DE102005014624B4 - Arthroscopic instruments - Google Patents

Abstract

arthroscopic Instrumentarium (10), in particular for the treatment of a due trauma and / or degeneration (164) a cartilage (70) and / or a bone (72) of a human or animal body, the instrumentation (10) having a longitudinal direction (42) defining one Instrumenteneinführkanal (14) comprehensive management tool (12) for insertion other instruments (20, 22, 24, 26, 28, 32) of the instruments (10) in the human or animal body, the instrumentation (10) an implant material processing instrument (22) for dissecting a carrier (146) of an implant material and wherein the implant material processing instrument (22) carries at its distal end a material cutting tool (106), characterized marked records that the Material cutting tool (106) in the form of an annular or essentially annular Cutting edge (108) or punch is formed that the implant material processing instrument (22) a nonwoven punch is for preparing a carrier (146) of an implant material that is a nonwoven, and that the guiding instrument (12) at or adjacent its distal end (46) at least one transverse to the longitudinal direction ...

Description

The The invention relates to an arthroscopic instrument, in particular to treat one due to trauma and / or degeneration resulting defect in a cartilage and / or bone of a human or animal body, the instrumentation being an instrument channel defining a longitudinal direction comprehensive management tool for insertion other instruments of the instrumentation in the human or animal body comprises the instrumentation being an implant material processing instrument comprises for dissection a carrier from an implant material and wherein the implant material processing instrument carries at its distal end a material cutting tool.

It is known to supply cartilage defects to joints, in particular traumatic cartilage defects in the knee with an area of 4 to 15 cm ² , preferably by means of a biological reconstruction. One possible type of care is to fill the defect with a sponge-like carrier material, especially for smaller defects with defect areas of less than 4 cm ² . Preferably, in this method of treatment prior to implantation, that is to say prior to the insertion of a replacement body comprising the carrier material, the subchondral plate of the cartilage defect is perforated in a targeted manner, which is referred to as "microfracturing". As a result of the targeted perforation of the subchondral plate, autologous cells bleed, for example from the fatty tissue of the cancellous bone underlying the defect into the carrier material. The cells from the fatty tissue can at least partially differentiate into cartilage cells.

A alternative treatment method is the autologous chondrocytes Transplantation (ACT). In this reconstruction method, cartilage cells, preferably taken from the patient to be treated, ex vivo cultivated, multiplied and then into the sponge-like carrier material, which at least a part of a defect to be used spare body introduced, which also as "inoculation" of the carrier material with the cartilage cells referred to as. Thereafter, the replacement body comprising the seeded carrier material is added filling of the defect in the body of the Patients used. Usually becomes the inoculated carrier material comprehensive replacement body referred to as a "graft".

following The term "implant" is used for both before implantation uninoculated carrier material comprehensive replacement body, an implant in the true sense, as well as for a vaccinated before insertion support material comprehensive replacement body ("Graft") used.

The Both of the methods described above are particularly applicable to joints currently only after their complete opening carried out. reason for this is that at an endoscopic surgical technique the size of the actual cartilage defect only difficult to transfer to an implant material. Thereby let yourself the implant outside only roughly pre-assemble the joint. Further, in arthroscopy of a joint usually a liquid used to widen the joint, thereby improving the visibility and thus to facilitate the work in the joint itself. By the liquid However, the implant used does not remain at the desired Position, it gets through the liquid usually flushed out, resulting in a fixation of the implant almost impossible. Against it would be possible the implant itself due to the moisture in the cartilage defect without problem positioning the use of an arthroscopic fluid.

From the EP 0 796 593 B1 For example, a surgical wound-spreading instrument is known which comprises a guide instrument having an instrument insertion channel. Other management tools are also available from DE 697 27 015 T2 , of the DE 201 10 491 U1 , of the US 5,489,291 as well as the KR 1020000010620 A known.

It is therefore an object of the present invention, an instrument to improve the type described above so that in particular a treatment of one due to trauma and / or degeneration resulting defect in a cartilage and / or bone of a human or animal body can be carried out in a simple manner and minimally invasive.

These Task becomes with an instrumentarium of the beginning described Type according to the invention thereby solved, that this Material cutting tool in the form of an annular or substantially annular Cutting or punch is formed, that the implant material a Fleece is that the implant material processing instrument is a nonwoven punch and that the management tool at or adjacent to its distal end at least one transverse to longitudinal direction oriented sight opening having.

The guiding instrument makes it possible, even with the use of an arthroscopic fluid, to introduce further instruments through the instrument insertion channel to the defect. Furthermore, the implant to be inserted can also be introduced through the instrument insertion channel. If, in addition, the guiding instrument with its distal end is brought directly to the defect, the implant can Do not flush out of the defect again after insertion through the arthroscopic fluid. By using the guide instrument in the manner described, the defect can thus be treated as desired in a simple way minimally invasive, in particular special also using an arthroscopic fluid. With the implant material, in particular, a carrier can be prepared, with which the defect can be completely filled. Furthermore, the implant material processing instrument may be designed in such a way that a carrier can be prepared which can be inserted in a form-fitting manner into the defect prepared prior to insertion of the implant. Advantageously, distal ends of the implant material processing instrument and the guide instrument are identical or substantially identical. It is also favorable if the implant material processing instrument can be introduced into the instrument insertion channel. Thus, even an implant already used can still be processed. This is particularly helpful in a patchwork-type treatment of the defect with multiple implants. In order to facilitate material processing, it is favorable that the implant material processing instrument carries a material cutting tool at its distal end. The implant material can thus be easily cut, cut or punched out. The material processing is particularly simple in that the material cutting tool is in the form of an annular or substantially annular cutting or punching. In particular, an annular cutting edge or punch allows the preparation of a disc-shaped implant. This has the advantage that it does not depend on an orientation of the implant when inserting the implant in a prepared for receiving the same defect. For example, from a nonwoven, preferably a collagen nonwoven fabric, desired carriers or implants can be punched out with the nonwoven punch and, if desired, inoculated with cartilage cells. It is advantageous if the guide instrument is at least partially transparent, for example, to allow a view into the interior of the guide instrument with an endoscope. In particular, the guide instrument can also be made transparent overall, for example as a transparent tube. Furthermore, however, it is also advantageous that the guide instrument has at least one viewing opening oriented transversely to the longitudinal direction at or adjacent to its distal end. The viewing aperture makes it possible to observe the treatment of the defect with an optical endoscope through the viewing aperture.

Especially simply the structure of the management instrument, if this in the form of a longitudinal direction elongated guide sleeve formed is. Furthermore, can so through the Instrumenteinführkanal even rigid instruments through and introduced to the defect.

to Treatment of the defect is beneficial if its edge around the defect before insertion of the implant prepared becomes. For this required cutting tools, for example, by the management tool passed through to the defect become. However, it is advantageous if the management instrument at his distal end carries a cutting tool. This embodiment allows it, with the management tool even edit the edge of the defect. The management tool thus comes a multiple function too. It serves to record further instruments, the shielding of an optionally used arthroscopic fluid and the processing of the edge of the defect.

The stability of the management instrument will be raised as well as the structure of the same simplifies when the cutting tool one piece with the management tool is trained.

Cheap is it if the management tool has a distal-facing edge and when the Edge at least partially includes the cutting tool. One such a management tool is suitable with the edge formed as a cutting tool to a Cut adjacent to or to set the defect to be treated. The shape of the cut preferably corresponds to the shape of the Rands of the guide instrument.

Conceivable would be particular a circular, an oval or a rectangular border. In any case, one can such a management tool to be used as trephine. Allow prefabricated trephine a fitting exact Implant design for defect.

Around For example, an endoscope also obliquely to observe the treatment the defect to the management instrument introduce, is it cheap when the viewing aperture in the form of a longitudinal direction extending elongated hole formed in a wall of the guide instrument is. In addition, the sight opening be arranged so that despite Use of an arthroscopic fluid of To be treated defect so shielded by the guide instrument he will yourself in a flow-free or very low-flow Zone within the lead instrument located.

According to a further preferred embodiment of the invention can be provided that the instrumentation comprises a cutting and / or a milling instrument, in particular for cartilage and / or bone processing, and that the cutting and / or Fräsinstrument at its dista len end carries at least one cutting or milling element and is inserted into the Instrumenteinführkanal. The cutting and / or milling instrument can be used to easily process a cartilage and / or bone within the guide instrument brought up to the defect. The management instrument thus also serves to limit the processing area. If the guide instrument also serves as a trephine, the cutting and / or milling instrument can be used to remove cartilage in particular within the section set by the guide instrument. It would also be conceivable to remove parts of a subchondral plate or the underlying bone lying below the cartilage.

A Machining the defect is further simplified when the cutting and / or milling instrument in the insertion channel is rotatable or rotatable. For example, the defect can be so with a front pages Edit cutting tool of the cutting and / or Fräsinstruments.

Especially easy and clean can be edit the defect if the at least one cutting or milling element two mutually offset by 180 ° Cutting includes.

If the management tool while of the procedure must be removed or withdrawn from the defect it cheap, if the instrumentation comprises a position-holding instrument and if that Position holding instrument has an insertion channel for insertion of the Assistance instrument. This configuration allows it, the management tool through the insertion channel of the position-holding instrument. With the at the defect brought up Position holding instrument can easily the original Position of the management instrument be marked. The management tool can then be either withdrawn or from the body led out and subsequently back to his original Position returned become. Further, the position holding instrument as a marker serve to the management tool adjacent or partially overlapping with a defect that has already been processed or partially processed to introduce this. So it's possible the defect "patchwork-like" to edit, where in each case the position of the management instrument can be specified by the position holding instrument.

In order to the position holding instrument a once predetermined position safely maintains, it is advantageous if the position holding instrument at his distal end carries at least one anchoring element. The Anchoring element serves, for example, for anchoring the position-holding instrument on a remaining cartilage, on the underlying subchondral Plate or the underlying bone.

Especially simply the structure of the position holding instrument, if at least one anchoring element in the form of a distal or in is formed substantially in the distal direction facing mandrel.

Advantageous would it be, the position holding instrument wholly or partly made of a transparent material manufacture. Cheap it may also be, if the position holding instrument on or at least one transverse to the longitudinal direction adjacent to its distal end has oriented viewing window. This embodiment makes it possible with an endoscope, the processing of the defect from the outside through the Observe window through.

Around with an endoscope also obliquely from the outside observe its treatment in the direction of the defect to be treated to be able to it is advantageous if the viewing window in the form of a in longitudinal direction extending slot in a wall of the position holding instrument is trained. In particular, when the guide instrument comprises a viewing port is it cheap, if the shape of the viewing aperture essentially corresponds to the shape of the viewing window of the guide instrument.

Around to simplify the handling of the instruments, it is Cheap, when the position holding instrument with the guide instrument releasably connectable is. For example, the management tool be connected to the position holding instrument at the common Introduce of the two instruments in a human or animal body. Further Thus, for example, the position-holding instrument in a relative to the management instrument withdrawn Position on the management instrument temporary be determined. This allows the position holding instrument only when needed by the management tool to solve and to advance for example in the distal direction.

Around the position holding instrument in a simple way with the management instrument to connect and to simplify the construction of both instruments, It may be advantageous if a latching connection for releasably connecting the position holding instrument is provided with the guide instrument.

Conveniently, the position holding instrument is shorter than the guiding instrument. This makes it possible, for example, to store the position-holding instrument on the guide element and to move it from a retracted position, in which it can in particular also be connected to the guide instrument, into an advanced, distal position bring.

advantageously, the implant material processing instrument is designed such that one with Cartilage cell inoculable implant material is workable. It let yourself for example, a carrier for Prepare inoculation with cartilage cells, preferably taken from the patient, the body's own and subsequently In the laboratory, increased cartilage cells are used to inoculate the carrier can.

Advantageous it is when the instrumentation is a perforation instrument for Perforating cartilage and / or subchondral plates and / or bone comprises and when the perforation instrument enters the instrument insertion channel insertable is. With the Perforationsinstrument can, as described above, a cartilage and / or a subchondral plate and / or a bone specifically micro-fracture, thus especially from the fatty tissue spongious Bone-derived cells in uninoculated or inoculated carrier material bleed or diffuse. Furthermore, the fact that the Perforation instrument in the Instrumenteinführkanal is retractable, the further processing of the defect protected by the management instrument, in particular before used arthroscopic fluid, be made.

A Microfracturing can be particularly easy to realize when the perforation instrument on its distal end carries at least one perforation projection. With this can be done for example, as a result of movement in the distal direction or across it the subchondral plate, the underlying bone or also adjacent or remaining cartilage tissue targeted mikrofrakturieren.

Of the Structure of the perforation instrument becomes particularly easy, if the at least one perforation projection in the form of a distal Direction protruding mandrel is formed.

According to one preferred embodiment of Invention may be provided that the Perforationsinstrument at least one in the longitudinal direction extending guide channel whose inner diameter is smaller than an outer diameter of the perforation instrument. Such a trained Perforationsinstrument allows one or more other instruments through the guide channel lead in the distal direction of the defect and further process this. The guide channel serves as a guide at the same time for the others Instruments.

Either Construction as well as application of the perforation instrument will continue simplified if the perforation instrument essentially the Has the shape of an elongated tube and if the guide channel coaxial with a longitudinal axis the perforation instrument is arranged. For example, can through the guide channel a drilling tool or a punching tool are introduced. Possibly provided Perforation projections can on distal end of the perforation around the guide channel be arranged around, both in asymmetrical and symmetrical Wise.

Further it can be cheap be when the instrumentation a Einsetzinstrument for inserting a Implant includes and when the insertion instrument in the Instrumenteinführkanal insertable is. With the insertion instrument, it is possible to implant, so For example, an implant in the true sense or at the beginning described "graft", by the management instrument through to the defect and put in these.

Advantageous it is when the insertion instrument is a guide tube and a guide tube longitudinal includes movable feed element and when the implant with the advancing element in the distal direction through the guide tube is movable. Such an insertion tool allows the guide tube into the management tool introduce and subsequently with the advancing element to move the implant in the distal direction, for example, to advance. A separately movable to the guide tube feed element must however not necessarily be provided.

conveniently, wear this Feed element at its distal end a plate on which the Implant transversely applied across or substantially transversely to the longitudinal direction is. With the plate can be that Implant easily in the distal direction through the insertion instrument through to the defect and introduce into this.

In order to the implant when approaching can not move laterally to the defect, it is advantageous if at the distal end of the insertion instrument or on the plate a Implant receiving intended for at least partially receiving an implant is. Preferably, the prepared implant can be positively and Completely be inserted into the receptacle. As a result, the implant is also laterally protected.

The formation of the implant receptacle is particularly simple if it is designed in the form of a pointing in the distal direction, flat pot-shaped depression. A prepared implant can be easily inserted into the implant receptacle. The implant can herausge from the implant receptacle only in the distal direction be led.

Around the insertion of a maximum size To enable implant can conveniently be provided that the distal end of the advancing element has an inner cross section of the Guide tube complete or essentially complete fills. In similar Way can also be the insertion instrument, the guide instrument in cross section completely or essentially complete fill out.

According to a preferred Embodiment of Invention may be provided that inside the Einsetzinstruments in the longitudinal direction extending fastener insertion channel is provided. Of the Fastener insertion channel has several advantages. On the one hand can through him a fastener or a fastener, preferably from a resorbable Material for fixing the implant in human or animal body introduced become. On the other hand, if an implant recording provided is the implant with a through the Befestigungselementeinführkanal insertable Aids moved out of the implant holder in the distal direction and be introduced into the unprepared or prepared defect.

Around a very good guide for a Fastener or to obtain a fastener, is it cheap when an inner cross section of the fastener insertion channel is much smaller than an inner cross section of the guide tube. For example, such a very small in diameter fixing pin while maintaining its orientation in the longitudinal direction targeted in distal Direction brought to the implant and to its definition at the subchondral plate or at the bone in these be driven.

Around not having to hold two instruments at the same time, it is beneficial when the insertion instrument with the guiding instrument solvable is connectable. The two instruments can then temporarily become one Unit to be connected.

Especially simply the insertion instrument and the management instrument can be connect together when they are screwed together. Further this has the advantage that a Positioning the insertion instrument relative to the guide instrument adjustable in the axial direction by screwing or jamming is. For example, can be so a distance between distal ends or proximal ends of the two Targeting instruments.

According to one another preferred embodiment The invention may be provided that the instrumentation an elongated Hole instrument for creating a hole or depression in a cartilage, a subchondral plate or a bone, and that the perforated instrument into the instrument insertion channel insertable is. With the perforated instrument can easily a hole or be created a recess, for example, for introducing a Fastener or a fastener. Furthermore, can the perforated instrument is inserted into the instrument insertion channel, so under Maintaining a position of the guide instrument an inserted Implant in the body can be determined.

A much improved leadership for the fastener or the fastener is reached when the perforated instrument in the guide channel insertable is. This configuration allows the perforated instrument through the introduced perforation instrument through to the defect. It can then simultaneously or sequentially, for example, the subchondral Microfractured plate and a hole in it are introduced.

Around the stability to increase the hole instrument, advantageously has a distal end of the perforated instrument Diameter smaller than that of the guide channel. This allows to make a major part of the hole instrument larger in diameter as its distal end. In a perforated instrument, the total has a smaller diameter than the guide channel can with the same instrument at different locations holes or Wells are formed.

conveniently, the perforated instrument has a distal end in the form of a Drill or a punch is formed. It can be so easily a hole with the desired dimensions in the form subchondral plate or underlying bone.

According to one another preferred embodiment The invention can be provided that the instrumentation a fastener insertion instrument comprises for insertion and / or inserting a fastener and that the fastener insertion instrument into the instrument insertion channel insertable is. With the Befestigungselementeinsetzinstrument can be through the management tool through a fastener for fixing the implant in body introduce.

Further, it may be advantageous if the fastener insertion instrument is insertable into the fastener insertion channel. In this way, the fastener insertion instrument can pass through both the guide instrument as well as being moved through the holding instrument for insertion of a fastener or fastener.

In order to the fastener can be safely brought to the implant to be determined, is it cheap when the fastener insertion instrument at its distal End has a fastener receiving element for receiving a Fastening element whose distal end in the distal direction has. The fastener can thus in the desired orientation to the Implant introduced Be this on the body set.

Around not just introduce the fastener to the defect, but also in the body for Fixing the implant, it is advantageous if the Befestigungselementeinsetzinstrument formed in the form of a plunger is. For example, a fastener may be subchondral Pressed plate or underlying bone or be taken.

Further can conveniently be provided that the Instrument includes at least one fastener. The Implant can be so after inserting into the defect fix it on the body by parting of the instrumentation remains specifically in the body.

On a particularly simple way can be fix the implant if the fastener is a bone pin is.

According to one preferred embodiment of Invention may also be provided that a proximal end of the guide instrument an axial stop for a radially extending projection of the

cutting and / or milling instruments Are defined. It can be prevented by grounding that the cutting and / or milling instrument too deep in the management tool introduced and thereby more cartilage substance from the underlying subchondral Plate or underlying bone is removed as the preparation the defect is absolutely necessary.

Further can be provided that a proximal end of the guide instrument an axial stop for a radially extending projection of the perforation instrument Are defined. This will ensure that a microfracture of a underlying the defect subchondral plate respectively of the underlying bone only to a predefined depth he follows.

Of another can conveniently a proximal end of the guide instrument an axial stop for a radially extending projection of the insertion instrument define. This ensures that the implant to be used when inserting is not compressed, but in the desired Approaching the defect and can be introduced into this.

conveniently, defines a proximal end of the insertion an axial Stop for a radially extending projection of the perforated instrument. This will ensure that the Perforated instrument is not inserted too deeply into the body. Furthermore, can be thus a hole depth in the desired Give way and with an adjustable stop in the desired Set way.

Of Another can according to a preferred embodiment be provided of the invention that a proximal end of the Einsetzinstruments an axial stop for a radially extending projection of the fastener insertion instrument Are defined. Such a stop prevents a fastener too deep placed in the subchondral plate or underlying bone becomes. This allows a secure hold of the defect filling Implant can be achieved.

According to one preferred embodiment of Invention may be provided that the instrumentation comprises a fastener holding member for holding a fastener that a Fastener releasably connectable to the fastener holding member is and that the fastener holding member detachably connectable with at least one of the instruments of the instrumentation is. The fastener holding member allows very small, hardly manageable fasteners for securing the implant use. For example, the fastener holding member have a size that easy to handle. It can then, for example, with one of Instruments of the instrument are releasably connected, for example with the insertion instrument. For insertion of the fastener itself can, for example, with a fastener insertion instrument the fastener in the desired Be moved in the distal direction.

Preferably is the fastener holding member having a proximal end detachable from the insertion tool connectable. For example, the fastener holding member after insertion of the implant are connected to the insertion tool for easier Handling of the fastener.

Advantageous it is when the fastener holding member in the form of an inelastic or plastic plug is formed and when the plug a in the longitudinal direction Having extending channel for receiving the fastener. The fastener can be introduced into the channel and is held in it. Due to the inelastic or plastic training the plug, the fastener in a simple manner relative be moved to plug, preferably in the distal direction to Determination of the implant.

Cheap is it, if the channel in a basic position an inside diameter which is smaller than a maximum outer diameter of the fastener or the fastener insertion instrument, and when the Channel through the fastener and / or the Befestigungselementeinsetzinstrument transverse to the longitudinal direction at least partially expandable. Due to the narrower cross-section the elastic or plastic plug may be the fastener hold securely. Only as a result of movement of the fastener or by a movement of the fastener insertion tool the channel will be widened. This will further ensure that even then, when a feed movement of the fastener in the distal Direction is prevented, the fastener securely held in the stopper is.

In order to the position holding instrument easily anchored to the body is included the instrument advantageously an impact instrument for Driving or driving the position holding instrument into a Cartilage, a subchondral plate or a bone. This can be done purposefully higher personnel Apply to the position holding instrument in the desired Way to the body anchor.

In order to the position holding instrument securely with the impact instrument can be driven forward, it is advantageous if the management tool at least one impact instrument guide for guiding a movement of the impact instrument in the distal direction. This can prevent the impactor is moved in an undefined manner, for example transversely to the longitudinal direction, and so on the position-holding instrument when driving or driving of the same can slip off.

One Particularly simple construction of Einschlaginstrumentführung results yourself when the management tool at its proximal end extending in the radial direction Wearing ring protrusion and if the at least one impact instrument guide in Shape at least one in the longitudinal direction extending, the annular projection passing through opening is formed. this makes possible it, parts of the impactor to pass through the openings, which a miss of the position holding instrument with the impact instrument can be avoided.

A Handling of the impactor will be further improved if it pointing at least one in the distal direction, corresponding to Einschlaginstrumentführung Firing pin covers. For example, you can from a striking plate of the impactor symmetrically over a circumference distributed several, for example, three firing pins project vertically, passing through through openings of the annular projection on the guide instrument are formed.

In order to the impactor targeted for driving the position holding instrument can be used conveniently the position holding instrument at its proximal end on a Einschlaginstrumentanlagefläche. The impact instrument investment surface preferably points in the proximal direction.

• – Eröffnen eines minimalinvasiven Zugangs in den menschlichen oder tierischen Körper,
• – Bereitstellen eines eine Längsrichtung definierenden Instrumentenkanal umfassendes Führungsinstruments,
• – Einführen des Führungsinstruments durch den minimalinvasiven Zugang bis an den Defekt heran,
• – Einführen des Implantats durch das Führungsinstrument hindurch und
• – Ausfüllen des Defekts mit dem Implantat.

Furthermore, a method is described below for minimally invasive treatment of a trauma and / or degeneration defect in a cartilage and / or bone of a human or animal body by filling the defect with an implant, comprising the steps:

• - opening a minimally invasive access to the human or animal body,
• Providing a guide instrument comprising a longitudinally defining instrument channel,
• Introduce the guide instrument through the minimally invasive approach to the defect,
• Insertion of the implant through the guide instrument and
• - Filling the defect with the implant.

By this approach is possible, a Implant in a simple and gentle way to fill in the Defect in these introduce. Especially can be avoided that the Implant with the body The patient comes into contact before it was brought to the defect. Of Another is to implant the implant only a minimally invasive Access required. Of course could the management tool also be used when the body is not only minimally invasive, but opened further is, for example, at a fully opened joint a defect to treat.

The described method is carried out especially simple if an instrument is used for this purpose, as described above. With such instruments All process steps can be easily by a perform minimally invasive access.

Around to achieve optimal fitting of the implant into the defect It is advantageous if, prior to insertion of the implant, an edge of the Defects prepared becomes. In this way, a defined edge can be formed, so in the defect form-fitting and without a gap between the implant and the prepared one Edge form the implant to be used. This is even more important since it is known that one between a cartilage implant used, for example, and a healthy cartilage shoulder formed gap very difficult from the body can be regenerated. In addition, such columns often form the Exit for new, bigger ones Defects.

On simple way can be prepare an edge of the defect, if a section defining a new border is along the original one Rands of the defect is set. This can be any shape have, preferably a cutting line is selected, which an outline of the corresponds to implant to be used. Furthermore, advantageously preferably little well-preserved or healthy material on the edge of the defect away.

Especially easy can be make a cut if this is circular or substantially circular is. A circular cut also has the advantage that a disc-shaped implant regardless to an orientation thereof used in the prepared defect can be.

Around To work the defect optimally, it is favorable if the cut through the cartilage is placed to the subchondral plate. To this Way becomes a cartilaginous edge from a cartilaginous surface to the Subchondral plate defined.

In order to not a variety of tools for working the defect must be used is it cheap when the cut is made with a cutting tool of the guide instrument and if the management tool after placement of the incision, positioned in abutment with the subchondral plate remains. With the cutting tool of the guide instrument can be so easy to cut. For example, that can Cutting tool by a pointing in the distal direction edge of the management instrument, which, for example, sleeve-shaped can be formed. This can be done easily put in self-contained cuts, preferably round or in essential round. The management tool after placing the incision in abutment with the subchondral plate to leave has also the advantage that the defect to be processed shielded to the outside is. In particular, such an arthroscopic fluid can not flush out of an inserted implant.

Around a defined recess for To create the implant to be used, it is advantageous if the cartilage within the redefined by the set cut Rands removed. As a result, a defined contact surface for the implant, in particular to the subchondral plate and the surrounding cartilage tissue, be created.

Of the To be removed cartilage can in a particularly simple way with a through the management tool introduced Cutting and / or milling instrument be removed. The management instrument shields while the treatment area, so that a processing of the defect surrounding parts and areas are not affected.

Preferably can be provided that the management tool at or adjacent to its distal end at least one transverse to longitudinal direction oriented sight opening and that a treatment the defect inside the guiding instrument through the viewing aperture from the outside is observed with an optic endoscope. Thereby the minimally invasive access can be kept so small that only the management tool is introduced by this. For example, by a second, for the Endoscope adapted minimally invasive Access is possible then introduce this and, without interfering with the processing of the defect, its treatment observe.

In order to the management tool is not unintentionally able to change its position on the defect is It is beneficial if the management tool before insertion through access into an insertion channel a position holding instrument and introduced together with the position holding instrument through the access in the body introduced becomes. It would be possible it also, the position holding instrument after inserting the Accession instrument in the body over that management tool to push.

Preferably, a position of the guide instrument with the position holding instrument is temporarily fixed by driving at least one anchoring element arranged on the position holding instrument into surrounding tissue. By temporarily fixing the position holding instrument to the body, the guiding instrument can even be withdrawn or brought out again through the minimally invasive access, without the risk of re-insertion of the guiding instrument by the minimally invasive access whose originally assumed position can no longer be found.

The Treatment of the defect can be furthermore, to carry out even more targeted, when the position-holding instrument is at or adjacent to its distal End at least one transverse to the longitudinal direction oriented viewing window and if a treatment of the defect inside the management instrument through the viewing aperture and the viewing window from the outside is observed with the endoscope. If the management tool and / or the Positioning instrument wholly or partly made of a transparent Material manufactured, the treatment of the defect can also at any transparent location of the two instruments through from outside an endoscope are observed.

Around the handling of the instruments and in particular the implementation of the To simplify treatment, the position-holding instrument can with the management tool before insertion in the body and the connection for temporarily fixing the position of the inserter solved and the position holding instrument in the distal direction relative to introducer to be moved. The position holding instrument can be so easily on the management instrument during the introducing both instruments in the body to back up. Only when needed, the position holding instrument in distal Be moved direction. This is the temporary connection of both instruments solved.

Around the formation of a gap between the implant described above and to avoid surrounding tissue, it is beneficial if the defect in shape and size accordingly or substantially corresponding carrier of an implant material prepared becomes. With such a carrier let yourself the defect completely or substantially complete fill out.

conveniently, the implant material used is a cartilage cell-implantable implant material. this makes possible it, before inserting the implant, for example in a first Intervention, the patient's body Remove cartilage cells, then multiply these in the laboratory and finally before inserting the implant this with the body's own to inoculate increased cartilage cells. In this way, a ingrowth of the implant can be significantly improved.

Further The process can be simplified if a disc-shaped carrier with a punch is punched out of the implant material.

Preferably a fleece is used as the implant material. In particular, can a collagen fleece can be used.

According to one Another preferred variant of the method described can be provided that after preparation the edge of the defect of the cartilage and / or the subchondral plate and / or The bone is microfractured to bleed the body's own Cells from the fatty tissue of the cancellous bone underlying the defect to enable. The microfracturing thus allows, in particular, an uninoculated Implant with the body's own Cells can be colonized. The microfracturing can also be made when a graft, that is one with cartilage cells inoculated implant is used. This will also provide a supply the cartilage cells used significantly improved.

Preferably if a perforation instrument is used for the microfracturing, that at its distal end at least one pointing in the distal direction Carries perforation projection. For example, by piercing the subchondral plate or the spongy underlying Bone can with the perforation instrument the processed tissue be microfractured.

Around to be able to set the implant targeted after insertion is it cheap, if after microfracturing within the prepared defect a mounting hole for a fastener for securing the implant within of the prepared Defect is set. The mounting hole can of course also be set if no microfracturing is performed. in principle the hole can already be set before a cut to the preparation of the cartilaginous margin and removes cartilage tissue within the incision becomes.

Especially easy can be make the hole when it is drilled or punched.

Preferably becomes a perforated instrument for drilling or punching the mounting hole through a guide channel introduced through the perforation channel. This allows the desired hole to provide at a precisely predefined position. Further, by the guide channel also a good guide for the Perforated instrument realized.

conveniently, The implant is guided by the guiding instrument through in the prepared Defective used. In this way, a contact of the implant with the body of the patient until the implant in the defect desired Fills in the way.

In order to improve implant ingrowth, it is advantageous if the implant is enriched with the body before insertion in the laboratory Inoculated cells. Such an implant, also referred to as a "graft", is generally not rejected by the body and, in addition, regeneration of the original cartilage is markedly improved.

Advantageous it is when the instrumentation is a placement tool for insertion of the implant and when the insertion instrument is inserted through the guide instrument. Depending on the version of the insertion tool, the implant can also be held on this be. This prevents it in an undefined way is inserted into the defect or lost upon insertion into the body goes.

Around the introduction of the implant in the body To simplify, it is advantageous if the implant before the Introduce of the insertion instrument into one at the distal end of the insertion instrument provided implant receptacle at least partially inserted and with the insertion instrument through the guide instrument into the prepared Defect is used. The small, difficult-to-handle implant can be easily moved and positioned. For this only the insertion instrument in the desired manner by the guide instrument moved through. In addition, if a stop on the insertion provided is that of a movement of the insertion instrument in the distal direction relative to the management tool limited, the implant can be moved directly into the defect, without one too big Pressure or otherwise stress on the implant itself exercised become.

In order to the implant retains a desired position after insertion it cheap if the implant used by sewing and / or gluing and / or is determined with at least one fastener.

Around a duration, so an intervention time, the treatment method too shorten and to further simplify the process, it may be advantageous if the insertion instrument with the guiding instrument before attaching the implant. It is enough then out, either just the management tool or to hold the insertion instrument as the other instrument is automatically kept.

According to one Another preferred variant of the method described can be provided that the Einsetzinstrument a in its interior in the longitudinal direction extending fastener insertion channel and that the implant after insertion at the subchondral plate and / or at the underlying Bone is set.

Preferably is a fastener insertion instrument for inserting the used at least one fastener and through the Befestigungselementeinführkanal introduced. The fastener insertion instrument thus becomes easy guided, an operator must therefore not superior and check where he introduces the instrument must, um the implant in the desired Way to set.

On a particularly simple way can be fix the implant if a bone pin is used as the fixation element is used and when the bone pin with the fastener insertion instrument held, is brought to the implant and used. For each Implant can one or more bone pins are used.

alternative or additionally It may be advantageous if an adhesive as a fastener is used as and when the fastener insertion instrument a glue cannula insertable through the fastener insertion channel. Under circumstances can directly through the Befestigungselementeinführkanal an adhesive be initiated so that this itself serves as an adhesive cannula.

Further it can be cheap if there is a stop on the insertion tool before the implant is set for specifying an insertion depth for the fastener insertion instrument is set. Depending on the thickness of the implant and depending on of the remaining tissue below the defect can be so simple Are given way, how deep the fastener in the tissue underneath the defect is driven.

advantageously, All procedural steps to treat the defect by the management tool passed through. So it's just the management tool needed to the desired Provide access to treat the defect and to the treatment area shield.

Especially for larger defects, the one area which is larger as defined by a distal end of the guide instrument Area, it can be cheap be if the defect is due to "patchwork-like" insertion of multiple implants is treated. It can, As described above, several implants inserted one after the other become overlapping Areas of the defect can be filled in succession with implant parts.

The treatment process becomes particularly simple when the defect to be treated is preprocessed by several overlapping circular steps is formed and when the plurality of implants are formed by several, at least partially disc-shaped carriers prepared, adjacent implants. The defect to be treated can thus be filled out completely in the manner of a patchwork patch with implants whose overall shape is the shape of the defect.

The The following description of a preferred embodiment of the invention serves in conjunction with the drawings for further explanation. Show it:

1 an arthroscopic instrumentation according to the invention;

2 a side view of a position holding instrument;

2a FIG. 4: an enlarged side view of the distal end of the position-holding instrument in the direction of the arrow A in FIG 2 ;

2 B : an enlarged view of the distal end of the position holding instrument in 2 ;

3 a side view of a guide instrument according to the invention;

4 a side view of an impactor;

5 a side view of a milling instrument;

6 a side view of a nonwoven punch;

7 a side view of a perforation instrument;

8th a sectional view taken along line BB in 7 ;

9 : an end view in the direction of the arrow C in 7 ;

10 a side view of an insertion instrument;

11 a sectional view along line DD in 10 ;

12 a side view of a drill;

13 a side view of a pestle;

14 : a schematic representation of the processing of a cartilage defect edge;

15 Fig. 3 is a sectional view through a joint layer during the removal of cartilage;

16 Fig. 3 is a sectional view during microfracturing of the subchondral plate;

17 a sectional view during insertion and fixing of the implant in the machined defect; and

18 : A plan view of a patchwork-like treated with multiple implants cartilage defect.

In 1 are some instruments of an overall reference numeral 10 provided arthroscopic instrumentation, which in particular for the treatment of a resulting from trauma and / or degeneration defect 164 on a cartilage 70 of a human body can be used. In addition to the instruments of the instrumentation described in more detail below 10 can be provided even more, not shown instruments. Furthermore, the instrumentation is suitable 10 also for the treatment of a bone defect.

A component of the instrumentation 10 this is the reference number 12 provided guide instrument, which has substantially the shape of an elongated tubular sleeve, and in its interior serving as an instrument insertion channel instrument channel 14 defined by almost all instruments of the instrumentation 10 for the treatment of cartilage defect 164 introduced and to the defect 164 can be introduced.

Further components of the instrumentation 10 are a position holding instrument 16 which also has substantially the shape of an elongated tube and in its interior an insertion channel 18 defined in which the management tool 12 coming from the proximal direction can be introduced in the distal direction.

Furthermore, the instruments include 10 a milling instrument 20 and a nonwoven punch intended as an implant material processing instrument 22 , Furthermore, it is a perforation instrument 24 for microfracturing a subchondral plate 74 as well as to lead a likewise to the instrumentarium 10 belonging, serving as a punch drill 26 intended. For inserting an implant 146 is an insertion instrument 28 provided and for fixing a serving as a fastener bone pins 30 a serving as Befestigungselementeinsetzinstrument ram 32 ,

The following is the structure of the individual instruments of the instrument 10 As well as their Function related to the 2 to 18 explained in more detail.

The management tool 12 has at its proximal end a substantially disc-shaped handle 34 on, to which a smaller in diameter ring flange 36 connected directly in the distal direction. To the ring flange 36 in turn closes a locking projection 38 whose outer diameter in about half of the outer diameter of the annular flange 36 equivalent. The locking projection 38 is with a circumferential annular groove 40 provided and forms part of a latching connection between the guide instrument 12 and the position holding instrument 16 ,

Starting from the locking projection 38 extends in the longitudinal direction 42 an elongated pipe section 44 inside the instrument channel 14 Are defined. A distal end 46 of the pipe section 44 Tapered slightly conical and ends in a trained as a ring cutting edge pointing in the distal direction 48 , Distances to the edge 48 is in a wall of the pipe section 48 in the transition from a cylindrical to conical region of the pipe section 44 a viewing opening 50 transverse to the longitudinal direction 42 in the form of a parallel to the longitudinal direction 42 extending slot provided.

On the handle 34 are three circumferentially extending over an angular range of about 100 ° slots extending 52 provided an opening of the handle 34 parallel to the longitudinal direction 42 form. A diameter of the curved slots 52 is smaller than an outer diameter of the annular flange 36 so that the slots 52 also through the ring flange 36 extend through.

The position holding instrument 16 has at its proximal end an annular flange 54 on, in the distal direction substantially one-stage to a retaining flange 56 tapered, in which a the insertion channel 18 defining pipe 58 is held. At the distal end of the tube 58 is from its distal-facing edge 60 a the edge 60 extending, distally pointing projection 62 from, the two serving as anchoring sharp spikes 64 carries, which also point in the distal direction. In a wall of the pipe 58 is adjacent to the edge 60 in a similar way as the viewing aperture 50 in the management tool 12 a viewing window 66 in the form of a parallel to the longitudinal direction 42 extending slot provided. A distance from a distal edge of the viewing port 50 to the edge 48 corresponds approximately to the distance of the distal end of the viewing window 66 from that by the projection 62 defined distal end of the position holding instrument 16 without the spines 64 , The lead 62 forms a distal stop for the position holding instrument 16 which limits the driving of the same in the body in the distal direction.

For temporarily connecting the position holding instrument 16 with the management tool 12 is one, in 2 schematically shown a ball catch 68 in the flange 54 arranged in a radial direction on an axis of symmetry of the position-holding instrument 16 Covered ball. The ball catch 68 is arranged such that the resiliently biased ball in a connecting position in the annular groove 40 the locking projection 38 can dip when the management tool 12 in the insertion channel 18 dips the position holding instrument and with the annular flange 36 on the flange 54 is applied.

To drive in the spines 64 the position holding instrument 16 in between the cartilage 70 and spongy bone 72 lying subchondral plate 74 serves a in 4 shown, also to the instrumentation 10 belonging impact instrument 76 , It comprises a disk-shaped carrier 78 of which there is an anvil-shaped impact head on the proximal side 80 rotationally symmetric path that extends a clubface 82 defined, which points in the proximal direction. Stand on the distal side of the carrier 78 three symmetrically distributed over the circumference cylindrical firing pin 84 starting parallel to the longitudinal direction 42 are arranged running. The firing pin 84 are also arranged so that they through the Einschlaginstrumentführung forming slots 52 can be inserted through. The impact instrument 76 can after inserting the firing pin 84 in the slots 52 relative to the management tool 12 to be twisted slightly, taking the length of the slots 52 in the circumferential direction a twisting of the impactor 76 relative to the management tool 12 define.

Distally facing end surfaces 86 The firing pin are in the distal direction over the ring flange 36 when the carrier 78 on the handle 34 is applied. A ring surface pointing in the proximal direction 88 of the flange 54 forms a Einschlaginstrumentanlagefläche, on which the end faces 86 come into investment when the management tool 12 in the insertion channel 18 is introduced. The length of the firing pin 84 is chosen so that the faces 86 on the ring surface 88 abut when the wearer 78 on the handle 34 is applied, wherein a distal end of the projection 62 then at the same height with the edge 48 of the management instrument 12 lies. This prevents the position holding instrument 16 too deep into the subchondral plate 74 or even in the bones 72 can be taken.

In 5 is the essentially rotationally symmetrical milling instrument 20 shown. It has an elongated cylindrical shaft 90 on, at the distal end of a two-piece milling element 92 is arranged, which two relative to each other by 180 ° offset cutting 94 includes. Overall, the milling element 92 designed as a face milling cutter. It also has a slightly larger diameter than the shaft 90 , An outer diameter of the milling element 92 is at an inner diameter of the distal end 46 of the management instrument 12 customized. Proximalseitig is on the shaft 90 a flange-like ring stop 96 provided, which as a stop for engagement with the handle 34 of the management instrument 12 serves. In this way it is ensured that the cutting edges 94 of the milling instrument do not project further in the distal direction than the edge 48 , From the proximal end of the ring stop 96 outstretched shaft 96 is in the proximal direction facing a drive pin 98 arranged, which can be connected to a drive to the milling instrument 20 in the instrument channel 14 to set in rotation.

In the 6 illustrated nonwoven punch corresponds in its essential structure of the milling instrument 20 , It includes a coupling pin on the proximal side 100 and also has a ring stop 102 on. A shaft extending distally therefrom 104 does not end in a milling element, but in a material cutting tool in the form of a punching head 106 with a circular-shaped cutting edge pointing in the distal direction 108 , The fleece punch 22 can also through the instrument channel 14 be introduced, taking the handle 34 fitting ring stop 102 make sure the cutting edge 108 not over the edge 48 protrudes.

This in 7 represented perforation instrument 24 comprises an elongated tube 110 , on which concentric an inner tube 112 for the formation of a guide channel 114 is arranged. At the proximal end of the tube 110 is a head 116 arranged in the radial direction over the pipe 110 protrudes and a stop to rest on the handle 34 forms when the perforation instrument 24 in the instrument channel 14 of the management instrument 12 is introduced. The guide channel 114 extends in the proximal direction through the head 116 therethrough. A distal end of the guide channel 114 is closed, with a diameter in relation to the guide channel 114 much smaller bore 118 is provided, which has a small opening of the guide channel 114 forms in the distal direction. One end of the guide channel 114 is opposite a distal edge 120 of the pipe 110 slightly set back in the proximal direction. One at or adjacent to the edge 120 arranged, pointing in the distal direction, serving as a perforation projection mandrel 122 is about as far from the edge 120 off like the spines 64 from the lead 62 the position holding instrument 16 ,

The guide channel 114 serves to insert the drill used as a perforated instrument 26 who in 12 is shown. It has an elongated, to an inner diameter of the guide channel 114 adapted shaft 124 on, at the proximal end of a cylindrical button 126 is arranged. The button 126 serves as a stop of the drill 26 at the head 116 the perforation instrument 24 , To the shaft 124 closes distally on a conical taper section 128 from which is coaxial with the shaft 24 pointing in the distal direction a drill bit designed as a drilling tool 130 extends away. An outer diameter of the drill bit 130 is slightly smaller than an inside diameter of the hole 118 that the guide channel 114 opens distally. Is the button 126 at the head 116 on, the drill bit protrudes about as far over the edge 120 the perforation instrument 16 out like the thorn 122 ,

This in 10 illustrated insertion instrument 28 resembles the perforation instrument 24 , It has a head 116 identical head 132 on, but in the proximal direction of a cup-shaped, concentric recording 134 followed. From the head 132 extends distally to the tube 110 corresponding pipe 136 which has an annular edge on the distal side 138 having. Adjacent to the head 132 is on the pipe 136 an annular projection 140 arranged, with an external thread section 142 is provided. The insertion instrument 28 can through the instrument channel 14 into the management tool 12 be introduced. In the area of the handle 34 is an external thread section 142 provided corresponding inner threaded portion, so that the Einsetzinstrument 28 with the management tool 12 can be screwed on the proximal side. Through the threaded sections can be a distance of the head 132 relative to the handle 34 be adjusted and changed.

The distal end is at the insertion instrument 28 an implant receptacle in the form of a cup-shaped depression 144 provided, in which a substantially disc-shaped implant 146 can be inserted. Through the insertion instrument 28 through extends a guide channel 150 defining tube 148 which the recording 134 and the depression 144 connects with each other.

For insertion into the depression 134 is an in 11 in section shown plastic stopper 152 provided a central hole 154 which is coaxial with the tube 148 runs when the plastic plug 152 in the recording 134 is used. An inner diameter of the bore 154 is slightly smaller than an inner diameter of the tube 148 , The plastic stopper 152 serves as Be fastening element holding element and is made of an elastic material. A bone pin 30 , whose outer diameter is slightly larger than an inner diameter of the bore 154 , so in the hole 154 the plastic stopper 152 held clamped.

The serving as Befestigungselementeinsetzinstrument ram 32 is in 13 shown. He has an elongated rod-shaped shaft 158 on whose outer diameter is slightly smaller than an inner diameter of the tube 148 , so that the shaft 158 in the guide channel 150 is insertable. At the proximal end of the shaft 158 is a head 160 arranged, which at maximum in the guide channel 150 inserted plunger 32 at the reception 134 or on the plastic stopper 152 of the insertion instrument 28 strikes. In the maximum inserted position is the distal end 162 of the plunger 32 something opposite the edge 138 reset in the proximal direction.

The use of the instruments 10 is hereinafter in connection with the figures, in particular with the 14 to 18 , explained in more detail.

For the treatment of a cartilage defect 164 For example, in a joint of a human or animal body, initially a minimally invasive approach 166 opened into the human or animal body, which makes it the guiding instrument 12 to the cartilage defect 164 introduce. Before inserting the guide instrument 12 into the body becomes the guiding instrument 12 in the insertion channel 18 of the position holding instrument inserted and connected proximally latching thereto. The two now releasably interconnected instruments are then through the minimally invasive approach 166 into the body and to the cartilage defect 164 introduced.

With the edge 48 of the management instrument 12 is used to treat a dislocated cartilage margin 170 a defined, circular cut 168 around the cartilage defect 164 set around. The edge 48 is completely or partially through the cartilage 70 through to the subchondral plate 74 introduced. The management tool 12 now stay with its edge 48 in abutment with the subchondral plate 74 positioned. In a next step, the milling instrument 20 through the instrument channel 14 inserted and remaining cartilage 70 within the cut 168 with the milling instrument 20 except for the subchondral plate 74 away. After that, the milling instrument 20 back from the management tool 12 pulled out. Optionally, in a next step, the perforation instrument 24 through the instrument channel 14 be introduced. With the thorn 122 becomes the subchondral plate 74 microfractured, that is the subchondral plate 74 is perforated specifically to allow cells from the fatty tissue of cancellous bone 72 emerge and bleed into the implant to be inserted later. Exemplary are in 16 perforations 172 in the subchondral plate 74 indicated.

If necessary, in addition by the inner tube 112 the drill 126 introduced and with the drill bit 130 a borehole 174 in the subchondral plate 74 set. A depth of the borehole 174 is given by the head 116 beating head 126 of the drill 26 , As in 16 shown is the borehole 174 of a plurality of identical, annular around the borehole 174 arranged perforations 172 surround.

The defect 164 is now for receiving the implant 146 prepared. The implant 146 may consist of a suitable carrier material, for example a collagen fleece with the nonwoven punch 22 be punched out. It then corresponds in diameter to the prepared cartilage defect 164 , Optionally, the implant 146 Inoculated with endogenous, proliferated in the laboratory cartilage cells before insertion.

The implant 146 is used for insertion into the cartilage defect 164 into the depression 144 of the insertion instrument 28 inserted and together with the insertion instrument 28 through the management tool 12 through into the prepared cartilage defect 164 inserted. To fix the implant 146 can the one bone pin 30 in the hole 154 carrying plastic plugs 152 in the recording 134 be used. Subsequently, with the pestle 32 the bone pin 30 out of the hole 154 in the guide channel 150 advanced until a shaft section 176 of the bone pin 30 in the borehole 174 dips. The head 156 of the bone pin holds the implant 146 in the prepared cartilage defect 164 ,

The implant 146 may alternatively at the subchondral plate 74 also sewn or with a through the guide channel 150 Glued applied adhesive.

The treatment of the cartilage defect 164 can with an unillustrated, introduced by a further minimally invasive access endoscope through the viewing port 50 and the viewing window 66 be observed from the outside. It would also be conceivable, both on the viewing window 66 as well as to dispense with the viewing port and instead the tube 58 and the pipe section 44 wholly or partly made of a transparent material.

For cartilage defects 164 that are bigger than a diameter of the rim 48 be multiple implants 146 , as in 18 presented, one after the other in the prepared cartilage defect 164 used. First, as above for a single implant 146 described, a first cut with the management instrument 12 set and a disc-shaped implant 146 used. Once this is used in its proper position and optionally fixed, the management tool becomes 12 slightly offset so that there is still an overlap area 178 remains. By setting another cut 168 the cartilage margin is further processed and remaining cartilage with the milling instrument 20 away. Before inserting the milling instrument 20 becomes optional with the fleece punch 22 a part of the implant already used 146 cut off, so that the milling instrument 20 the already used implant 146 can not damage. This described procedure is performed several times in succession until the original cartilage defect 164 with implants 146 is covered.

If for unforeseen reasons the management tool 12 must be withdrawn, the locking connection between the position holding instrument 16 and the management tool 12 solved and the position retaining element 16 advanced in the distal direction. With the impact instrument 76 becomes the position holding instrument with its thorns 64 into the subchondral plate 74 hammered in and temporarily anchored. This approach allows the management tool to be completely through the minimally invasive approach 166 retract and then return to its original position in abutment with the subchondral plate 74 bring to.

Through the management tool 12 a treatment area is completely shielded, that is, even after opening a joint, the treatment of the cartilage defect 164 be performed in the manner described, without the risk that Arthroskopieflüssigkeit used to widen the joint hinders the treatment and the insertion of the implant 146 in the prepared cartilage defect 164 makes it difficult or even impossible.

Claims (57)

Arthroscopic instrumentation ( 10 ), in particular for the treatment of a defect due to trauma and / or degeneration ( 164 ) on a cartilage ( 70 ) and / or a bone ( 72 ) of a human or animal body, the instrumentation ( 10 ) a a longitudinal direction ( 42 ) instrument insertion channel ( 14 ) comprehensive management tool ( 12 ) for introducing further instruments ( 20 . 22 . 24 . 26 . 28 . 32 ) of the instruments ( 10 ) in the human or animal body, the instrumentation ( 10 ) an implant material processing instrument ( 22 ) comprises for preparing a carrier ( 146 ) of an implant material and wherein the implant material processing instrument ( 22 ) at its distal end a material cutting tool ( 106 ), characterized in that the material cutting tool ( 106 ) in the form of an annular or substantially annular cutting edge ( 108 ) or punch is formed, that the implant material processing instrument ( 22 ) a nonwoven punch is for preparing a carrier ( 146 ) of an implant material which is a fleece, and that the guiding instrument ( 12 ) at or adjacent to its distal end ( 46 ) at least one transverse to the longitudinal direction ( 42 ) oriented viewing aperture ( 50 ) having. Instrumentation according to claim 1, characterized in that the management instrument ( 12 ) in the form of a longitudinally elongated guide sleeve ( 44 ) is trained. Instrumentation according to one of the preceding claims, characterized in that the management instrument ( 12 ) at its distal end a cutting tool ( 48 ) wearing. Instrumentation according to claim 3, characterized in that the cutting tool ( 48 ) in one piece with the management instrument ( 12 ) is trained. Instrumentation according to one of Claims 3 or 4, characterized in that the management instrument ( 12 ) has a pointing edge in the distal direction and that the edge at least partially the cutting tool ( 48 ). Instrumentation according to one of the preceding claims, characterized in that the viewing aperture ( 50 ) in the form of a longitudinal ( 42 ) extending in a wall of the guide instrument ( 12 ) is trained. Instrumentation according to one of the preceding claims, characterized in that the instrumentation ( 10 ) a cutting and / or milling instrument ( 20 ), in particular for cartilage and / or bone processing, and in that the cutting and / or milling instrument ( 20 ) at its distal end at least one cutting or milling element ( 92 ) and into the Instrumenteinführkanal ( 14 ) is insertable. Instrumentation according to claim 7, characterized in that the cutting and / or milling instrument ( 20 ) in the instrument insertion channel ( 14 ) is rotatable or rotatable. Instrumentation according to one of claims 7 or 8, characterized in that the at least one cutting or milling element ( 92 ) two mutually offset by 180 ° asymmetrically cutting ( 94 ). Instrumentation according to one of the preceding claims, characterized in that the instrumentation ( 10 ) a position-holding instrument ( 16 ) and that the position-holding instrument ( 16 ) an insertion channel ( 18 ) for insertion of the guiding instrument ( 12 ). Instrumentation according to claim 10, characterized in that the position-holding instrument ( 16 ) at its distal end at least one anchoring element ( 64 ) wearing. Instrumentarium according to claim 11, characterized in that the at least one anchoring element ( 64 ) in the form of a mandrel pointing in a distal or substantially distal direction ( 64 ) is trained. Instrumentation according to one of Claims 10 to 12, characterized in that the position-holding instrument ( 16 ) at or adjacent its distal end at least one transverse to the longitudinal direction ( 42 ) oriented viewing window ( 66 ) having. Instrumentarium according to claim 13, characterized in that the viewing window ( 66 ) in the form of a longitudinal ( 42 ) extending in a wall of the position holding instrument ( 16 ) is trained. Instrument set according to one of Claims 10 to 14, characterized in that the position-holding instrument ( 16 ) with the management tool ( 12 ) is releasably connectable. Instrumentarium according to claim 15, characterized in that a latching connection ( 68 . 40 ) for detachably connecting the position holding instrument ( 16 ) with the management tool ( 12 ) is provided. Instrumentarium according to one of claims 10 to 16, characterized. that the position-holding instrument ( 16 ) shorter than the management tool ( 12 ). Instrument set according to one of the preceding claims, characterized in that the implant material processing instrument ( 22 ) is designed such that an implantable with cartilage cells implant material is machinable. Instrumentation according to one of the preceding claims, characterized in that the instrumentation ( 10 ) a perforation instrument ( 24 ) for perforating cartilage ( 70 ) and / or subchondral plates ( 74 ) and / or bones ( 72 ) and that the perforation instrument ( 24 ) into the instrument insertion channel ( 14 ) is insertable. Instrumentarium according to claim 19, characterized in that the perforation instrument ( 24 ) at its distal end at least one perforation projection ( 122 ) wearing. Instrumentarium according to claim 20, characterized in that the at least one perforation projection ( 122 ) in the form of a distally projecting spike ( 122 ) is trained. Instrumentarium according to one of Claims 19 to 21, characterized in that the perforation instrument ( 24 ) at least one longitudinally ( 42 ) extending guide channel ( 114 ) whose inner diameter is smaller than an outer diameter of the perforation instrument ( 24 ). Instrumentarium according to claim 22, characterized in that the perforation instrument ( 24 ) substantially the shape of an elongated tube ( 110 ) and that the guide channel ( 114 ) coaxial with a longitudinal axis of the perforation instrument ( 24 ) is arranged. Instrumentation according to one of the preceding claims, characterized in that the instrumentation ( 10 ) an insertion instrument ( 28 ) for inserting an implant ( 146 ) and that the insertion instrument ( 28 ) into the instrument insertion channel ( 14 ) is insertable. Instrumentarium according to claim 24, characterized in that the insertion instrument ( 28 ) a guide tube ( 136 ) and one in the guide tube ( 136 ) in the longitudinal direction movable feed element and that the implant ( 146 ) with the advancing element in the distal direction through the guide tube ( 136 ) is movable. Instrumentation according to Claim 25, characterized in that the advancing element has a plate (8) at its distal end. 144 ) on which the implant ( 146 ) transversely or substantially transversely to the longitudinal direction ( 42 ) can be applied flat. Instrument set according to claim 26, characterized in that at the distal end of the insertion instrument ( 28 ) or on the plate an implant receptacle ( 144 ) for at least partially receiving an implant ( 146 ) is provided. Instrumentarium according to claim 27, characterized in that the implant receptacle ( 144 ) in Form of a distally pointing, flat pot-shaped depression ( 144 ) is trained. Instrument set according to one of Claims 25 to 28, characterized in that the distal end of the advancing element has an internal cross-section of the guide tube ( 136 ) completely or substantially completely fills. Instrument set according to one of Claims 25 to 29, characterized in that, inside the insertion instrument ( 28 ) a longitudinally extending Befestigungselementeinführkanal ( 150 ) is provided. Instrumentation according to claim 30, characterized in that an inner cross-section of the fastener insertion channel ( 150 ) is substantially smaller than an inner cross section of the guide tube ( 136 ). Instrument set according to one of Claims 24 to 31, characterized in that the insertion instrument ( 28 ) with the management tool ( 12 ) is releasably connectable. Instrumentation according to claim 32, characterized in that the insertion instrument ( 28 ) with the management tool ( 12 ) is screwed. Instrumentation according to one of the preceding claims, characterized in that the instrumentation ( 10 ) an elongated perforated instrument ( 26 ) for creating a hole ( 174 ) or a depression in a cartilage ( 70 ), a subchondral plate ( 74 ) or a bone ( 72 ) and that the perforated instrument ( 26 ) into the instrument insertion channel ( 14 ) is insertable. Instrumentation according to Claim 34, characterized in that the perforated instrument ( 26 ) in the guide channel ( 114 ) is insertable. Instrument set according to one of claims 34 or 35, characterized in that a distal end of the perforated instrument ( 26 ) has a diameter smaller than that of the guide channel ( 114 ). Instrument set according to one of claims 34 to 36, characterized in that the perforated instrument ( 26 ) has a distal end which is in the form of a drill ( 130 ) or a punch is formed. Instrumentation according to one of the preceding claims, characterized in that the instrumentation ( 10 ) a fastener insertion instrument ( 32 ) for insertion and / or insertion of a fastener ( 30 ) and that the fastener insertion instrument ( 32 ) into the instrument insertion channel ( 14 ) is insertable. Instrument set according to claim 38, characterized in that the fastener insertion instrument ( 32 ) in the fastener insertion channel ( 150 ) is insertable. Instrument set according to one of claims 38 or 39, characterized in that the fastener insertion instrument ( 32 ) at its distal end ( 162 ) has a fastener receiving element for receiving a fastener ( 30 ), whose distal end ( 176 ) points in the distal direction. Instrument set according to one of claims 38 to 40, characterized in that the fastener insertion instrument ( 32 ) in the form of a plunger ( 32 ) is trained. Instrumentation according to one of the preceding claims, characterized in that the instrumentation ( 10 ) at least one fastening element ( 30 ). Instrument set according to claim 42, characterized in that the fastening element ( 30 ) a bone pin ( 30 ). Instrument set according to one of Claims 7 to 43, characterized in that a proximal end of the guide instrument ( 12 ) an axial stop ( 34 ) for a radially extending projection ( 96 ) of the cutting and / or milling instrument ( 20 ) Are defined. Instrument set according to one of claims 19 to 44, characterized in that a proximal end of the guide instrument ( 12 ) an axial stop ( 34 ) for a radially extending projection ( 116 ) of the perforation instrument ( 24 ) Are defined. Instrument set according to one of Claims 24 to 45, characterized in that a proximal end of the guide instrument ( 12 ) an axial stop ( 34 ) for a radially extending projection ( 132 ) of the insertion instrument ( 28 ) Are defined. Instrument set according to one of Claims 34 to 46, characterized in that a proximal end of the perforation instrument ( 24 ) an axial stop for a radially extending projection ( 126 ) of the perforated instrument ( 26 ) Are defined. Instrumentarium according to one of the claims 38 to 47, characterized in that a proximal end of the insertion instrument ( 28 ) an axial stop ( 134 . 152 ) for a radially extending projection ( 160 ) of the fastener insertion instrument ( 32 ) Are defined. Instrumentation according to one of the preceding claims, characterized in that the instrumentation ( 10 ) a fastener holding member ( 152 ) for holding a fastener ( 30 ) that a fastener ( 30 ) with the fastener holding element ( 152 ) is releasably connectable and that the fastener holding member ( 152 ) with at least one of the instruments ( 28 ) of the instruments ( 10 ) is releasably connectable. Instrumentation according to Claim 49, characterized in that the fastening element holding element ( 152 ) with a proximal end ( 134 ) of the insertion instrument ( 28 ) is releasably connectable. Instrument set according to one of claims 49 or 50, characterized in that the fastening element holding element ( 152 ) in the form of an elastic or plastic plug ( 152 ) is formed and that the plug ( 152 ) a longitudinally extending channel ( 154 ) for receiving the fastener ( 30 ) having. Instrumentation according to claim 50, characterized in that the channel ( 154 ) in an initial position has an inner diameter which is smaller than a maximum outer diameter of the fastening element ( 30 ) or the fastener insertion instrument ( 32 ), and that the channel ( 154 ) by the fastener ( 30 ) and / or the fastener insertion instrument ( 32 ) transverse to the longitudinal direction ( 42 ) is at least partially expandable. Instrumentarium according to one of Claims 10 to 52, characterized in that the instruments ( 10 ) a striking instrument ( 76 ) for driving or driving in the position holding instrument ( 16 ) into a cartilage ( 70 ), a subchondral plate ( 74 ) or a bone. ( 72 ). Instrumentation according to Claim 53, characterized in that the management instrument ( 12 ) at least one impact instrument guide ( 52 ) for guiding a movement of the impactor ( 76 ) in the distal direction. Instrumentation according to Claim 54, characterized in that the management instrument ( 12 ) at its proximal end a radially extending annular projection ( 34 ) and that the at least one impact instrument guide ( 52 ) in the form of at least one longitudinally ( 42 ) extending, the annular projection ( 34 ) penetrating aperture ( 52 ) is trained. Instrument set according to one of claims 53 to 55, characterized in that the impact instrument ( 76 ) at least one pointing in the distal direction, the Einschlaginstrumentführung ( 52 ) corresponding striker ( 84 ). Instrument set according to one of Claims 10 to 56, characterized in that the position-holding instrument ( 16 ) at its proximal end ( 54 ) an impactor investment surface ( 88 ) having.