WO2018208437A2

WO2018208437A2 - Footprint in-lay anterior cruciate ligament (acl) reconstruction technique

Info

Publication number: WO2018208437A2
Application number: PCT/US2018/027617
Authority: WO
Inventors: Konsei Shino; Jo NAGASE; Jennifer Ng
Original assignee: Smith & Nephew, Inc.
Priority date: 2017-05-10
Filing date: 2018-04-13
Publication date: 2018-11-15
Also published as: JP2020519326A

Description

FOOTPRINT IN-LAY ANTERIOR CRUCIATE LIGAMENT (ACL) RECONSTRUCTION

TECHNIQUE

BACKGROUND OF THE INVENTION

[0001 ] Reconstruction of a torn ACL in the knee is typically performed using a soft tissue or bone-tendon-bone (BTB) autograft or allograft. Routine ACL reconstructions are performed by drilling femoral and tibial tunnels, passing the ACL graft through the tunnels and fixating the graft securely at the femoral origin and tibial insertion areas.

[0002] What is needed is an improved approach to creating, inserting and fixating a graft for ACL repair.

BRIEF SUMMARY OF THE INVENTION

[0003] In one approach, a method of preparing a bone for ACL reconstruction, comprises: creating a pair of holes in the bone, each hole of a same first depth;

crushing bone material located adjacent the holes to create a cavity; dilating the cavity to provide the cavity with a first shape of the first depth; determining if the first shape of the cavity meets a set of predetermined dimensions; and if it is determined that the first shape of the cavity does not meet the set of predetermined dimensions then further shaping the cavity by removing crushed material from the cavity.

[0004] In another approach, a method of preparing a bone for ACL reconstruction, comprises: creating a pair of holes in the bone, each hole of a same first depth;

crushing, with a crushing tool, bone material located adjacent the holes to create a bed area; dilating the bed area with a dilator tool to provide the bed area with a first shape of the first depth; determining if the first shape of the bed area meets a set of

predetermined dimensions by applying a bed template tool to the bed area; and if it is determined that the first shape of the bed area does not meet the set of predetermined dimensions then further shaping the bed area by removing crushed material from the bed area with a curved rasp.

[0005] In yet another approach, a method of ACL reconstruction comprises: inserting a pair of parallel guide wires through a Far Antero Medial (FAM) portal to locate a bed area on a surface of a bone; over-drilling the guide wires and creating a pair of holes in the bed area to a predetermined depth in the bone; guiding a crushing tool with the guide wires to the bed area; crushing bone material between the holes with the crushing tool; guiding a dilator tool with the guide wires to the bed area; dilating the bed area with the dilator tool to provide the bed area with a rectangular shape with the predetermined depth; inserting a curved rasp through an AL portal; and tapping the curved rasp with an impacting tool inserted through the FAM portal to further shape the bed area by removing crushed material.

BRIEF DESCRIPTION OF THE DRAWINGS

[0006] Various aspects of at least one embodiment per the present disclosure are discussed below with reference to the accompanying figures. It will be appreciated that for simplicity and clarity of illustration, elements shown in the drawings have not necessarily been drawn accurately or to scale. For example, the dimensions of some of the elements may be exaggerated relative to other elements for clarity or several physical components may be included in one functional block or element. Further, where considered appropriate, reference numerals may be repeated among the drawings to indicate corresponding or analogous elements. For purposes of clarity, not every component may be labeled in every drawing. The figures are provided for the purposes of illustration and explanation and are not intended as a definition of the limits of the invention. In the figures:

[0007] Figures 1 A and 1 B are representations of a bone-tendon-bone (BTB) graft and a preparation jig;

[0008] Figure 2 shows a sizing template used to confirm proper size of bone plug of a BTB graft;

[0009] Figure 3 is a conceptual presentation of a cannula with obturator provided locating an ACL footprint on a femur;

[0010] Figures 4 - 14B present steps in accordance with aspects of the present disclosure of preparing a receiving bed on a femur;

[001 1 ] Figures 15A - 15C present steps in accordance with aspects of the present disclosure of preparing a tibia for ACL repair; and

[0012] Figures 16A - 16E present steps in accordance with aspects of the present disclosure for inserting a BTB graft for ACL repair.

DETAILED DESCRIPTION

[0013] In the following detailed description, numerous specific details are set forth in order to provide a thorough understanding of the embodiments of the present

disclosure. It will be understood by those of ordinary skill in the art that these

embodiments may be practiced without some of these specific details. In other instances, well-known methods, procedures, components and structures may not have been described in detail so as not to obscure the embodiments of the present disclosure.

[0014] Prior to explaining at least one embodiment in detail, it is to be understood that the embodiment is not limited in its application to the details of construction and the arrangement of the components set forth in the following description or illustrated in the drawings. Other embodiments or other ways of being practiced or carried out are possible. Also, it is to be understood that the phraseology and terminology employed herein are for the purpose of description only and should not be regarded as limiting.

[0015] It is appreciated that certain features, are, for clarity, described in the context of separate embodiments but may also be provided in combination in a single

embodiment. Conversely, various features are, for brevity, described in the context of a single embodiment but may also be provided separately or in any suitable subcombination.

[0016] Referring now to Figures 1A and 1 B, initially a BTB graft 100 having a tendon portion 104 and a bone plug 108, 109 at each end is provided in a jig to be adapted for implantation in a particular patient based on her anatomy, e.g., bone size, structure, etc. The bone plug 108 is shaped, for example, to have a rectangular shape of 6.5x13 mm. A guide portion 1 16 of the jig 1 12 is then positioned over the bone plug 108 to facilitate the creation of two holes 1 13, 1 14, for example, 1 .2 mm diameter or, alternatively, one hole of 2.0 mm diameter, depending upon the fixation method that is chosen, as is known to one of ordinary skill in the art. Once the holes 1 13, 1 14 are created, each is provided with a suture 120, for example, the SUTUREFIX anchor suture available from Smith & Nephew of Memphis, TN.

[0017] Once the bone plug 108 has been drilled and the sutures 120 inserted, a sizing template 200 is used to confirm that the bone plug 108 is sized properly. As shown in Figure 2, multiple reference openings 202, 204, 206 are defined in the sizing template 200 to confirm proper size. In one non-limiting example, the opening 202 may be used to simulate the bone plug 108 passing through a 6.5x13 mm bone tunnel.

[0018] As the ACL is being repaired, referring to Figure 3, and per known techniques, a cannula 300 with obturator is provided through a far antero medial (FAM) portal (not shown) in order to locate the ACL footprint 304 on the femur (the left knee being shown for example).

[0019] Referring now to Figure 4, a bone model 400 is used to represent the femur with a first cortical layer 404, a cancellous layer 408 and a second cortical layer 412, as known to those of ordinary skill in the art. The obturator 300 is removed and two marks are made, for example, by a known RF marking device. One mark is an anteromedial (AM) mark 416 and the other is a posterior lateral (PL) mark 420.

[0020] An AM guide wire 504, as shown in Figure 5, is inserted via the FAM portal into the AM mark 416 and through and out to the other side. In one example, the guide wire 504 has a diameter of 2.4 mm.

[0021 ] Subsequently, as shown in Figure 6, a pin-guide/bone crusher 604 is provided via the FAM portal over the AM guide wire 504.

[0022] A PL guide wire 704 is then inserted, via the pin-guide/bone crusher 604, into the location identified by the PL mark 420, as shown in Figure 7. This insertion results in the configuration as shown in Figure 8, when the pin-guide/bone crusher is removed with both guide wires having passed through and out the other side.

[0023] A drill bit 904, for example of 6 mm diameter, as shown in Figure 9, is provided over each of the AM and PL guide wires 504, 704. A corresponding hole 1016, 1020, for example, of 5 mm depth, is created at each location 416, 420, as shown in Figure 10. In this example, the holes 1016, 1020 are located about 6 mm, on center, from one another.

[0024] Referring now to Figures 1 1 A and 1 1 B, the pin-guide/bone crusher 604 is then re-inserted, via the FAM portal, over the AM and PL guide wires 504, 704 and used to crush most of the remainder of a bone bridge 1 104 located between the two holes 1016, 1020. A distal portion 1 108 of the pin-guide/bone crusher 604 is made from a sufficiently hard material, for example, stainless steel, to crush the bone to create a cavity, also referred to as a footprint or bone bed, 1302 (See Figure 13A).

[0025] The pin-guide/bone crusher 604 is removed and replaced with a pin-guide/bed dilator 1204, again via the FAM portal as shown in Figures 12A and 12B. The pin- guide/bed dilator 1204 has a distal portion 1208 used to give the bed a more defined rectangular shape.

[0026] If the edges of the bed are not at right angles after forming with the pin-guide/bed dilator 1204, additional operations on the bed are performed. Referring now to Figures 13A-13C, the AM and PL guide wires 504, 704 are advanced further into the bed. A rasp 1304 is introduced via an anterolateral (AL) portal and a hitting shaft 1308 is introduced via the FAM portal. The rasp 1304 includes a distal portion 1312 that is configured with a cutting surface 1316 to provide straight walls and right angles to the bed 1302. The hitting shaft 1308 is used in a manner similar to a hammer and chisel with the rasp 1304.

[0027] The surgeon can check the shape of the bed 1302 by providing a bed template 1404 that has a distal portion 1408 of the correct dimension, as shown in Figures 14A and 14B. If the size is not correct, the rasp 1304 can be re-applied until the desired bed shape is obtained.

[0028] A tibial tunnel is now prepared, referring to Figures 15A-15C, with the insertion of a tibial guide 1504 to locate the tibial footprint. A 2.4 mm, for example, guide wire is drilled into the joint space, per known techniques. The tibial tunnel is overdrilled using, for example a 13 mm drill 1508, to break the cortex. Next, a rectangular dilator 1512, for example, 6.5 x 13 mm, is used to dilate the tibial bone tunnel to a rectangular shape to allow the bone plug portion 108 of the graft 100 to pass through.

[0029] To complete the ACL repair, the bone plug 108 of the BTB graft 100 is introduced and fixed in place as shown in Figures 16A - 16E. The graft 100 is introduced from the tibial tunnel entrance. Each suture 120 is introduced from the tibial tunnel entrance to the femoral lateral cortex exit using, for example, a passing pin with an eyelet. The fixation is completed by using, for example, a double spiked plate 1604 and fixation post 1608 on the femoral lateral cortex, per known techniques.

[0030] Advantageously, and as set forth above, rather than suspensory fixation on the outer cortex of the femur, or positioning an interference screw within a femoral tunnel, embodiments of the present disclosure maximize contact of the graft to the bone bed of the native femoral origin while preserving the bone stock of the femur. This is

accomplished by using the measurement tool to create the properly sized footprint and preparing the graft sized to the footprint having, for example, a rectangular prism configuration and a depth of 5 mm. Further, graft fixation can be accomplished with either a suspensory fixation, for example, an EndoButton, an interference screw, suture anchors, sutures, washers, posts or the like.

[0031 ] It is to be understood that the detailed descriptions of the embodiments of the present invention are provided by way of example only and are not intended to limit the scope of the invention. Features and/or steps described with respect to one

embodiment may be used with other embodiments and not all embodiments of the invention have all of the features and/or steps shown in a particular figure or described with respect to one of the embodiments. Variations of embodiments described will occur to persons of skill in the art.

[0032] Although the present disclosure has been described herein with reference to particular materials and embodiments, the present disclosure is not intended to be limited to the particulars disclosed herein; rather, the present disclosure extends to all functionally equivalent structures, methods and uses, such as are within the scope of the appended claims.

Claims

1 . A method of preparing a bone for anterior cruciate ligament (ACL) reconstruction, comprising:

creating a pair of holes in the bone, each hole of a same first depth;

crushing bone material located adjacent the holes to create a cavity;

dilating the cavity to provide the cavity with a first shape of the first depth;

determining if the first shape of the cavity meets a set of predetermined dimensions; and

if it is determined that the first shape of the cavity does not meet the set of predetermined dimensions then further shaping the cavity by removing crushed material from the cavity.

2. The method of claim 1 , wherein creating the pair of holes in the bone comprises: inserting a pair of guide wires on to a surface of the bone; and

over-drilling each guide wire to create the pair of holes in the bone.

3. The method of claim 2, further comprising:

inserting the two guide wires parallel to one another.

4. The method of claim 2, wherein the pair of guide wires are inserted via a Far Antero-Medial (FAM) portal.

5. The method of claim 4, wherein crushing bone material further comprises:

providing a crushing tool over the pair of guide wires via the FAM portal.

6. The method of claim 4, wherein dilating the cavity further comprises:

providing a dilator tool provided over the pair of guide wires via the FAM portal.

7. The method of claim 1 , wherein determining if the first shape of the cavity meets a set of predetermined dimensions further comprises:

providing a bed template via an anterolateral (AL) portal.

8. The method of claim 1 , further comprising:

repeating the determining step until the cavity meets the set of predetermined dimensions.

9. The method of claim 1 , wherein crushing bone material located adjacent the holes comprises:

crushing bone material located between the holes.

10. The method of claim 1 , wherein the first shape is rectangular.

1 1 . The method of claim 1 , wherein dilating the cavity further comprises:

providing the cavity with the first shape corresponding to a portion of a bone graft.

12. The method of claim 1 , wherein further shaping the cavity comprises:

providing a curved rasp; and

tapping the curved rasp with an impacting tool.

13. The method of claim 12, wherein the impacting tool is provided via the FAM portal and the curved rasp is provided via an AL portal.

14. A method of preparing a bone for anterior cruciate ligament (ACL) reconstruction, comprising:

creating a pair of holes in the bone, each hole of a same first depth;

crushing, with a crushing tool, bone material located adjacent the holes to create a bed area;

dilating the bed area with a dilator tool to provide the bed area with a first shape of the first depth;

determining if the first shape of the bed area meets a set of predetermined dimensions by applying a bed template tool to the bed area; and if it is determined that the first shape of the bed area does not meet the set of predetermined dimensions then further shaping the bed area by removing crushed material from the bed area with a curved rasp.

15. The method of claim 14, wherein creating the pair of holes in the bone comprises:

inserting a pair of guide wires on to a surface of the bone; and

over-drilling each guide wire to create the pair of holes in the bone.

16. The method of claim 15, further comprising:

inserting the two guide wires parallel to one another.

17. The method of claim 15, wherein the pair of guide wires are inserted via a Far Antero Medial (FAM) portal.

18. The method of claim 17, wherein:

the crushing tool is provided over the pair of guide wires via the FAM portal.

19. The method of claim 17, wherein:

the dilator tool is provided over the pair of guide wires via the FAM portal.

20. The method of claim 14, wherein the bed template is provided via an

anterolateral (AL) portal.

21 . The method of claim 14, further comprising:

repeating the determining step until the bed area meets the set of predetermined dimensions.

22. The method of claim 14, wherein crushing bone material located adjacent the holes comprises:

crushing bone material located between the holes.

23. The method of claim 14, wherein dilating the bed area further comprises:

providing the bed area with the first shape corresponding to a portion of a bone graft.

24. The method of claim 14, wherein further shaping the bed area with the curved rasp comprises:

tapping the curved rasp with an impacting tool to further shape the bed area.

25. The method of claim 24, wherein the impacting tool is provided via the FAM portal and the curved rasp is provided via an anterior lateral (AL) portal.

26. The method of claim 14, wherein the first shape is rectangular.

27. A method of anterior cruciate ligament (ACL) reconstruction, comprising:

inserting a pair of parallel guide wires through a Far Antero Medial (FAM) portal to locate a bed area on a surface of a bone;

over-drilling the guide wires and creating a pair of holes in the bed area to a predetermined depth in the bone;

guiding a crushing tool with the guide wires to the bed area;

crushing bone material between the holes with the crushing tool;

guiding a dilator tool with the guide wires to the bed area;

dilating the bed area with the dilator tool to provide the bed area with a rectangular shape with the predetermined depth;

inserting a curved rasp through an anterolateral (AL) portal; and

tapping the curved rasp with an impacting tool inserted through the FAM portal to further shape the bed area by removing crushed material.