fifth and sixth resectedtissue surface tissues104,104a,104b,104c,104d. (SeeFIGS. 33 and 34). Thewindow trial198 may have aninner surface198athat generally has the shape of an inner surface of the secondendoprosthetic component18 of the totaljoint replacement10. Thewindow trial198 may have anouter surface198bthat generally has the shape of an outer surface of the firstendoprosthetic component18 of the totaljoint replacement10. In one embodiment, thewindow trial198 has the same shape and configuration as the firstendoprosthetic component18 of the totaljoint replacement10.
• In one embodiment, thewindow trial198 includes the one or more openings200 for viewing and evaluating the shape of one or more of the second, third, fourth, fifth and sixth resected tissue surfaces104,104a,104b,104c,104d,104e. Thewindow trial198 may includeside openings200a,200bproximate the fifth and sixthresected tissue surface104c,104drespectively. In one embodiment, theside openings200a,200bare generally aligned or parallel with the fifth and sixthresected tissue surface104c,104drespectively such that the fifth and sixth resected tissue surfaces104c,104dare not visible if the resections are proper when viewing the fifth and sixth resected tissue surfaces104c,104dat a viewing angle that is parallel and in-line with the fifth and sixth resected tissue surfaces104c,104drespectively. In one embodiment, first and secondtop openings200c,200dexpose the second and fourth resected tissue surfaces104,104brespectively. The first and secondtop openings200c,200dmay each expose the second resectedtissue surface104 proximate the thirdresected tissue surface104asuch that theinner surface198aof thewindow trial198 proximate the thirdresected tissue surface104ais visible.
• Thewindow trial198 may include afin aperture200e. In one embodiment, a keel mill or wire driver (not shown) is used to cut a keel slot (not shown) into the second14 using thefin aperture200eas a guide. The keel slot may be made for receiving thefin18bof the firstendoprosthetic component18. Thewindow trial198 may include one ormore pin apertures204 for securing thewindow trial198 to thesecond bone14 using one or more pins42. Thewindow trial198 optionally includes ahandle202 to assist in installing and removing thewindow trial198 from thesecond bone14 using a tool such as forceps (not shown). Thewindow trial198 may include indicia (not shown) such as a colored polymeric plug or printed graphic that indicates the size and/or right or leftfoot26.
• Barrel Cut Guide
• Referring to the embodiment ofFIG. 17, a barrel cutguide208 may be provided. The barrel cutguide208 may be configured to guide a fifthtissue resection tool210 used to form the resectedcavities12athat receive theprojections20aof the secondendoprosthetic component20. (SeeFIGS. 1 and 2). In one embodiment, the fifthtissue resection tool210 is a drill bit. In one embodiment, the barrel cutguide208 includes asupport plate212. Thesupport plate212 may contact the first resectedtissue surface100 during use. Thesupport plate212 may also be used to measure the first resectedtissue surface100 for the appropriately sized secondendoprosthetic component20. In one embodiment,various support plates212 are provided that correspond to the size of the secondendoprosthetic component20. In an alternative embodiment, thesupport plate212 is partially transparent and includes various size markings for determining the size of the secondendoprosthetic component20.
• The barrel cutguide208 may be fixed to thefirst bone12 by one or more pins42. The barrel cutguide208 may include aheight adjuster214 that may be used to space the barrel cutguide208 an appropriate distance from thefirst bone12. The space between the barrel cutguide208 may be adjusted using theheight adjuster214 after thepins42 are set if thepins42 are inserted generally parallel with theheight adjuster214 or the length ofheight adjuster214 extending from the barrel cutguide208 may be set prior to inserting thepins42 if the pins are inserted at an angle as shown. In one embodiment, theheight adjuster214 is a manually adjustable screw. However, theheight adjuster214 may be any device suitable to space the barrel cutguide208 from thefirst bone12.
• The barrel cutguide208 may include abody216 that extends generally perpendicular from thesupport plate212 such that thebody216 extends at least partially over the top of thefirst bone12. Thebody216 may include twoapertures216a(only one shown inFIG. 35) that are generally sized and shaped similar to theprojections20aof the secondendoprosthetic component20 and guide the fifthtissue resection tool210. The fifthtissue resection tool210 may include ashoulder210athat contacts thebody216 and a maximum drilling depth to limit the depth of the resectedcavities12aa predetermined distance.
• Referring to the embodiment ofFIG. 15, the resectedcavities12amay be opened or exposed through the first resectedtissue surface100 using afin cutter218 that is inserted through theapertures216a,216bof the barrel cutguide208. In one embodiment, thefin cutter218 includes a pair offins220 that are generally parallel and spaced apart from one another. Thefins220 may be configured to cut perpendicularly through the first resectedtissue surface100 through the resectedcavities12a. Thesupport plate212 may includeslots212a,212bfor receiving thefins220 and the bone that is cut out by thefins220. Thefin cutter218 may include ashaft218athat is generally equal in size to the resectedcavities12aand alimit stop218bthat contacts thebody216 once thefins220 have reached the end of the resectedcavities12a.
• Method of Use
• Referring toFIGS. 16-35, there are shown exemplary embodiments of using the various instrumentation disclosed above for implanting the totaljoint replacement10. Referring toFIG. 16, after thefoot26 andankle24 have been correctly positioned, thefoot26 andankle24 are preferably elevated. Thefoot26 andankle24 are elevated for approximately two minutes. A high thigh tourniquet (not shown) may be inflated or tightened with an appropriate amount of pressure for the size of theleg84 andfoot26. Anincision224 may be made along the anterior side of theankle24 parallel to theleg84 to expose the joint between thetibia12 and thetalus14. Theincision224 may be approximately 5 cm to approximately 30 cm in length. In one embodiment, theincision224 is approximately 20 cm in length. Theincision224 may be centered over theankle24 immediately lateral to an anterior tibial tendon (not shown). Theincision224 may be deepened into theankle224 while moving the extensor hallucis longus (not shown) and the neurovascular bundle laterally. Theincision224 may expose the superficial dorsal peroneal nerve (not shown) and should be retracted carefully to the lateral side. In one embodiment, it may be necessary to sacrifice one branch of the superficial dorsal peroneal nerve that goes to the first metatarsal. Theincision224 may open the tendon sheath of the extensor hallucis longus (not shown) inline with theincision224. In one embodiment, every effort is made not to open the anterior tibial tendon sheath (not shown) as such action might cause bolstering of the tendon during closing of theincision224.
• After the extensor hallucis longus tendon sheath is opened, the deep peroneal nerve and artery (not shown) which are just beneath the tendon sheath, may be retracted laterally in a gentle manner. The capsular tissues (not shown) in theankle24 may be incised in line with theincision224 and then elevated and mobilized to expose themedial malleolus12b(seeFIG. 1) and the entire ankle joint. Care should be taken not to release the anterior talofibular ligament (not shown) as this will produce ankle instability.
• The ankle joint may be distracted slightly using any suitable tool and excess synovium (not shown) and any loose bodies or bone spurs are removed using any suitable technique. In one embodiment, the anterior osteophytes (not shown) are excised so thetibial plafond12ccan be visualized.Retractors226 are optionally used to hold theincision224 open. In one embodiment, manually positionedretractors226 are used over self retaining retractors. Theretractors226 may be frequently repositioned to minimize the risk of tissue trauma.
• Referring toFIG. 17, thealignment guide30 may be secured to thefirst bone12 by inserting thepin34 into afirst end12dof thefirst bone12. In one embodiment, thefirst end12dis the anterior tibial tubercle of the tibia. Thepin34 may be oriented approximately perpendicular tofirst bone12. In one embodiment, thealignment guide30 is positioned relative to thepin34, both anteriorly and laterally, and secured to thepin34 using thefirst securement36.
• In one embodiment, theattachment block38 is positioned proximate asecond end12cof thefirst bone12. In one embodiment, thesecond end12cis the tibial plafond of the tibia. Thepositioning tool46 may be secured to thesecond positioning block54 to assist in positioning theattachment block38 relative to thefirst bone12. Theattachment block38 may be secured to thefirst bone12 using one or more pins42. Thesecond securement40 may be tightened to fix the length between theattachment block38 and thefirst end30aof thealignment guide30.
• In one embodiment, an osteotome (not shown), placed within the medial gutter, is used for additional visualization and setting proper orientation of theattachment block38. Thespace adjustments48 may be used to stabilize theattachment block38 with respect to thefirst bone12. In one embodiment, the distance between theattachment block38 and thefirst bone12 is as small as possible. In one embodiment, theattachment block38 is positioned the approximate distance from thefeature12cof thefirst bone12 such as the tibial plafond. A C-arm or other imaging device may be used to align thealignment rod44 generally parallel with the longitudinal axis of thefirst bone12. In one embodiment, thealignment rod44 is generally aligned with abone feature12fin the anterior/posterior and lateral views (lateral view shown). In one embodiment, thebone feature12fis the tibial crest of the tibia.
• Referring toFIG. 18, once theattachment block38 has be secured to thefirst bone12, the firsttissue resection guide66 is attached to thesecond positioning block58.
• Referring toFIGS. 19 and 20, thespacer guide78 may be attached to the firsttissue resection guide66 by inserting the mount82 into thefirst guide path70 of the firsttissue resection guide66. The C-arm or other imaging device may be used to view theankle24 from the lateral side proximate theextension arm80 of thespacer guide78. In one embodiment, theprojections86 are used to set the positionfirst positioning block50. In one embodiment, asingle spacer guide78 may be used for viewing theankle24 from either the medial or lateral side (FIG. 20). Thespacer guide78 may be removed and the C-arm or other imaging device may be used from the anterior side of theankle24. In one embodiment, the firsttissue resection guide66 is positioned by using thesecond positioning block58 and by aligning thefirst guide path70 between the between the medial andlateral malleolus12e,16a.
• Once the position of the firsttissue resection guide66 is determined, pins42 are inserted into thesuperior-most pin apertures50b,50b′ of the respective plurality ofpin apertures50a,50a′ in thefirst positioning block50. In one embodiment, pins42 may be placed within thepin apertures70a,70bin the first tissue resection guide66 to protect the medial andlateral malleolus12e,16a. In one embodiment, the first tissue resection tool such as a blade (not shown) is inserted within thefirst guide path70 to resect or cut the distal end of thefirst bone12 along a first cut line228 (FIG. 18). The blade may be placed against thesecond guide path72 to resect or cut a second cut line230 (FIG. 18).
• In one embodiment, when thealignment rod44 is aligned with thefeature12fof thefirst bone12, the top of theguide path94 is angled back toward thealignment guide30 such that theguide path94 is at an approximately 87 degree angle with respect to thefirst bone12. This allows for an angled firstresected tissue surface100 as best shown by the angle of thespacer guide78 inFIG. 20 and the angle of the secondendoprosthetic component20 inFIG. 2. The angle of theguide path94 relative to thefirst bone12 may be altered by raising or dropping thefirst end30aof thealignment guide30 along thepin34. The angle of theguide path94 relative to thefirst bone12 may be approximately 85 degrees to approximately 95 degrees and may have any orientation when thealignment rod44 is generally parallel to longitudinal axis of thefirst bone12. Once theguide path94 is set to the desired positioned, the first resection tool is used to resect thefirst bone12 along the first andsecond cut lines228,230. The resections along the first andsecond cut lines228,230 expose the first resected tissue surface100 (FIG. 20).
• Referring toFIG. 21, after the first resectedtissue surface100 is exposed, a secondtissue resection guide90 is inserted onto the firsttissue resection guide66. Thefoot26 may be moved to a general plantigrade position (shown) such that the top of thesecond bone14 engages the first resectedtissue surface100 or thetab extension102′. Thespacer guide78 may be used to verify neutral positioning of thesecond bone14. In one embodiment, the secondtissue resection guide90 is secured to thesecond bone14 bypins42 extending through the pin mounts92. In such an embodiment, thesecond bone14 is now fixed relative to thealignment guide30. The first tissue resection tool may be inserted within theguide path94 of the second tissue resection guide90 to resect or cut thesecond bone14 exposing the second resectedtissue surface104.
• Referring toFIG. 22, once the first and second resected tissue surfaces100,104 have been exposed, aspace evaluator234 may be inserted between the first and second resected tissue surfaces100,104 to ensure that the proper amount of tissue from the first andsecond bones12,14 has been resected. In one embodiment, thespace evaluator234 includes a plurality of finger grips234c. The finger grips234cmay be inwardly extending grooves positioned on at least one side or lateral edge of thespace evaluator234.
• Thespace evaluator234 may have a predetermined thickness toward afirst end234aand a predetermined thickness toward asecond end234b. In one embodiment, the thickness of thefirst end234ais approximately 6 mm to approximately 20 mm. In one embodiment, the thickness of thefirst end234ais approximately 12 mm. For example, thefirst end234ahaving a 12 mm thickness may include 3 mm of space for the secondendoprosthetic component20, 6 mm of space for the middleendoprosthetic component22 and 3 mm of space for the firstendoprosthetic component18. If thespace evaluator234 does not fit between the first and second resected tissue surfaces100,104, thefirst bone12 may be further resected. In one embodiment, thespace evaluator234 has a thinner thickness (e.g. approximately 9 mm) toward asecond end234bin the event that the distance measured using thespacer guide78 is off, the measurement included cartilage or other non-bone tissue or if a joint is lax. In one an embodiment, if the final distance between the first and second resected tissue surfaces100,104 is thinner than the thickness of thefirst end234aof thespace evaluator234, thesecond end234bof thespace evaluator234 may be inserted between the first and second resected tissue surfaces100,104 to gauge the additional space needed. For example, if thesecond end234bof thespace evaluator234 fits snugly between the first and second resected tissue surfaces100,104 then an additional distance, such as 2 mm, can be resected from thefirst bone12. Thefirst bone12 may be further resected by removing thepins42 fromfirst positioning block50, moving thefirst positioning block50 one or more predetermined length increments (e.g. 2 mm) such that the original pin holes50b,50b′ in thefirst bone12 align with the adjacent pin holes50c,50c′ and then reinserting thepins42 into thefirst positioning block50 through the pin holes50c,50c′.
• Referring toFIG. 23, once there is sufficient space for implanting the totaljoint replacement10 between the first andsecond bones12,14 thefoot26 may be plantar flexed (shown) to achieve better access to the second resectedtissue surface104. In one embodiment, asizer236 is inserted over the second resectedtissue surface104. Thesizer236 may be used to measure the size of the second resectedtissue surface104 such as the anterior/posterior depth and the medial/lateral width. In one embodiment, thesizer236 has a general shape and size of thedatum108. The appropriatelysized datum108 may be determined by adding, or leaving, a predetermined distance (e.g. 3 mm) to each medial/lateral side of thesizer234. In one embodiment, adifferent sizer234 is provided for each datum size. In one embodiment, the size of thesizer234 and right or leftfoot26 being measured is indicated byindicia238 such as printed words (e.g. left ankle, size small). Thesizer234 may included ahandle240 that is color coded to the size of thesizer234. In an alternative embodiment, thesizer234 is at least partially transparent with nested outlines (not shown) of differentlysized datum108 that allow a user to select the appropriate size. In one embodiment, the size of the firstendoprosthetic component18 is verified by measuring the distance between the medial andlateral malleolus12e,16a. In one embodiment, thesizer234 is outlined or traced on the second resectedtissue surface104 using a marking material such as a skin marker to help indicate the position thedatum108. Thesizer234 may be properly positioned by aligning thehandle240 with asecond metatarsal26aof thefoot26.
• Referring toFIGS. 24 and 25, once the appropriatelysized datum108 is selected, thedatum108 is attached and secured to thedistractor120. In one embodiment, thedatum108 is positioned relative to thealignment block38 using a guide (not shown). Thedatum108 may be inserted onto the second resectedtissue surface104 using thedistractor120 and may be generally positioned within the outline previously marked on the second resectedtissue surface104. In one embodiment, thedatum108 is positioned on the second resectedtissue surface104 by aligning thedistractor122 with thesecond metatarsal26a. In one embodiment, the C-arm or other imaging device is used to further verify the position of thedatum108 with respect to thesecond surface104. In one embodiment, thepaddle140 engages the first resectedtissue surface100 in the insertion position (FIG. 24) and theupper handle136 is squeezed toward thelower handle130 to separate the first resectedtissue surface100 from the second resectedtissue surface104. Theratchet142 may hold the upper andlower handles136,130 in position with respect to each other such that thedistractor120 can be held in a distracted position without having to continually squeeze thehandles130,136. Alternatively, theratchet142 may be disengaged and is folded inwardly to lay on the lower handle130 (seeFIG. 10D).
• With the first resectedtissue surface100 distracted from the second resected tissue surface in the distraction position (FIG. 25), thedatum108 may be secured to the second resectedtissue surface104 by inserting the shoulder pins114 through thepin apertures112 of thedatum108. Once thedatum108 is sufficiently secured to the second resectedtissue surface104, the distractor may be returned to the insertion position (FIG. 24), thedatum lock126 is released and thedistractor120 is removed from theankle24 leaving thedatum108 in place on the second resected tissue surface104 (FIG. 26).
• Referring toFIG. 27, once thedatum108 has been secured to the second resectedtissue surface104, the thirdtissue resection guide146 is releasably secured to thedatum108. A secondtissue resection tool170 may be inserted within thesecond frame160 and guided by theguide path166 of thesecond frame160 to resect thesecond bone14 relative to thedatum108 and expose the thirdresected tissue surface104a. In one embodiment, the secondtissue resection tool170 is slid back and forth within thesecond frame160 and along thefirst side108aof thedatum108 such that the cuttingend170aresects tissue proximate thedatum108. The secondtissue resection tool170 may be viewed through theopen perimeter160c. In one embodiment, the secondtissue resection tool170 is removed from the thirdtissue resection guide146 to inspect the thirdresected tissue surface104a.
• Referring toFIG. 28, the thirdtissue resection tool168 may be inserted within theenlarged end154aoffirst guide path154 of the thirdtissue resection guide146. In one embodiment, the thirdtissue resection tool168 is inserted until thestop168cof the thirdtissue resection tool168 abuts thefirst frame152. The thirdtissue resection tool168 may be guided proximate thefourth side108eof thedatum108 to resect or cut thesecond bone14 and expand the second resectedtissue surface104 away from thefourth side108eof thedatum108. In one embodiment, thefourth side108eof thedatum108 nearly contacts thehead170aof the thirdtissue resection tool170. The thirdtissue resection tool168 may be guided back along thefirst guide path154 and the cuttinghead168amay be removed from thefirst guide path154 through theenlarged end154a.
• Referring toFIG. 29, in one embodiment, the thirdtissue resection tool168 is inserted within theenlarged end156aofsecond guide path156. The thirdtissue resection tool168 may be inserted until thestop168bof the thirdtissue resection tool168 abuts thefirst frame152 of the thirdtissue resection guide146. The thirdtissue resection tool168 is guided proximate thefourth side108eof thedatum108 to resect or cut thesecond bone14 and expand the second resectedtissue surface104 away from thefourth side108eof thedatum108. The thirdtissue resection tool168 is guided back along thesecond guide path156 and the cuttinghead168ais removed from thesecond guide path156 through theenlarged end156a.
• Referring toFIG. 30, the thirdtissue resection guide146 may be removed from thedatum114 revealing the third and fourth resected tissue surfaces104a,104bleft after use of the thirdtissue resection guide146.
• Referring toFIGS. 31 and 32, the fourthtissue resection guide176 may be releasably secured to thedatum108. In one embodiment, thedatum108 remains in the same position on the second resectedtissue surface104 for use with both the third and fourth tissue resection guides146,176. Once the fourthtissue resection guide176 is secured to thedatum114, the fourthtissue resection tool182 may be inserted into thefirst guide path180cof thefirst frame180. In one embodiment, the fourthtissue resection tool182 is inserted into thefirst guide path180cof thefirst frame180 in the posterior anatomical direction until a feature such as the depth marking182aof the fourthtissue resection tool182 aligns with a feature of thefirst frame180 such as anedge180f. The fourthtissue resection tool182 may be slid and/or pivoted downwardly though thefirst guide path180cuntil theupper edge182bof the fourthtissue resection tool182 aligns with thealignment line188. The proximal end of the fourthtissue resection tool182 may be pulled upwardly to contact theedge180bof thefirst frame180 to thereby pivot the distal end of the fourthtissue resection tool182 downwardly toward and into thesecond bone14.
• In one embodiment, the fourthtissue resection tool182 is inserted into thesecond guide path190cof thesecond frame190. In one embodiment, the fourthtissue resection tool182 is inserted into thesecond guide path190cin the posterior anatomical direction until a feature such as the depth marking182aof the fourthtissue resection tool182 aligns with a feature of thesecond frame190 such as anedge190f. The fourthtissue resection tool182 may be slid and/or pivoted downwardly though thesecond guide path190cuntil theupper edge182bof the fourthtissue resection guide182 aligns with thealignment line194. The proximal end of the fourthtissue resection guide182 may be pulled upwardly to contact theedge190bto thereby pivot the distal end of the fourthtissue resection guide182 downwardly toward and into thesecond bone14.
• Referring toFIG. 33, the fourthtissue resection guide176 and thedatum108 may be removed from thesecond bone14 to expose the second third, fourth, fifth and sixth resected tissue surfaces104,104a,104b,104c,104d. In one embodiment, the resected tissue surfaces104,104a,104b,104c,104dare inspected for any burrs and/or missed or miss cut portions. The resected tissue surfaces104,104a,104b,104c,104dmay be resected further if necessary using the instrumentation above and/or through free hand resection.
• Referring toFIG. 34, thewindow trial198 may be used to further evaluate the second resectedtissue surface104 and the various cuts made to thesecond bone14. Thewindow trial198 may be installed or inserted over the second resectedtissue surface104 using a tool, such as forceps, attached to thehandle202. If the resections made to thesecond bone14 are off, theinner surface198aof thewindow trial198 will be at least partially raised off of the second resectedtissue surface104 and/or tissue will be visible through one or more of the openings200. In one embodiment, if thewindow trial198 does not fit and/or if excess tissue is visible through the openings200, a bone rasp (not shown) or other resection device is used to clean up the resections and provide a better fit with thewindow trial198 and ultimately the firstendoprosthetic component18. Thewindow trial198 may be pinned to thesecond bone14 using one or more pins42. A keel mill or wire driver (not shown) may be used to cut a keel slot (not shown) into thesecond bone14 using thefin aperture200eas a guide. In one embodiment, a keel broach (not shown) is used to clean any remaining tissue in the keel slot.
• Referring toFIG. 35, the barrel cutguide208 may be attached to thefirst bone12. In one embodiment, the barrel cutguide208 is configured to utilize thesame pins42 and/or pin holes in thefirst bone12 that were used to secure thefirst positioning block50 to thefirst bone12. In one embodiment, thesupport plate212 is generally flush against the first resectedtissue surface100. The position of the barrel cutguide208 toward and away from thefirst bone12 may be adjusted with theheight adjuster214. Thewindow trial198 may be left on the second resectedtissue surface104 to protect the second resectedtissue surface104 during installation and use of the barrel cutguide208. In one embodiment, ajoint spacer242 having the general shape and size of the middleendoprosthetic component22 of the totaljoint replacement10 is inserted between thewindow trial198 and thesupport plate212 to keep thesupport plate212 in contact with the first resectedtissue surface100. Thejoint spacer242 may also be used to determine the appropriate size and shape of the middleendoprosthetic component22.
• A fifthtissue resection tool210 may be inserted into theapertures216aof the barrel cutguide208 to create the resectedcavities12a. (SeeFIG. 1). A barrel broach (not shown) may be used to clean thecavities12aof remaining bone. The resectedcavities12amay be opened or exposed through the first resectedtissue surface100 by using thefin cutter218. Thefin cutter218 is inserted into the apertures of the barrel cutguide208 to remove the section of bone between the resectedcavities12aand the first resectedtissue surface100 such that theprojections20amay extend from the secondendoprosthetic component20 into the resectedcavities12a. The resected bone may be removed from theankle24 by any suitable technique.
• In one embodiment, the size of the resectedcavities12ais assessed using atrial bearing244. (SeeFIG. 14). Thewindow trial198, thejoint spacer242 and the barrel cutguide208 may be removed from theankle24. The firstendoprosthetic component18 may be inserted over the second resectedtissue surface104. In one embodiment, an impactor (not shown) is used to seat the firstendoprosthetic component18 on the second resectedtissue surface104. A notchedend234dof the space evaluator234 (seeFIG. 10) may be used to lift an anterior edge of the firstendoprosthetic component18 and drive the posterior of the firstendoprosthetic component18 inferiorly in an effort to seat the firstendoprosthetic component18 on the second resectedtissue surface104. In one embodiment, the secondendoprosthetic component20 is implanted or mounted using an insertion device (not shown). Theprojections20amay be aligned with the resectedcavities12a. In one embodiment, a mallet (not shown) is used to gently drive the secondendoprosthetic component20 downwardly and into position on thefirst bone12. An anterior edge of the secondendoprosthetic component20 may be flush with the anterior tibial cortex. In one embodiment, a sponge (not shown) is placed over the firstendoprosthetic component18 to protect the firstendoprosthetic component18 while the secondendoprosthetic component20 is being inserted. Variously sized and shaped joint trials orspacers242 may be inserted between the first and secondendoprosthetic components18,20 to evaluate desired joint tension and position. After a satisfactory reduction is accomplished, thejoint spacer242 may be replaced with the appropriate middleendoprosthetic component22. Theincision24 may then be closed.
• The bone removed from the first andsecond bones12,14 using the above instrumentation and methods may be kept to a minimum. In one embodiment, the reduced amount of bone resection achieved as a result of the above procedures means that if the totaljoint replacement10 needs to be removed and a salvage ankle joint fusion performed, the patient will not have a noticeable leg-length discrepancy.
• Tissue Resection Kit
• In one embodiment, a tissue resection kit (not explicitly shown) for implanting the totaljoint replacement10 is provided and includes any combination of the above instrumentation. In one embodiment, the tissue resection kit includes thedatum108 and one or more tissue resection guides (e.g., the third and fourth resection guides146,176) that are size and configured to releasably engage thedatum108 and guide a tissue resection tool. In one embodiment, the tissue resection guide of the tissue resection kit includes the thirdtissue resection guide146. In one embodiment, tissue resection guide of the tissue resection kit includes the fourthtissue resection guide176. The tissue resection kit may include the firsttissue resection guide66. The tissue resection kit may include thespacer guide78. The tissue resection kit may include the secondtissue resection guide90. The tissue resection kit may include thesizer236. The tissue resection kit may include thedistractor120. The tissue resection kit may include thewindow trial198. The tissue resection kit may include the barrel cutguide208. The tissue resection kit may include thefin cutter218. In one embodiment, the tissue resection kit includes more than one of the same instrument or component but of various sizes. The tissue resection kit may include instrumentation for one of the left andright ankle24. The tissue resection kit optionally includes instrumentation for both left andright ankle24.
• It will be appreciated by those skilled in the art that changes could be made to the exemplary embodiments shown and described above without departing from the broad inventive concept thereof. It is understood, therefore, that this invention is not limited to the exemplary embodiments shown and described, but it is intended to cover modifications within the spirit and scope of the present invention as defined by the appended claims. For example, specific features of the exemplary embodiments may or may not be part of the claimed invention and combinations of disclosed embodiments may be combined. The words “right”, “left”, “lower” and “upper” designate directions in the drawings to which reference is made. The words “inwardly” and “outwardly” refer to directions toward and away from, respectively, the geometric center of the device. Unless specifically set forth herein, the terms “a”, “an” and “the” are not limited to one element but instead should be read as meaning “at least one”.
• Further, to the extent that the methods do not rely on the particular order of steps set forth herein, the particular order of the steps should not be construed as limitation on the claims. The claims directed to the method of the present invention should not be limited to the performance of their steps in the order written, and one skilled in the art can readily appreciate that the steps may be varied and still remain within the spirit and scope of the present invention.

Claims (20)

1. A method of utilizing a distractor in a joint replacement procedure, the method comprising:

releasably engaging a datum to a datum securement of the distractor;

gripping a handle of the distractor in an insertion position, the handle comprising:

a first handle portion having a length extending between the datum securement and a grip portion of the first handle portion such that a combined length of the first handle portion and a length of the datum securement is generally planar when the distractor is in the insertion position, in a distraction position and in positions between the insertion position and the distraction position, and

a second handle portion having a distal portion that is generally parallel to the first handle portion when the distractor is in the insertion position and that is not generally parallel to the first handle portion when the distractor is in the distraction position;

disposing a paddle of a tissue engaging portion of the distractor against a tissue surface, the paddle attached directly and exclusively to a distal tip of the second handle portion such that the paddle pivots about an axis transverse to a length of the handle; and

adjusting the handle from the insertion position to the distraction position to thereby independently move the paddle with respect to both the second handle portion and the first handle portion such that the paddle remains at a generally constant angle against the tissue surface as the tissue surface is distracted.

2. The method ofclaim 1, wherein the first handle portion extends from the datum securement and the second handle portion extends from the tissue engaging portion, and wherein the adjusting the handle from the insertion position to the distraction position includes moving a distal end of the first handle portion towards a distal end of the second handle portion, thereby causing the datum securement to move apart from the tissue engaging portion.

3. The method ofclaim 1, wherein the second handle portion is pivotable with respect to the first handle portion and the first handle portion is releasably attached to the second handle portion.

4. The method ofclaim 1, wherein the adjusting the handle from the insertion position to the distraction position includes operating a rachet extending between the first handle portion and the second handle portion, the ratchet being pivotably attached to the first handle portion and detachable from the second handle portion.

5. The method ofclaim 1, wherein at least a portion of the paddle is sized and configured to extend over the datum and the portion is narrower than a space between pin apertures of the datum when the datum securement is engaged with the datum.

6. The method ofclaim 1, wherein the distractor includes an abutment member engagable with the datum and movable from a secured position to a released position.

7. The method ofclaim 6, wherein the distractor further includes a datum lock configured to move the datum securement from the secured position to the released position.

8. The method ofclaim 7, wherein the datum lock includes a rotatable nut that threadably engages a shaft extending from the datum securement.

9. The method ofclaim 1, wherein the gripping the handle of the distractor further comprises gripping a gripping portion of the handle having a plurality of indentations separated by columns that are orientated perpendicular to the longitudinal axis of the handle.

10. The method ofclaim 3, wherein the paddle and the second handle portion pivot about axes that are generally parallel to one another.

11. The method ofclaim 5, wherein the paddle is sized and configured such that it is movable from the space between the pin apertures of the datum.

12. The method ofclaim 1, wherein a proximal end of the paddle is larger than a distal end of the paddle.

13. The method ofclaim 12, wherein a width of the proximal end of the paddle is wider than a space between pin apertures of the datum, the space measured in a direction transverse to the length of the handle, when the datum securement is engaged with the datum.

14. The method ofclaim 5, wherein the paddle includes one or more ribs extending from a bottom surface of the paddle in a direction distal to the paddle such that the one or more ribs rest in a recess of the second handle portion when the handle is in the insertion position.

15. The method ofclaim 6, wherein the abutment member, having a length extending between a proximal end and a distal end, includes one or more forks extending from between the proximal end and the distal end to distally facing end surfaces and positioned such that each fork extends along a side of the datum securement, wherein the datum is connected to the abutment member at one or more points of contact with the distally facing end surfaces of the forks.

16. The method ofclaim 15, wherein each distally facing end surface of the abutment member is shaped such that it is generally parallel to an engagable surface of the datum.

17. The method ofclaim 6, wherein the distractor includes a stop configured to engage with the abutment member when the datum is engaged to the distractor.

18. A method of utilizing a distractor in a joint replacement procedure, the method comprising:

releasably engaging a datum to a datum securement of the distractor;

gripping a handle of the distractor in an insertion position, the handle comprising:

a first handle portion having a length extending between the datum securement and a grip portion of the first handle portion such that a combined length of the first handle portion and a length of the datum securement is generally planar when the distractor is in the insertion position, in a distraction position and in positions between the insertion position and the distraction position,

a second handle portion comprising an inflection point between a grip portion of the second handle portion and a tissue engaging portion of the distractor, the second handle portion being adjustable from the insertion position to the distraction position;

disposing a paddle of the tissue engaging portion of the distractor against a tissue surface, the paddle attached directly and exclusively to a distal tip of the second handle portion such that the paddle pivots about an axis transverse to a length of the handle; and

adjusting the handle from the insertion position to the distraction position to thereby independently move the paddle with respect to both the second handle portion and the first handle portion such that the paddle remains at a generally constant angle against the tissue surface as the tissue surface is distracted.

19. The method ofclaim 18, wherein the first handle portion extends from the datum securement and the second handle portion extends from the tissue engaging portion, and wherein the adjusting the handle from the insertion position to the distraction position includes moving a distal end of the first handle portion towards a distal end of the second handle portion, thereby causing the datum securement to move apart from the tissue engaging portion.

20. The method ofclaim 18, wherein the adjusting the handle from the insertion position to the distraction position includes operating a rachet extending between the first handle portion and the second handle portion, the ratchet being pivotably attached to the first handle portion and detachable from the second handle portion.

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