US20090216232A1 - Modular segmented intramedullary system, apparatus and methods - Google Patents
Modular segmented intramedullary system, apparatus and methods Download PDFInfo
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- US20090216232A1 US20090216232A1 US12/345,340 US34534008A US2009216232A1 US 20090216232 A1 US20090216232 A1 US 20090216232A1 US 34534008 A US34534008 A US 34534008A US 2009216232 A1 US2009216232 A1 US 2009216232A1
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Abstract
Description
- This application is a continuation-in-part of U.S. application Ser. No. 12/052,919, filed Mar. 21, 2008, which claims the benefit of priority from U.S. Provisional No. 60/896,342 filed Mar. 22, 2007, all of which are incorporated by reference in their entireties herein.
- This application claims the benefit of priority from U.S. Provisional No. 61/055,747, filed May 23, 2008, which is incorporated by reference in its entirety herein.
- Embodiments of the present invention relate to an orthopedic prosthesis, and, more particularly, to an implantable structure, commonly called an intramedullary or IM nail, that is adapted to be received in the intramedullary canal for the treatment of long bone fractures.
- The intramedullary structure of the present disclosure, in one embodiment, utilizes a plurality of segments that are preferably introduced into the intramedullary canal over a guide member that has been previously introduced into the intramedullary canal through a percutaneous access hole, or access port at an access site. Each segment is preferably configured so that it interconnects with the segments adjacent thereto. In one embodiment an elongated tensioning member is received interiorly of the segments and is secured to the end segments to secure all the segments in the structure together. In one embodiment, the guide member is a wire or cable that can also serve as the tensioning member. In one embodiment each segment may have an aperture, in the form of an open interior, so that the segment can be threaded over a guide or tensioning member. The segments also have opposed ends that preferably are complementarily-shaped so that a first interface of a first segment is adapted to cooperatively engage with a second interface of a second segment adjacent thereto. In one embodiment each segment has a male end portion and a complementarily-shaped female end portion.
- In one embodiment a method of manufacturing a customized implant includes evaluating a parameter of an intramedullary canal of a bone, providing a plurality of segments comprising a channel configured to move along a guide, assembling a customized structure by selecting a first segment based on the evaluating a parameter of the intramedullary canal of the bone and distally advancing the first segment along the guide, and selecting a second segment based on the evaluating a parameter of the intramedullary canal of the bone and distally advancing the second segment along the guide.
- In one embodiment a method of constructing an implant customized for a patient includes selecting from an array of segments, assembling two or more segments along an elongate element in to a structure, and locking the structure to retain the structure in a substantially rigid configuration. Each segment includes a channel configured to be moveable along the elongate element. In one embodiment the assembling two or more segments in to a structure also includes advancing each segment over the elongate element and interfacing adjacent segments with corresponding interfaces. In one embodiment the locking the structure comprises tensioning an elongate element.
- In one embodiment an assembly for tensioning a surgical elongate member includes an elongate member, a locking feature, a tensioner, and a locking mechanism actuator. The elongate member has a first location connectable to an implant. The locking feature is configured to circumferentially engage the elongate member to lock onto a second location on the elongate member. The tensioner is configured to engage the locking feature, wherein the tensioner is actuatable to move the locking feature relative to the first location to regulate tension on the elongate member between the first location and the second location when the first location is connected to the implant and the second location is locked in the locking feature. The locking mechanism actuator is configured to actuate a locking mechanism to lock onto a third location on the elongate member. In one embodiment the implant is a segmented intramedullary fracture fixation device. In one embodiment the third location is between the first location and the second location.
- In one embodiment an assembly for tensioning a surgical elongate member includes an elongate member having a first location connectable to an implant, a locking feature configured to engage the elongate member to lock onto a second location on the elongate member, a tensioner configured to engage the locking feature, and a locking mechanism actuator. The tensioner is actuatable to move the locking feature relative to the first location to regulate tension on the elongate member between the first location and the second location when the first location is connected to the implant and the second location is locked in the locking feature. The locking mechanism actuator is configured to reversibly actuate a locking mechanism to lock and unlock onto a third location on the elongate member, wherein the locking mechanism actuator is contained within the tensioner. In one embodiment the implant is a segmented intramedullary fracture fixation device. In one embodiment the third location is between the first location and the second location. In one embodiment the locking feature is configured to circumferentially engage the elongate member.
- In one embodiment an implantable intramedullary fixation structure includes a proximal end, a distal end and an elongate body adapted to be received in the intramedullary canal of a long bone. The implantable intramedullary fixation structure includes a plurality of segments, a tensioning member and a lock. Each segment includes a first interface and a complementarily-shaped second interface such that the first interface of a segment cooperatively engages the second interface of an adjacent segment. The segments include a guide lumen so as to be receivable over a guide for positioning in the intramedullary canal. The tensioning member extends through the fixation structure to apply a compressive force along the longitudinal axis of the structure. The lock in at least one of the proximal end and the distal end secures the tension member. Activation of the tensioning member causes the fixation structure to convert from a substantially flexible state to a substantially rigid state. In one embodiment the intramedullary structure also includes a radially-expandable member in a segment and having tensioning member secured thereto, the tensioning member residing in a channel extending along a length of the intramedullary structure. In one embodiment the expandable member includes an expander having a plurality of depending legs and a wedge, the tensioning member being secured to the wedge so that when the tensioning member is tensioned, the wedge spreads the legs of the expander radially outwardly.
- Other features and aspects will become apparent upon reference to the accompanying drawings and description.
- These and other features, embodiments, and advantages of the present invention will now be described in connection with preferred embodiments of the invention, in reference to the accompanying drawings. The illustrated embodiments, however, are merely examples and are not intended to limit the invention.
-
FIG. 1 is a perspective of an assembled segmented intramedullary structure, such as a nail, according to a first embodiment of the disclosure. -
FIG. 2 is a perspective view of a single segment of the intramedullary nail ofFIG. 1 . -
FIG. 3 is a longitudinal cross-sectional view of the segment ofFIG. 2 . -
FIG. 4 is a perspective view of an intramedullary nail utilizing a second embodiment of an individual nail segment. -
FIGS. 5 and 6 are perspective views of a third embodiment of an individual segment for use in an intramedullary structure and a plurality of such segments received over a guide member. -
FIGS. 7 and 8 are perspective views of a fourth embodiment of an individual segment and a plurality of such structures received over a guide member. -
FIGS. 9 and 10 are perspective views of a fifth embodiment of an individual segment and a plurality of such segments mounted together. -
FIGS. 11 and 12 are perspective views of a sixth embodiment of a segment for use in an intramedullary nail in which a plurality of peripheral rods is used in the assembled nail. -
FIG. 13 is a perspective of a seventh embodiment of an IM nail in which the segments are connected to each other by a hinge member so that the nail can be inserted into the intramedullary canal through an access hole that is oblique to the axis of the intramedullary canal. -
FIGS. 14-22 schematically illustrate the procedure for installing a segmented intramedullary nail according to one embodiment of the present invention into the intramedullary canal of a long bone. -
FIG. 23 is a perspective view of a system for implanting an intramedullary fracture fixation device comprising the implantable fracture fixation device, a screw guide, and a cable tensioner according to one embodiment of the present invention. -
FIG. 24 is a front view of the implantable intramedullary fracture fixation device shown inFIG. 23 . -
FIG. 25 is a front view of the proximal-most segment of the implantable fracture fixation device shown inFIG. 24 . -
FIG. 26 is a front view of a typical intermediate segment of the implantable fracture fixation device shown inFIG. 24 . -
FIG. 27 is a front view of the distal-most segment of the implantable fracture fixation device shown inFIG. 24 . -
FIGS. 28 and 29 are perspective views of the intermediate segment shown inFIG. 26 . -
FIGS. 30 and 31 are perspective view of the proximal-most segment shown inFIG. 25 . -
FIG. 32 is a cross-sectional view of the distal portion of the implantable fracture fixation device ofFIG. 23 , showing details as to the distal-most segment. -
FIG. 33 is a perspective view of an expander forming a portion of the distal-most segment ofFIG. 32 . -
FIG. 34 is a perspective view of a screw guide interface adapted to be seated on the proximal end of the implantable fracture fixation device shown inFIG. 23 . -
FIG. 35 is a cross-sectional view of the screw guide interface and the proximal end of the fracture fixation structure shown inFIG. 24 . -
FIG. 36 is an enlarged perspective view of the cable tensioner according to one embodiment of the present invention. -
FIG. 37 is a cross-sectional view of the cable tensioner shown inFIG. 36 . -
FIG. 38 is an enlarged cross-sectional view of the cooperating structure of the cable tensioner and the proximal-end segment of the fracture fixation device according to one embodiment of the present invention. -
FIGS. 39A-39B are schematic representations of secondary compression in a long bone using an embodiment of a segmented intramedullary structure. -
FIGS. 40A-40B are schematic representations of secondary compression in a humerus using an embodiment of a segmented intramedullary structure. -
FIG. 41A is a schematic side view of an embodiment of a stepped segment of a segmented intramedullary structure. -
FIG. 41B is a schematic cross-sectional side view of the stepped segment ofFIG. 41A . -
FIG. 41C is a schematic perspective view of the stepped segment ofFIG. 41A . -
FIG. 42A is a schematic side view of an embodiment of a pair of adjacent stepped segments ofFIG. 41A in a bent configuration. -
FIG. 42B is a schematic cross-sectional side view of the pair of adjacent stepped segments ofFIG. 41A in a bent configuration. -
FIG. 42C is a schematic perspective view of the pair of adjacent stepped segments ofFIG. 41A in a bent configuration. -
FIG. 43A is a schematic side view of an embodiment of a pair of adjacent stepped segments ofFIG. 41A in a straightened, or compressed configuration. -
FIG. 43B is a schematic cross-sectional side view of the pair of adjacent stepped segments ofFIG. 41A in a straightened configuration. -
FIG. 43C is a schematic perspective view of the pair of adjacent stepped segments ofFIG. 41A in a straightened configuration. -
FIG. 44A is a schematic front view of an embodiment of a snap segment of a segmented intramedullary structure. -
FIG. 44B is a schematic cross-sectional front view of the snap segment ofFIG. 44A . -
FIG. 44C is a schematic side view of an embodiment the snap segment ofFIG. 44A . -
FIG. 44D is a schematic cross-sectional side view of the snap segment ofFIG. 44A . -
FIG. 44E is a schematic perspective view of the snap segment ofFIG. 44A . -
FIG. 45A is a schematic side view of an embodiment of a pair of adjacent snap segments ofFIG. 44A in a bent configuration. -
FIG. 45B is a schematic cross-sectional side view of the pair of adjacent snap segments ofFIG. 44A in a bent configuration. -
FIG. 45C is a schematic front view of the pair of adjacent snap segments ofFIG. 44A in a bent configuration. -
FIG. 45D is a schematic cross-sectional front view of the pair of adjacent snap segments ofFIG. 44A in a bent configuration. -
FIG. 45E is a schematic perspective view of the pair of adjacent snap segments ofFIG. 44A in a bent configuration. -
FIG. 46A is a schematic side view of an embodiment of a pair of adjacent snap segments ofFIG. 44A in a straightened configuration. -
FIG. 46B is a schematic cross-sectional view of the pair of adjacent snap segments ofFIG. 44A in a straightened configuration. -
FIG. 46C is a schematic front view of the pair of adjacent snap segments ofFIG. 44A in a straightened configuration. -
FIG. 46D is a schematic cross-sectional front view of the pair of adjacent snap segments ofFIG. 44A in a straightened configuration. -
FIG. 46E is a schematic perspective view of the pair of adjacent snap segments ofFIG. 44A in a straightened configuration. -
FIG. 47A is a schematic side view of an embodiment of a unidirectional segment of a segmented intramedullary structure. -
FIG. 47B is a schematic cross-sectional side view of the unidirectional segment ofFIG. 47A . -
FIG. 47C is a schematic perspective view of the unidirectional segment ofFIG. 47A . -
FIG. 48A is a schematic side view of another embodiment of a unidirectional segment of a segmented intramedullary structure. -
FIG. 48B is a schematic cross-sectional side view of the unidirectional segment ofFIG. 48A . -
FIG. 48C is a schematic perspective view of the unidirectional segment ofFIG. 48A . -
FIG. 49A is a schematic side view of an embodiment of a pair of adjacent unidirectional segments ofFIG. 48A in a bent configuration. -
FIG. 49B is a schematic transparent cross-sectional side view of the pair of adjacent unidirectional segments ofFIG. 48A in a bent configuration. -
FIG. 49C is a schematic partial cross-sectional side view of the pair of adjacent unidirectional segments ofFIG. 48A in a bent configuration. -
FIG. 50A is a schematic side view of an embodiment of a pair of adjacent unidirectional segments ofFIG. 48A in a straightened configuration. -
FIG. 50B is a schematic transparent cross-sectional side view of the pair of adjacent unidirectional segments ofFIG. 48A in a straightened configuration. -
FIG. 50C is a schematic partial perspective side view of the pair of adjacent unidirectional segments ofFIG. 48A in a straightened configuration. -
FIG. 51A is a schematic side view of an embodiment of a threaded segment of a segmented intramedullary structure. -
FIG. 51B is a schematic cross-sectional side view of the threaded segment ofFIG. 51A . -
FIG. 51C is a schematic perspective view of the threaded segment ofFIG. 51A . -
FIG. 52A is a schematic side view of another embodiment of a threaded segment of a segmented intramedullary structure. -
FIG. 52B is a schematic cross-sectional side view of the threaded segment ofFIG. 52A . -
FIG. 52C is a schematic perspective view of the threaded segment ofFIG. 52A . -
FIG. 53A is a schematic side view of an embodiment of a pair of adjacent threaded segments ofFIG. 52A in a bent configuration. -
FIG. 53B is a schematic transparent cross-sectional side view of the pair of adjacent threaded segments ofFIG. 52A in a bent configuration. -
FIG. 53C is a schematic partial cross-sectional side view of the pair of adjacent threaded segments ofFIG. 52A in a bent configuration. -
FIG. 54A is a schematic side view of an embodiment of a pair of adjacent threaded segments ofFIG. 52A in a straightened configuration. -
FIG. 54B is a schematic transparent cross-sectional side view of the pair of adjacent threaded segments ofFIG. 52A in a straightened configuration. -
FIG. 54C is a schematic partial perspective side view of the pair of adjacent threaded segments ofFIG. 52A in a straightened configuration. -
FIG. 55A is a schematic side view of an embodiment of a snap ring segment of a segmented intramedullary structure. -
FIG. 55B is a schematic cross-sectional side view of the snap ring segment ofFIG. 55A . -
FIG. 55C is a schematic front view of the snap ring segment ofFIG. 55A . -
FIG. 55D is a schematic cross-sectional front view of the snap ring segment ofFIG. 55A . -
FIG. 55E is a schematic perspective view of the snap ring segment ofFIG. 55A . -
FIG. 56A is a schematic side view of an embodiment of a pair of adjacent snap ring segments ofFIG. 55A in a bent configuration. -
FIG. 56B is a schematic cross-sectional side view of the pair of adjacent snap ring segments ofFIG. 55A in a bent configuration. -
FIG. 56C is a schematic front view of the pair of adjacent snap ring segments ofFIG. 55A in a bent configuration. -
FIG. 56D is a schematic cross-sectional front view of the pair of adjacent snap ring segments ofFIG. 55A in a bent configuration. -
FIG. 56E is a schematic perspective view of the pair of adjacent snap ring segments ofFIG. 55A in a bent configuration. -
FIG. 57A is a schematic side view of an embodiment of a pair of adjacent snap ring segments ofFIG. 55A in a straightened, compressed configuration. -
FIG. 57B is a schematic cross-sectional view of the pair of adjacent snap ring segments ofFIG. 55A in a straightened configuration. -
FIG. 57C is a schematic front view of the pair of adjacent snap ring segments ofFIG. 55A in a straightened configuration. -
FIG. 57D is a schematic cross-sectional front view of the pair of adjacent snap ring segments ofFIG. 55A in a straightened configuration. -
FIG. 57E is a schematic perspective view of the pair of adjacent snap ring segments ofFIG. 55A in a straightened configuration. -
FIG. 58A is a schematic side view of an embodiment of a pair of adjacent segments in a detached configuration in one embodiment of a segmented intramedullary structure. -
FIG. 58B is a schematic side view of the pair of adjacent segments ofFIG. 58A in a distracted configuration with an axial displacement length between the adjacent segments. -
FIG. 58C is a schematic side view of the pair of adjacent segments ofFIG. 58A in a bent configuration with a rotational displacement angle between the adjacent segments. -
FIG. 58D is a schematic side view of the pair of adjacent segments ofFIG. 58A in a compressed configuration. -
FIG. 59A is a schematic perspective view of an embodiment of a segmented intramedullary structure in a compressed configuration. -
FIG. 59B is a schematic side view of the segmented intramedullary structure ofFIG. 59A . -
FIG. 59C is a schematic front view of the segmented intramedullary structure ofFIG. 59A . -
FIG. 59D is a schematic top view of the segmented intramedullary structure ofFIG. 59A . -
FIG. 59E is a schematic rear view of the segmented intramedullary structure ofFIG. 59A . -
FIG. 59F is a schematic bottom view of the segmented intramedullary structure ofFIG. 59A . -
FIG. 59G is a schematic perspective partially exploded view of the segmented intramedullary structure ofFIG. 59A . -
FIG. 59H is a schematic cross-sectional side view of the segmented intramedullary structure ofFIG. 59A . -
FIG. 60 is a schematic side view of various embodiments of segmented intramedullary structures in bent configurations. -
FIG. 61 is a schematic perspective view of an embodiment of a cross-screw distal fixation structure segment of an intramedullary structure. -
FIG. 62 is a schematic perspective view of an embodiment of a polymer distal fixation segment of an intramedullary structure. -
FIG. 63 is a schematic perspective view of an embodiment of a radially-expandable distal fixation segment of an intramedullary structure. -
FIG. 64 is a schematic cross sectional side view of the cross-screw distal fixation structure segment of an intramedullary structure ofFIG. 61 . -
FIG. 65 is a schematic side view of a cable and cable tube according to one embodiment of the present invention. -
FIG. 65A is a schematic cross sectional view of the cable and the cable tube according toFIG. 65 . -
FIG. 66 is a schematic perspective view of an embodiment of a proximal end segment. -
FIG. 67 is a schematic top view of the proximal end segment ofFIG. 66 . -
FIG. 68 is a schematic cross sectional side view of the proximal end segment ofFIG. 66 . -
FIG. 69 is a schematic perspective view of a cable collet anchor according to one embodiment of the present invention. -
FIG. 70 is a schematic side view of a surgical procedure in a bone according to an embodiment of the present invention. -
FIG. 71 is a schematic side view of a surgical procedure in a bone with a broach according to an embodiment of the present invention. -
FIG. 72 is a schematic side view of a surgical procedure in a bone with a guide wire according to an embodiment of the present invention. -
FIG. 73 is a schematic side view of a surgical procedure in a bone with a measurement of implant length according to an embodiment of the present invention. -
FIG. 74 is a schematic side view of a surgical procedure in a bone with a bone reamer according to an embodiment of the present invention. -
FIG. 75 is a schematic side view of a surgical procedure in a bone with an exchange tube according to an embodiment of the present invention. -
FIG. 76 is a schematic side view of a segmented intramedullary structure being inserted in a bent configuration in to a sectional view of a bone according to an embodiment of the present invention. -
FIG. 77 is a schematic side view of a surgical procedure in a bone with a segmented intramedullary structure being inserted in a bent configuration in to a sectional view of a bone with a proximal drill guide according to an embodiment of the present invention. -
FIG. 78 is a schematic side view of a surgical procedure in a bone with a tensioner and a segmented intramedullary structure according to an embodiment of the present invention. -
FIG. 79 is a schematic side view of a modular, customizable segmented intramedullary structure according to an embodiment of the present invention. - Throughout the figures, the same reference numerals and characters, unless otherwise stated, are used to denote like features, elements, components or portions of the illustrated embodiments. In certain instances, similar names may be used to describe similar components with different reference numerals which have certain common or similar features. Moreover, while the subject invention will now be described in detail with reference to the figures, it is done so in connection with the illustrative embodiments. It is intended that changes and modifications can be made to the described embodiments without departing from the true scope and spirit of the subject invention as defined by the appended claims.
- In accordance with the present disclosure, various embodiments of an intramedullary structure are provided that are adapted to be received in the intramedullary canal of a bone, such as a long bone, including but not limited to a humerus, tibia, femur, radius, ulna, phalange, metatarsal, metacarpal, clavicle or other long bone. In various embodiments the structure comprises a plurality of segments, with complementary interfaces between the segments. In various embodiment the complementary interfaces can comprise complementary surfaces, complimentarily-shaped features, mating male and female portions, nested features, paired geometries, and the like which can interface a proximal, medial, intermediate, middle, or distal portion, area, or end of the respective segments. In one embodiment a segment has a first interface and a complementarily-shaped second end interface, so that the first interface of a segment cooperatively engages the second interface of an adjacent segment.
- In various embodiments the segments can define a channel, aperture or lumen so as to be receivable over an elongate member for introduction of the segments into the intramedullary canal. In various embodiments, the elongate member can be a wire, guide wire, pull wire, push wire, cable, rod, threaded rod, or other similar structure. Use of terms related to embodiments of elongate members may be used interchangeably and should be understood to refer to the various types of embodiments of the elongate member being used. For example, cable may be used to describe any number of types of elongate members, but should not be necessarily limited to use only with a cable. For example, a cable tensioner tool can be understood to refer to other possible embodiments of elongate member tensioner tools. In one embodiment the elongate member is a tensioning member extending along the length of the segmented intramedullary structure that cooperates with the two or more segments, such as in one embodiment the end-most segments, of the structure to apply a compressive force along the longitudinal axis of the structure, thus providing the structure with enhanced rigidity. In one embodiment the compressive force for enhancing rigidity also provides secondary compression to the surrounding bone segments by brining bone segments closer together.
- In various embodiments, different combinations of segments can be used or combined in a modular fashion to assemble custom made structures based on the bone and application for the structure. In some embodiments the intramedullary structure is removable from the body. In various embodiments the overall configuration or shape of the intramedullary structure may be straight, substantially straight, or curved along any one segment or any sets of segments. Each segment can be substantially straight or curved, and any set of straight segments can have interfaces providing for angles between adjacent segments. In one embodiment the intramedullary structure has a first configuration and a second configuration. In one embodiment the first configuration is substantially the configuration of the intramedullary structure once it is assembled and delivered into the intramedullary canal. In one embodiment the second configuration is the configuration of the intramedullary structure once it is locked. In one embodiment an intramedullary structure configuration is linear. In one embodiment an intramedullary structure configuration is substantially linear. In one embodiment an intramedullary structure configuration is curved. In one embodiment an intramedullary structure configuration is predetermined. In one embodiment a predetermined configuration mimics the contour of the intramedullary canal. In one embodiment an intramedullary structure configuration is governed by the native structure of the intramedullary canal in which the structure is inserted. In one embodiment an intramedullary structure configuration conforms to the structure of the surrounding tissue. In one embodiment an intramedullary structure configuration is flexible. In one embodiment an intramedullary structure configuration is substantially rigid. In one embodiment an intramedullary structure configuration is rigid. In one embodiment an intramedullary structure can change from a relatively longer configuration to a relatively shorter configuration. In one embodiment an intramedullary structure configuration is movable within one plane. In one embodiment an intramedullary structure configuration is movable in two planes. In one embodiment an intramedullary structure configuration is movable in three or more planes. In one embodiment an intramedullary structure configuration is axially compressible. In one embodiment an intramedullary structure configuration is rotatable about a longitudinal axis. In one embodiment an intramedullary structure configuration is axially rotatable. In one embodiment an intramedullary structure configuration is locked.
- Turning to
FIG. 1 , a first embodiment of a segmentedintramedullary structure 10 is shown. The illustrated embodiment of the segmentedintramedullary structure 10 comprises eightsegments 12 that are received over anoptional tension rod 14 to provide anintramedullary structure 10 having an overall length of approximately 175 mm. Of course, the number ofsegments 12 and the overall length and other geometric measurements, including but not limited to diameter, curvature, fixation structures, and other features of the segmentedintramedullary structure 10 can vary depending on the size and type of bone, and can depend upon the length of the intramedullary canal into which it is to be inserted, as well as any features the medical practitioner elects is preferred for a particular use. - As shown, in one embodiment the ends 16 of the
tension rod 14 are threaded and thesegments 12 are maintained thereon by complementarily threaded members (nuts 18 andwashers 20 are shown) received on the threaded ends 16 of thetension rod 14. However, alternate methods for securing thesegments 12 to thetension rod 14 may be employed, such as a swage fitting that is received on the tension rod and which seats in the open interior of the end segments, or a press nut received on the tension rod in engagement with the end segments. -
FIGS. 2 and 3 show one embodiment of asingle segment 12 of the intramedullary structure shown inFIG. 1 . The specific configuration of theindividual segment 12 shown inFIGS. 2 and 3 is by way of example only. In one embodiment thesegment 12 comprises amale end 22 having a frusto-conical outer shape and afemale end 24 having a cylindrical outer shape and a frusto-conical inner shape complementarily to the outer shape of themale end 22. - In one embodiment, the overall length of the
segment 12 is preferably no greater than about 32 mm, which allows thesegment 12 to be relatively easily introduced into the intramedullary canal through a 10 mm percutaneous access hole that is oriented at approximately 30 degrees with respect to the bone axis. The largest outside diameter of thesegment 12 is dictated by the inside diameter of the intramedullary canal. In one embodiment the largest outer diameter of thesegment 12 is about 9 mm. In one embodiment the inside diameter of themale end 22 of the segment is approximately 3.6 mm, which allows a 3 mm guide wire or cable to easily pass there through. - In one embodiment components of the implant are made of a biocompatible material of sufficient rigidity and strength, such as Titanium. In one embodiment the implant comprises materials made of a Titanium Alloy. In one embodiment the implant comprises material made of Ti-6AI-4V alloy. In one embodiment the
segments 12 are made of a biocompatible material of sufficient rigidity and strength, such as Titanium or its alloys. In one embodiment the inside surface of thefemale end 24 and the outside surface of themale end 22 may be smooth (“mirror polished”) to facilitate nesting. In one embodiment the outside surface of thefemale end 24 may be roughened or textured (“knurled”) to promote tissue growth thereon. In various embodiments, various coatings may be applied to part or all of the external and/or internal surfaces of the segments. In one embodiment, segments can be anodized. In one embodiment, anodizing segment surfaces can reduce the likelihood of cold fusion from binding parts under compression together. - In the illustrated embodiment,
adjacent segments 12 are secured to each other by a friction fit between the inside surface of the female end and the outside surface of the male end. However, a more positive interlocking can be obtained, if desired, by providing the segments with mechanically-interlocking structures, such as slots and pins, prongs, tabs, screw threads, etc. The segments may also be configured to prevent rotational movement there between when assembled. This may be accomplished by, e.g., providing the outer surface of the male end and the inner surface of the female end with complementary non-circular cross sections, such as a square with rounded-off corners. Alternatively, or additionally, bone cement or other hardenable surgical fluid may be introduced into the interior of the segments once in place in the intramedullary canal, to impart additional structural integrity for the assembly and to help secure the assembled structure in place. -
FIG. 4 illustrates an embodiment of an intramedullary structure in accordance with the present disclosure utilizing a second embodiment ofindividual segments 12A. Themale end 22A of thesegments 12A comprise an externally-threaded standoff that is received in the complementary internally threadedfemale end 24A of anadjacent segment 12A. -
FIGS. 5 and 6 disclose a third embodiment ofsegments 12B for an intramedullary structure in accordance with the present disclosure. The male ends 22B of the segments compriseprongs 26 with shoulders ordetents 28 on their distal ends that provide for a snap fit with the complementarily-shapedend 24B of theadjacent segment 12B. A series of interfitting spacedtabs 30 on the periphery of both the male and female ends provides for alignment of the segments and serve to prevent rotation of thesegments 12B with respect to each other. When introduced into the intramedullary canal, the segments are preferably received over a rod or guidewire 32 to facilitate their mating engagement. -
FIGS. 7 and 8 disclose a fourth embodiment ofsegments 12C for use in an intramedullary structure that is similar to the embodiments ofFIGS. 4 and 5 . However, thesegments 12C have a more elaborate interlocking configuration of the tabs, prongs and detents. -
FIGS. 9 and 10 illustrate a fifth embodiment ofsegments 12D for an intramedullary structure in accordance with the present disclosure. Themale end 22D of the segment presents a plurality of longitudinal splines that provide a cross-section similar in appearance to a gear. Thefemale end 24D has a complementarily gear shape and includes aconcentric ring 34 that provides a close fit with the inside diameter of themale end 22D. As can be appreciated, this configuration also provides for interfitting segments that are not rotatable with respect to each other. -
FIGS. 11 and 12 illustrate a sixth embodiment ofsegments 12E for use in an intramedullary structure according to the present disclosure. In one embodiment thesegments 12E are generally cylindrical in configuration withcomplementary interfitting tabs 30E on their male and female ends 22E, 24E. Thesegments 12E also contain a number of spaced,longitudinal throughbores 36 in the walls of the segments (foursuch throughbores 36 are shown inFIGS. 11 and 12 ). In one embodiment thethroughbores 36 receive elongatedperipheral rods 38 that provide the assembled intramedullary structure with additional rigidity and strength. In one embodiment thethroughbores 36 receive guide wires or guide mechanisms to help direct a distal end of the intramedullary structure during insertion. - With reference to
FIG. 13 , a further embodiment of a segmentedintramedullary structure 10 is shown. In one embodiment the segmentedintramedullary structure 10 is a hingedstructure 62. The hingedstructure 62 comprises a plurality ofsegments 64 that are joined to each other by ahinge member 66. Thehinge member 66 permits thesegments 64 to pivot with respect to each other to facilitate introduction of the structure into the intramedullary nail through an angled access hole. - In various embodiments segmented
intramedullary structures 10 can be bent into a curvature for insertion into an access hole to avoid damaging articulating surfaces, joints, or other tissue structures at or near the ends of a long bone. Instead of introducing a rigid nail, embodiments of the segmented intramedullary structures can be inserted in less-invasive access points, which can result in less tissue damage and an easier surgical process for insertion or removal of the intramedullary structure. The various curvatures that are contemplated can vary depending on the type of bone being repaired, but can vary depending on size of the bone, tissue anatomy around the access site, retrograde access, antegrade access, and other potential considerations. For one non-limiting example, an access curvature of the intramedullary structure configured for a humerus can be roughly 80 mm, in the general range of 60-100 mm, and/or in the general range of 20-200 mm. For other bones, the curvature can be larger or smaller, again depending on factors such as bone size. As shown inFIG. 13 one embodiment of theintramedullary structure 10 is made of a single cylindrical member with the V-shaped notches cut out at regular intervals along the length of thestructure 62, the material from which the cylindrical member is made providing a “living hinge” between the adjacent segments at the apex of each notch. In one embodiment, once theintramedullary structure 10 is inserted into the intramedullary canal, bone cement is introduced to keep the intramedullary structure straight and provide further structural integrity. -
FIGS. 14-22 schematically illustrate the insertion of an embodiment of a segmentedintramedullary structure 10 into theintramedullary canal 40 of along bone 42. In one non-limiting embodiment thelong bone 42 is a humerus. In another non-limiting embodiment the long bone is a tibia. In other embodiments, thelong bone 42 can be any long bone, such as but not limited to a radius, ulna, femur, fibula, phalange, or other bone. - With reference to
FIG. 14 , along bone 42 is shown having afracture 44 intermediate it's proximal and distal ends or regions. In one embodiment anaccess hole 46 is percutaneously made into theintramedullary canal 40 at the proximal end of theintramedullary canal 40 at an angle oblique to the axis or centerline of the long bone, and preferably at an angle of approximately 30 degrees with respect to the axis of the long bone. In other embodiments the angle can be in the range of 10-90 degrees with respect to the longitudinal axis of the long bone. In various embodiments anaccess hole 46 can be made in the proximal end, proximal region, intermediate region, distal region, or distal end of theintramedullary canal 40. In one embodiment anaccess hole 46 can be made for retrograde insertion of a segmentedintramedullary structure 10 into the bone. Theaccess hole 46 is of a diameter to accommodate the introduction of theindividual segments 12 that comprise the intramedullary structure. In one embodiment theaccess hole 46 is approximately 10 mm in diameter, but other diameters are contemplated depending on the size of the embodiment of the intramedullary structure being used. In one embodiment, after theaccess hole 46 is made, a guide wire orcable 32 is inserted there through and advanced into theintramedullary canal 40 and across thefracture site 44 to the distal end of theintramedullary canal 40. - Turning to
FIG. 15 , a second step of one embodiment is shown in which a first ordistal-most segment 12 is threaded over the guidewire and advanced through thepercutaneous access hole 46 into theintramedullary canal 40. In one embodiment as shown inFIG. 16 , thesegment 12 is forced through theaccess hole 46 and advanced along theguidewire 32 by means of aninserter 48 that also fits over theguidewire 32. Theinserter 48 has a slottedhammer 50 associated therewith to impart additional force to thesegment 12 as it is advanced into theintramedullary canal 40. - In one embodiment as reflected in reference to
FIG. 17 , once thesegment 12 is positioned within theintramedullary canal 40, it is advanced along theguidewire 32 to the distal end of theIM canal 40 using aflexible push rod 52. The steps of inserting asegment 12 over the guidewire and advancing it distally along the guidewire, shown in FIGS. 15-17, can be repeated until an intramedullary structure of the desired length is created. With reference to the embodiment illustrated inFIG. 18 , the segmentedintramedullary structure 10 has thirteen segments. Therefore the steps ofFIGS. 15-17 are repeated twelve times. Other numbers of segments can be used. In one embodiment the doctor can add or subtract one or more segments during the insertion process. Modifications to the overall segment structure can be made and changed during, or in the midst of a device implantation. - With reference to
FIG. 19 , in one embodiment the segmentedintramedullary structure 10 is secured to the distal end of the IM canal. In one embodiment the distal-most and proximal-most segments include one or more throughbores for receiving bone screws, or lockingbolts 54. In oneembodiment locking bolts 54 are introduced percutaneously and are advanced through bores in the distal-most and proximal-most segments, using fluoroscopy for guidance. In the illustrated method, theguidewire 32 is left in place. However, if the segments comprising the IM nail positively interlock, theguidewire 32 may be removed after all the segments comprising the IM nail are interconnected. With reference toFIG. 20 , a lockingnut 56 is inserted over theguidewire 32 and into the proximal-most segment, aflexible driver 58 being used to tighten thenut 56 to a prescribed torque. In one embodiment the exposed portion of theguidewire 32 is then cut off (seeFIG. 21 ) and in one embodiment percutaneous lockingbolts 60 are used to secure the proximal-most segment in place (seeFIG. 22 ). Means other than locking bolts, fixation screws, or other fasteners may be used to secure the intramedullary structure in place in the intramedullary canal, including but not limited to a bone cement or other hardenable surgical fluid, or radially expandable elements. - With reference to
FIGS. 23-38 , a further embodiment of a segmented intramedullary system, generally designated 100, is disclosed. Thesystem 100 comprises three basic components: an implantable segmented intramedullary fracture fixation device structure 102 (which can be the same or similar to any embodiment of a segmented intramedullary structure 10), a proximal fixation screw guide-interface 104, and acable tensioner assembly 200. - With reference to
FIGS. 24-26 , one embodiment of animplantable fixation structure 102 comprises a plurality of substantially identical, inter-fittingintermediate segments 108, (nine shown), aproximal end segment 110 having a plurality of holes orthroughbores 112 adapted to receive fixation screws, and a radially-expandabledistal end segment 114. Acable 116 is secured to the distal end segment that extends through the implantable structure beyond theproximal end segment 110 and through thecable tensioner 200 to apply a compressive force to the segments so as to result in a rigid implant. Each of thesegments tensioning cable 116 to pass there through and to allow the segments to slide along thecable 116 during insertion into the intramedullary canal. - In one embodiment the
proximal end segment 110 and theintermediate segments 108 are pre-assembled, with the various segments hingedly secured to each other. In one embodiment, in order to facilitate insertion of thefixation structure 102 into the head of a long bone, where the entry point for the implant is offset from the axis of the long bone, thevarious segments FIGS. 26 , 28 and 29, theintermediate segments 108 have inter-fitting male and female portions, 118 and 120, respectively, that comprise three substantially planar faces (118 a, 118 b and 118 c for the male portion, and 120 a, 120 b and 120 c for the female portion). The faces 118 a, 120 a are generally parallel tofaces faces faces fourth face - Experience has shown that when members with smooth or regular tapered or conical surfaces nest, there can be a tendency for the tapered surfaces to lock together. This, of course, would be disadvantageous in the present structure when trying to insert or remove the structure in its non-rigid state, as it would result in a reduced flexibility of the implantable structure required for insertion into and removal from the intramedullary canal. Accordingly, in one embodiment the obliquely-oriented
surfaces female portions segments 108 are formed with a series ofsteps 122 having surfaces that are substantially parallel to the axis of the segment. This ensures that if tension is not applied to thecable 116, and thefixation structure 102 is not under compression, the mating portions of the segments freely slide apart. - In one embodiment the
various segments female portion 120 of the segment with a pin 124 (best seen inFIG. 28 ) lying in a plane perpendicular to that in which the assembled implant flexes. Thepin 124 extends through the open interior of thefemale portion 120 of its associated segment and is captured in an axially-oriented,elongated slot 126 in themale portion 118 of the proximally adjacent segment. As seen in the drawings, theslot 126 is wider at the distal end than at the proximal end, providing for greater flexibility of the expanded implantable structure. Of course, the pin could be carried by themale portion 118 of the segment and ride in a slot in thefemale portion 120 to achieve the same or similar result. - In one embodiment the
proximal end segment 110 has an open interior for passage of the tensioning cable and comprises two sections: anarcuate section 128 and amating section 130, the latter having amale portion 118 as described above for seating in thefemale portion 120 of the immediately distal intermediate segment. In one embodiment, to allow for fixation of the proximal end of the implantable structure to the bone, the arcuate segment includes one or more throughbores 112 (three shown) oriented generally perpendicular to the axis of theimplantable fixation structure 102 for the receipt of bone screws (not shown). Thethroughbores 112 are located so as to not intersect the open interior of the arcuate section, thus ensuring that thetensioning cable 116 is not contacted by the fixation screws. In one embodiment,throughbores 112 can be configured for insertion into a left-sided bone, a right-sided bone, or for both sides. For example,throughbores 112 can be configured for insertion into a right humerus, a left humerus, or either humerus, withthroughbores 112 oriented in light of anatomy or access. - In one embodiment the proximal end of the
arcuate section 128 is configured to receive a two-part distal collet assembly 132 (FIGS. 35 and 38 ) for locking the tensioning cable 116 (as will be described in greater detail below) and to also seat thescrew guide interface 104 in a predetermined orientation. - As described in connection with the prior embodiments, the distal portion of the implantable structure can be configured to be fixed to the bone by bone screws, bone cement, or other fixing means. In one embodiment the fixation of the implantable structure to the distal portion of the long bone is accomplished by having the distal-most segment 140 be radially expandable so as to engage the surface of the intramedullary canal. To this end, and with reference to
FIGS. 27 , 32 and 33, in some embodiments the distal segment 140 comprises an expandingmember 142 that receives awedge member 144 on the interior thereof. Thewedge member 144 is secured to the distal end of the tensioning cable so that as tension is placed on thecable 116, thewedge member 144 is moved proximally into the expandingmember 142 to cause the expandingmember 142 to radially expand into engagement with the surface of the intramedullary canal. - The illustrated embodiments of an
expander 142 inFIGS. 27 , 32 and 33 can comprise anupper collar portion 146 from which extend in cantilever fashion a plurality oflegs 148. In one embodiment the plurality oflegs 148 are evenly radially-spaced legs 148 (four shown). In one embodiment in its undeformed state, theexpander 142 has a radial dimension no greater than that of theother segments implantable fixation structure 102 in order to facilitate insertion into the intramedullary canal. Thewedge member 144 is generally conical in shape, and has elongatedgrooves 150 in its surface for seating thelegs 148 of theexpander 142. Preferably, thegrooves 150 have a cross-sectional shape that is complimentary to the inner surfaces of thelegs 148. - In order to enhance the anchoring of the expander in the intramedullary canal, the outer surfaces of the legs may be formed with structures designed to more easily penetrate into the boney surface of the intramedullary canal. Such structures may take the form of points or a narrow edge or blade-like structure. In the illustrated embodiment, the outer surface of each leg is provided with a continuous raised
spine 152. In one embodiment thespines 152 have a wavy or zig-zag configuration, which provides resistance to both axial and rotational movement of the embeddedexpander 142. - As noted above, in one embodiment, the
proximal end segment 110 includes one, two, three, four or more throughbores 112 for receiving bone screws to secure the proximal end of theimplant 102 in position. In one embodiment, multipleoptional throughbores 112 can be configured for the optional use of bone screws for particular orientations or anatomy. To facilitate the placement of the screws, in one embodiment theproximal segment 110 is adapted to mount ascrew guide interface 104. In various embodiments, thescrew guide interface 104 can be configured to guide the one, two, three, four or more screws in proper orientation. In the illustrated embodiment, three screws are being used for illustrative purposes. In one embodiment a collet is adapted to mount ascrew guide interface 104. As seen in the embodiments inFIGS. 34 and 35 , thescrew guide 104 comprises a pair of dependingarms first arm 154 mounting a pair ofguide tubes second arm 156 mounting asingle guide tube 162. When thescrew guide interface 104 is secured to theproximal end segment 110 of theimplant 102, theguide tubes throughbores 112. The upper ends of thearms segment 164 depending downwardly from the juncture of thearms segment 164 and the upper end of theproximal segment 110 are configured so that thescrew guide interface 104 seats on theproximal segment 110 in proper orientation, with thescrew guide tubes intended throughbores 112. Once properly seated, thescrew guide interface 104 is secured to the implant by aninsertion guide 166. Theinsertion guide 166 has an enlargedgripping surface 168 and a dependingtubular section 170. Thegripping surface 168 of theinsertion guide 166 seats in a recessed portion of thescrew guide interface 104, with thetubular section 170 of theinsertion guide 166 extending through thetubular segment 164 of thescrew guide interface 104 so as to be received in the proximal end of theproximal segment 110 of theimplant 102. The distal end of thetubular section 170 of theinsertion guide 166 is externally threaded, while the interior surface of the proximal end of theproximal segment 110 is internally threaded. Thus, theinsertion guide 166 can be screwed into theproximal end segment 110 to secure thescrew guide interface 104 in position on theimplantable fixation device 102. - A tensioner tool assembly may be utilized to regulate and/or lock tension on the cable in the fixation device. In one embodiment the
tensioner tool assembly 200 may comprise a cable, a locking feature, a tensioner, and a locking mechanism actuator. Referring toFIG. 36 , a perspective view of one embodiment of atensioner tool assembly 200 is shown. It is appreciated that thetensioner tool assembly 200 may be used to provide and regulate tension to a cable, cord, tether or other flexible member connected to a segmented intramedullary fracture fixation device as set forth above, or may be used to provide and regulate tension for other implants, devices or systems. When used with a segmented intramedullary fracture fixation device such as segmentedintramedullary structure 10 orfixation device 102, thetensioner tool assembly 200 may be guided over the cable 116 (connected to and extending from the fixation device, not shown), and releasably attached to the proximal end of the device. In one embodiment a proximal collet screw, a tensioner and a distal collet assembly comprising a cable collet screw may be actuated in sequence to attain and lock down the tension on the cable in the fixation device at a preferred level. Thetensioner tool assembly 200 may then be removed, and the cable extending outside of thefixation device 200 may be cut off, while the cable inside the fixation device remains at the preferred tension. - In one embodiment the
tensioner tool assembly 200 comprises aproximal collet 210 which engages within a threadedshaft 220. Distal to the proximal collet is a threadedknob 240 which partially extends into ahousing 230. Thehousing 230 is shaped to be dockable in theinsertion guide 166, which can connect to the proximal end of the fixation device. Acollet driver 250 is captured within thehousing 230 and is configured to be rotatable within thehousing 230. Within the connection between theinsertion guide 166 and the fixation device is thedistal collet assembly 132. Acable bore 202 extends longitudinally along a straight path within the entire length of theassembly 200. - In one embodiment, when connecting the
tensioner tool assembly 200 to thefixation device 102, first theinsertion guide 166 may be guided over thecable 116 and attached to thefixation device 102, and then the remainder of thetensioner tool assembly 200 guided over thecable 116 and docked via thehousing 230 within theinsertion guide 166. Alternately, thetensioner tool assembly 200 may first be docked to theinsertion guide 166, and the entire assembly then guided over thecable 116 and attached to thefixation device 102. Threads or other coupling features may provide an interface to dock thehousing 230 to theinsertion guide 166. - Referring to
FIG. 37 , a longitudinal partial cross-sectional view of thetensioner tool assembly 200 is shown. For clarity in distinguishing the parts of the tensioner tool assembly, the cable is not shown. The cable bore 202 is seen extending the length of theassembly 200 along a straight path. The threadedknob 240 has an internally threadedlumen 242 through which the threadedshaft 220 extends. The threadedshaft 220 extends through thelumen 242 from the proximal end of the threadedknob 240, and into thehousing 230. Acrossbar 232, through which theshaft 220 passes, may provide an anti-rotation feature preventing rotation of the shaft. A retainingfeature 221 may retain the distal end of threaded shaft within thehousing 230, preventing accidental withdrawal of the threadedshaft 220 from thelumen 242. The threadedshaft 220 hasexternal threads 222 which extend for a distance along its exterior. At the proximal end of the threadedshaft 220 is a short section ofinternal threads 224, and distal to theinternal threads 224 is achamber 226 with atapered wall 228. - The
proximal collet 210 fits into the proximal end of the threadedshaft 220.External threads 212 engage with theinternal threads 224 on the threaded shaft to hold thecollet 210. A plurality offlexible fingers 214 extend distally from thecollet 210, into thechamber 226. As previously described, thetensioner tool assembly 200 is guided over the cable 116 (not shown), and the cable extends through the cable bore 202 and out the proximal end of theproximal collet 210. Theproximal collet 210 is a locking feature which may be locked onto a location on the cable by screwing theproximal collet 210 into the threadedshaft 220. As thecollet 210 is screwed in, thefingers 214 advance distally into thechamber 226. As thefingers 214 bias against thetapered wall 228, they are urged together, engaging and constricting the cable, until the cable is securely gripped. As thefingers 214 engage the cable, they may substantially circumferentially surround the cable. In this position, the cable is locked and prevented from being pulled in either direction. However, the cable can again be freely moved by simply unscrewingcollet 210 from within threadedshaft 220 so thatfingers 214 are able to freely, outwardly flex and disengage from the cable. In one embodiment it is noted that in the locking process, thecable 116 remains oriented substantially along a straight path within theassembly 200 and is not bent, curved, crimped or severed. - Once the cable is locked the tensioner may be actuated to regulate tension to the cable. In one embodiment the tensioner may comprise the
housing 230, the threadedknob 240, the threadedshaft 220, thecrossbar 232, and the retainingfeature 221. The threadedknob 240 may be actuated by turning it to provide tension to the cable. As theknob 240 is turned,internal threads 244 engage with theexternal threads 222 on the threadedshaft 220, and theknob 240 moves distally while the threadedshaft 220 moves proximally as the rotational motion is translated into linear motion. Since the cable is connected to the fixation device at a first location at the distal end segment of the fixation device, and locked within thecollet 210 within theshaft 220 at a second location, moving theshaft 220 proximally moves thecollet 210 relative to the fixation device, putting tension on the cable between the first location at the fixation device and the second location at the collet. - In one embodiment, as the
knob 240 moves distally, adistal face 246 of theknob 240 pushes on aspring 248 which surrounds the threadedshaft 220 in thehousing 230. As theknob 240 is turned further, thespring 248 is compressed between the knobdistal face 246 and alip 234 formed in the wall of thehousing 230. This compression may provide a measure of the amount of force applied to the knob. Indicator markings 247 (shown inFIG. 36 ) may be present on the outside of adistal wall 249 of the threadedknob 240 to indicate a measurement. In one embodiment the indicator markings 247 indicate the amount of force as the knob is turned. In one embodiment the indicator markings 247 indicate the amount of axial movement by the cable with respect to the distal end of the fixation device in terms of length as theknob 246 is turned. Theknob 246 is actuated by turning either direction, increasing or decreasing the tension, until a preferred level of tension is reached. - Referring to
FIG. 38 , a partial cross-sectional view of acable 116 passing through thedistal collet assembly 132, which is surrounded by a connection between a portion of theinsertion guide 166 and aproximal end segment 110 of thefixation device 102, is shown. For clarity, thecable 116 is not shown in cross-section, but a stylized outer surface of thecable 116 is shown.External connection threads 262 on theinsertion guide 166 engage withinternal connection threads 264 on thefixation device 102 to hold theinsertion guide 166 in a fixed position relative to thefixation device 102. Acable collet anchor 272 fits within theproximal end 110 of thefixation device 102 and extends for a short distance into theinsertion guide 166. Thecable collet anchor 272 may be integrally formed in, welded, bonded, press-fit or otherwise connected to thefixation device 102. Achamber 274 having a taperedwall 276 is in a distal end of thecable collet anchor 272, and the proximal end of the cable collet anchor hasinternal collet threads 278. - A
cable collet screw 280 fits within thecable collet anchor 272, held in place byexternal collet threads 282 which engage with theinternal collet threads 278. At a proximal end of thecable collet screw 280, a shapedinner wall 286 surrounds thecable bore 202. A plurality offlexible fingers 284 extend distally, into thechamber 274. In one embodiment, together thecable collet screw 280 and thecable collet anchor 272 form a locking mechanism. - Extending distally through the
insertion guide 166 is adriver shaft 252 of thecollet driver 250. As seen inFIG. 38 , thecollet driver 250 is captured within the tensioner, but operates independently from the tensioner. A workingend 254 of thedriver shaft 252 is shaped to mate with the shapedinner wall 286 of thecable collet screw 280. In various embodiments the workingend 254 may be shaped as a hexagon or any other shape configured to mate with the cable collet screw. In various embodiments, the workingend 254 of thedriver shaft 252 can be configured to operate with any shaped interface on thecable collet screw 280. - In one embodiment, after the
cable 116 has been tensioned as set forth above, thecollet driver 250 is actuated to actuate the locking mechanism which includes thecable collet screw 280 andanchor 272. To lock the position of the tensionedcable 116 at a third location, which is relative to thefixation device 102, thecable collet screw 280 is tightened. To tighten thecable collet screw 280, thecollet driver 250 is turned, turning thecollet driver shaft 252. The workingend 254 mates with the shapedinner wall 286 of the cable collet screw, and consequently thecable collet screw 280 is turned. As thecollet screw 280 turns and advances within theanchor 272, thefingers 284 advance into thechamber 274. As thecollet fingers 284 bias against thetapered wall 276, they are urged together, gripping thecable 116 and locking its position relative to thefixation device 102. In this position,cable 116 is prevented from being pulled in either direction. However,cable 116 can again be freely moved by simply unscrewingcollet screw 280 from within theanchor 272 so thatfingers 284 are able to freely, outwardly flex. - In one embodiment, once the
cable 116 is locked in thecable collet screw 280, the tension on the cable relative to thefixation device 102 is fixed. Theproximal collet 210 may be unscrewed, releasing its grip on thecable 116. Thehousing 230 may be undocked from theinsertion guide 166, allowing removal of thetensioner tool 200 from theinsertion guide 166. The insertion guide may then be unscrewed and removed from thefixation device 102, leaving thecable 116 locked in thecable collet screw 280. Alternately, in one embodiment, thehousing 230 may remain docked within theinsertion guide 166, and theinsertion guide 166 may be uncoupled from thefixation device 102, bringing the dockedtensioner tool 200 with it. After both the insertion guide and tensioner tool are removed, thecable 116 extending proximally from thedistal collet screw 280 may be cut to a preferred length proximal to thecable collet screw 280. - Various embodiments of intramedullary structures as disclosed herein may list various parameters, such as sizes, lengths, diameters, widths, curvatures and geometry that can conform to or be implanted based on various parameters of bones and of structures in which embodiments of the devices may be configured to be implanted. Listings provide some examples, but should not be read to limit the disclosure to those specific dimensions or characteristics. For example, the number of segments used in a device and its various size and shape and feature characteristics can vary depending on parameters of the bone and/or patient, the type of fracture, and other factors. Embodiments of the intramedullary structures are scalable. For example, some non-limiting diameters (or widths) of certain embodiments could range from about 5 mm (for such uses as pediatric bones, or adult clavicle, radius) to about 18 mm (for such uses as an adult femur). Embodiments of lengths could very from a few inches to 800 mm in a knee fusion nail (from ankle to hip). Various embodiments may be configured for implantation in any long bone anatomies, including but not limited to a femur, tibia, fibular, humerus, ulna, radius, clavicle, metatarsals, metacarpals, and others.
- In one embodiment a segmented
intramedullary structure 300 comprisingsegments 310 is similar or has features the same or similar to the features ofintramedullary structure 10 withsegments 12 and/or implantable segmented intramedullary fracturefixation device structure 102 withsegments intramedullary structure 300 comprises a number of primary components: a segment construct, a braided cable, a stiffening tube for the cable, a collet, an end cap and bone screws. In one embodiment the segment construct contains a series ofsegments 310 with complementary interfaces between thesegments 310. In various embodiments the complementary interfaces can comprise complementary surfaces, complimentarily-shaped features, mating male and female portions, nested features, paired geometries, and the like which can interface a proximal, medial, intermediate, middle, or distal portion, area, or end of the respective segments. In one embodiment asegment 310 has a first interface and a complementarily-shaped second end interface, so that the first interface of asegment 310 cooperatively engages the second interface of anadjacent segment 310. In oneembodiment segments 310 have a male geometry at one end, a female geometry on the opposite end and a hole or channel substantially extending along the linear axis. In various embodiments the segment construct can contain straight segments and/or transition segments. In one embodiment the individual segments are rigid. In one optional embodiment the individual segments are flexible. In one embodiment transition segments increase or decrease in width or diameter along the length of the transition segment. One or more transition segments can be used to transition the width, size, diameter, or thickness of the segment construct between proximal, intermediate, and/or distal ends or regions. In one embodiment the male geometry of the links comprises an elliptical shaped cone or taper which mates with a similar elliptical taper on the female geometry of the adjacent link. In one embodiment the individual links are connected together with a snap ring so that the male geometry resides within the female geometry. - In various embodiments the complementary interfaces of the individual links or
segments 310 can be configured to allow movement ofsegments 310 with respect to each other between two, three, or more configurations. In one embodiment thesegments 310 can be distracted from each other, in adistracted configuration 308 in which two ormore segments 310 are at least axially moved away from each other. SeeFIG. 58B . In one embodiment distractedsegments 310 can still be attached to each other, but farther apart. In oneembodiment segments 310 are removably attachable from each other to preventsegments 310 from completely separating from each other when distracted. In oneembodiment segments 310 are locked to each other to preventsegments 310 from completely separating from each other when distracted. In oneembodiment segments 310 are permanently attached to each other to preventsegments 310 from completely separating from each other when distracted. In one embodiment thesegments 310 can have anaxial displacement length 304, indicating the axial distance along a longitudinal axis of one or bothadjacent segments 310 that theadjacent segments 310 can move with respect to each other while still connected to each other. In various non-limiting embodiments, theaxial displacement length 304 between adjacent segments can be anywhere in a range of 2-10 mm, including but not limited to roughly 2 mm, 3 mm, 4 mm, 5 mm, 6 mm, 7 mm, 8 mm, 9 mm and 10 mm. In one embodiment, the overall length of a segmentedintramedullary structure 300 increases as segments are distracted with respect to each other withsegments 310 in one or more respectivedistracted configurations 308. In one embodiment a segmentedintramedullary structure 300 can maintain an overall configuration, such as a straight configuration, while distracted. In one embodiment a segmentedintramedullary structure 300 can be configured to bend or flex or havesegments 310 that move rotationally with respect to each other in adistracted configuration 308. - In one embodiment the
segments 310 can be flexed, rotated or bent with respect to each other, in abent configuration 307 in which two ormore segments 310 are at least radially rotated with respect to each other. SeeFIG. 58C . In one embodiment thesegments 310 can have arotational displacement angle 305, indicating the angle between the respective longitudinal axes of theadjacent segments 310 that theadjacent segments 310 can move with respect to each other while still connected to each other. In various non-limiting embodiments, the rotational displacement angle can be up to 4, 5, 10, 15, 20, 30, 45 or 90 degrees. In one embodiment thesegments 310 are distracted in order to bend with respect to each other. In one embodiment, pushingsegments 310 together or compressing them causes thesegments 310 to move towards each other in to a compressed configuration. In oneembodiment pushing segments 310 together or compressing them while thesegments 310 are more than a specific angle with respect to each other temporarily locks thesegments 310 in abent configuration 307, allowing thesegments 310 to be pushed or to transmit an axial load without collapsing out of itsbent configuration 307. In oneembodiment segments 310 are configured to remain in a first bent configuration 307 a whileadjacent segments 310 are at least a first rotational displacement angle 305 a. In oneembodiment segments 310 are configured to move out of a first bent configuration 307 a whileadjacent segments 310 are less than the first rotational displacement angle 305 a. For example, in one embodiment the overall shape of a segmentedintramedullary structure 300 can be bent, flexed, or curved with two or more of itssegments 310 rotated with respect to each other with an angle of at least a first rotational displacement angle 305 a. When thesegments 310 are at an angle of at least the first rotational displacement angle 305 a, the curved segmentedintramedullary structure 300 can be pushed or pulled through a hole in tissue such as skin or bone while still curved. Once the angle betweensegments 310 reduces to an angle less than the first rotational displacement angle 305 a, thesegments 310 can move out of the first bent configuration 307 a. In various embodiments, multiple rotational displacement angles 305 can determine multiplebent configurations 307. - In various embodiments, a compressed configuration may have an overall shape for the adjacent segments in a curved or straight configuration. In one embodiment two or
more segments 310 can be compressed against each other, in acompressed configuration 306 in which two ormore segments 310 are configured to be aligned with respect to each other with a reduced axial displacement and a reduced rotational displacement with respect to each other. SeeFIG. 58D . In oneembodiment segments 310 are in a straightened configuration when compressed. In one embodiment the axial displacement length betweensegments 310 is substantially zero when in thecompressed configuration 306. In one embodiment therotational displacement angle 305 betweensegments 310 is substantially zero when in thecompressed configuration 306. The measurement of various lengths and angles may depend on the application, size of the segments, number of segments, size of bone for implantation, approach (retrograde, etc.), or other factors. In various embodiments, interaction between features on the interior and/or exterior surfaces ofadjacent segments 310 can be configured to adjust or determine the axial distraction range of motion and/or rotational bending range of motion of thesegments 310 with respect to each other. - In one embodiment the individual links can be partially separated to provide flexibility but will become substantially rigid once the individual links are compressed together. In one embodiment the individual links can be partially separated to provide a first level of flexibility but will become a different, second level of flexibility once the individual links are compressed together. In one embodiment the second level of flexibility is less than the first level of flexibility. In one embodiment an attachment structure prevents the segments from becoming permanently separated, thus aiding with device removal or extraction if necessary. In various non-limiting embodiments, the attachment structure can include a pin, slot, snap fit, threads, or a snap ring. In one embodiment, during the surgical procedure, the segment construct will be inserted into the bone canal over the cable and cable stiffening tube. Tension is applied to the cable in order to compress the tapered male geometry and tapered female geometry together to form a rigid nail. The cable tension will be held by a collet that is threaded into the proximal end of the segment construct. In one embodiment, the device is intended to function as a flexible intramedullary nail during the surgical procedure but will become rigid once the cable is tensioned and the segment construct is compressed. In one embodiment the rigid device is secured to the bone with bone screws that are inserted through the proximal and distal segments. In one embodiment, two bone screws are used in the proximal segment and two bone screws are used in the distal segment. In one embodiment, an end cap is threaded into the proximal segment after the device is secured in order to prevent bone in-growth around the cable collet. Once the end cap is in place the cable will be cut flush with the end cap.
- In one embodiment, a segmented intramedullary structure is configured for insertion in a humeral bone. In one embodiment the bone screws are 4.0 mm in diameter. In one embodiment of a humeral segmented intramedullary structure the hole, or channel, is 2.25 mm in diameter. In various embodiments the humeral segmented intramedullary structure can be provided in various diameters, such as (but not limited to) 8 mm, 9 mm or 10 mm. In various embodiments the humeral segmented intramedullary structure can be provided in various lengths, such as (but not limited to) 170 mm, 187 mm, 205 mm, 222 mm, 240 mm, 257 mm, 275 mm or 292 mm. In various embodiments the humeral stiffening tube can be provided in various lengths which can correspond to the increasing length of the segmented intramedullary structure. In various embodiments the humeral end cap can be provided in various lengths, such as (but not limited to) 12.7 mm, 17.7 mm or 22.7 mm. In various embodiments the humeral bone screws can have a 4.0 mm diameter and any of the following non-limiting examples of lengths: 16 mm, 18 mm, 20 mm, 22 mm, 24 mm, 26 mm, 28 mm, 30 mm, 32 mm, 34 mm, 36 mm, 38 mm, 40 mm, 42 mm or 46 mm. In various embodiments, the cable length can be configured to work with any device, depending on device length. In one embodiment the cable has a pre-cut length of 914 mm.
- In various embodiments a segmented intramedullary structure is configured for insertion in bones of varying shapes and/or sizes. In various embodiments, the nominal diameter of a segmented intramedullary structure can be 8 mm, 9 mm, 10 mm, 11 mm, 12 mm, 13 mm, 14 mm, 15 mm or other dimensions. In various embodiments, the diameter of a proximal end segment of a segmented intramedullary structure can be 11 mm, 14 mm, 16 mm or other dimension. In various embodiments, transition segments can range in width or diameter from 8 to 9 mm, 9 to 10 mm, 10 to 11 mm, 11 to 12 mm, 12 to 13 mm, 13 to 14 mm, 14 to 15 mm, 15 to 16 mm, or other transition sizes. In various embodiments, straight segments can have a width or diameter of 8 mm, 9 mm, 10 mm, 11 mm, 12 mm, 13 mm, 14 mm, 15 mm, or other sizes. In one embodiment, a distal segment can be tapered. In various embodiments a distal segment can be tapered distally by 1 mm, 0.5 mm or other values. In various embodiments, a segmented intramedullary structure can built to varying lengths, comprising varying numbers of segments (transition, straight, or otherwise) as needed. In various embodiments, lengths can be about 170 mm to about 500 mm.
- Secondary Compression
- Various embodiments of segmented intramedullary structures as disclosed herein allow the surgeon to compress the fracture site after placing the segmented intramedullary structure in the bone and fixating the proximal and distal bone segments. See
FIGS. 39A-B andFIGS. 40A-B , which illustrate an embodiment of a segmentedintramedullary structure 300 before and after secondary compression in abone 42. Segmentedintramedullary structure 300 can have the same or similar aspects as segmentedintramedullary structure 10 and implantable segmented intramedullary fracturefixation device structure 102.Bone 42 can be any type of bone, such as, but not limited to, a long bone.FIGS. 39A and 40A illustrate one embodiment of a segmentedintramedullary structure 300 with the fracturedlong bone 42 attached superiorly and inferiorly to the fracture site to the segmentedintramedullary structure 300. After this superior and inferior anchoring or attaching at a proximal and distal sites, an embodiment of the segmentedintramedullary structure 300 can have an interior cable or tensioning mechanism lock or rigidly connect the segments of the segmentedintramedullary structure 300 together, imparting a compressive load across thebone fracture site 44 to assist in healing thefracture 44, as shown inFIGS. 39B and 40B . This compression feature is particularly useful innon-load bearing bones 42 such as in the arm where even a 1 mm gap at the fracture site can prevent healing. In one embodiment, this type of compression can be called “Secondary Compression.” - In some embodiments secondary compression may be expressed in terms of compressive force applied to bring bone segments together with a device. In some embodiments secondary compression may be expressed in terms of the tensile force applied to a tensioning mechanism to bring bone segments together with a device. In some embodiments, secondary compression can be described in terms of a distance, such as the distance that bone segments are brought together in secondary compression. In one embodiment secondary compression is expressed in terms of the decrease in the decrease in axial length of the device along the direction of the secondary compression. In one embodiment the distance associated with secondary compression is proportional to the amount of compressive or tensile force applied to the device. In one embodiment segmented intramedullary structures can be configured to provide substantially one level or one distance in secondary compression. In one embodiment segmented intramedullary structures can be configured to provide varying levels or ranges of secondary compression. In one embodiment a segmented intramedullary structure can provide a smooth, continuous transition between levels of secondary compression. In one embodiment a segmented intramedullary structure can provide a discrete transition between levels of secondary compression. In one embodiment a segmented intramedullary structure can provide a discrete transition between levels of secondary compression with a ratcheting action.
- In one embodiment a segmented intramedullary structure can provide no secondary compression. In various embodiments a segmented intramedullary structure can be configured to provide a single secondary compression distance with a value in the range of about 1 mm to 5 mm. In various embodiments a segmented intramedullary structure can be configured to provide 1 mm, 2 mm, 3 mm, 4 mm, or 5 mm of secondary compression. In one embodiment a segmented intramedullary structure is configured to provide anywhere in the range of about 1 mm to 5 mm of secondary compression.
- Studies were performed with various embodiments of the segmented intramedullary structure confirming that secondary compression of the fracture site after the fracture has been reduced and proximal and distal fixation is in place helps ensure that the surgeon reaches full reduction at the fracture site. In one embodiment, an additional benefit of secondary compression is that it takes some of the load off the implant which will help in implant longevity.
- Segments
- With reference to
FIGS. 41A-78 , further embodiments of segmentedintramedullary structures 300 with segments, generally designated 310, are disclosed. In one embodiment,segment 310 can have features similar to the various embodiments of the various other segments described herein, such assegments various embodiments segment 310 has a male mating section 320 and a female mating section 330. Invarious embodiments segment 310 has achannel 340 extending through a longitudinal axis of thesegment 310. - In various embodiments,
segments 310 can be subjected to secondary compression with anelongate member 350. In various embodiments elongatemember 350 can be a wire, guide wire, pull wire, push wire, cable, rod, threaded rod, or other similar structure. In one embodiment the elongate member is a tensioning member extending along the length of the segmented intramedullary structure. In one embodimentelongate member 350 is atensioning rod 14, which is extended through thesegment 310. In one embodiment theelongate member 350 iscable 116. In one embodiment theelongate member 350 provides a means for holding thesegments 310 together in a generally axial, straight, straightened or curved configuration. Although the term “straight” or “straightened” may be used with respect to the segments, it is contemplated that segments may be configured to align an assembly in a straight line, but may also be configured in certain embodiments to “lock” in a rigid configuration that has a curvature or bend to the overall structure. Thesegments 310 can be distracted from each other in order to allow bending in one or more planes or about one or more axes. - With reference to
FIGS. 41A-C , in one embodiment, a steppedsegment 310 a can be distracted or pulled apart axially to allow two or more steppedsegments 310 a to bend in one plane. In one embodiment a steppedsegment 310 a can be distracted or pulled apart axially to allow two or more steppedsegments 310 a to bend about one axis. With reference toFIGS. 42A-C in one embodiment, a pair of steppedsegments 310 a are bent with respect to each other. With reference toFIGS. 43A-C in one embodiment, a pair of steppedsegments 310 a are in axial alignment with respect to each other in a straightened configuration. - With reference to
FIGS. 44A-E , in one embodiment asnap segment 310 b hasmale mating section 320 b with aflat feature 321 b and ataper feature 322 b and afemale mating section 330 b with aflat feature 331 b and ataper feature 332 b which are configured to allow bending in one plane when at least partially distracted. In one embodiment the taper features 322 b and 332 b enable easier engagement of theadjacent segments 310 b when they are compressed together. Thesnap feature 323 b provides for ease of assembly ofadjacent snap segments 310 b. Thesnap feature 323 b can also lock to retainadjacent snap segments 310 b together so they do not fall apart when the assembly is distracted, moved or subjected to tensile forces. In one embodiment asnap segment 310 b can be distracted or pulled apart axially to allow two ormore snap segments 310 b to bend in one plane. In one embodiment asnap segment 310 b can be distracted or pulled apart axially to allow two ormore snap segments 310 b to bend about one axis. With reference toFIGS. 45A-E in one embodiment, a pair ofsnap segments 310 b are bent with respect to each other in the side view inFIGS. 45A-45B but remain straight and distracted in the front view inFIGS. 45C-45D . In one embodiment, segments may be distracted from one view while bent from another view. Although the segments are bent with respect to each other, the rotational displacement may occur substantially within one only one plane. With reference toFIGS. 46A-E in one embodiment, a pair ofsnap segments 310 b are in axial alignment with respect to each other in a straightened configuration. In one embodiment,adjacent snap segments 310 b have corresponding taper features 322 b and 332 b to enable easier engagement of thesnap segments 310 b when they are compressed together. Thesnap feature 323 b allows thesegments 310 b to be assembled together easily and retains thesnap segments 310 b together so they do not fall apart when the assembly is distracted. - With reference to
FIGS. 47A-C , in one embodiment aunidirectional segment 310 c has amale mating section 320 c and afemale mating section 330 c and achannel 340 c. Adjacentunidirectional segments 310 c can be mated together and a pin 361 (not illustrated here) is placed in apin hole 337 to retain theunidirectional segments 310 c together. In one embodiment astep surface 324 c is slideably and/or rotationally moveable with respect to the pin 361 allowing the pin 361 to keep thesegments 310 c from falling apart while allowing movement to actuate the system between straightened and bent configurations. In various embodiments, interaction between the pin 361 andstep surface 324 c can be configured to adjust or determine the axial, bend, and/or rotational range of motion of the segments with respect to each other. - With reference to
FIGS. 48A-C , in one embodiment aunidirectional segment 310 d has amale mating section 320 d and afemale mating section 330 d and achannel 340 d. In one embodimentunidirectional segment 310 d is similar tounidirectional segment 310 c, but is longer. In one embodiment, a slight taper on both the male and female mating sections, 320 d and 330 d respectively, keeps the parts locked together tightly and greatly reduces play between theunidirectional segments 310 d when they are assembled with a tensionedelongate member 350. Adjacentunidirectional segments 310 d can be mated together and a pin 361 (not illustrated here) is placed in apin hole 337 to retain theunidirectional segments 310 d together. In one embodiment astep surface 324 d is slideably and/or rotationally moveable with respect to the pin allowing the pin to keep theunidirectional segments 310 d from falling apart while allowing movement to actuate the system between straightened and bent configurations. In one embodiment, thestep surface 324 d is located in a plane perpendicular to the plane of bending, and strengthens the assembled intramedullary structure in bending and also serves as a stop when the assembled intramedullary structure is bent. This allows the bent intramedullary structure to be pushed into the intramedullary canal without theunidirectional segments 310 d seating. The assembled intramedullary structure 300 d is bent by pulling theunidirectional segments 310 d apart longitudinally and then bending or rotating theunidirectional segments 310 d with respect to each other. In one embodiment theunidirectional segments 310 d are designed such that bending mainly occurs in one direction. With reference toFIGS. 49A-C in one embodiment a pair ofunidirectional segments 310 d are bent with respect to each other. With reference toFIGS. 50A-C in one embodiment, a pair ofunidirectional segments 310 d are in axial alignment with respect to each other in a straightened configuration. - With reference to
FIGS. 51A-C , in one embodiment a threadedsegment 310 e has amale mating section 320 e, a male threadedsection 325 e, afemale mating section 330 e, a female threadedsection 335 e, anarticulation chamber 333 e, and achannel 340 e. Adjacent threadedsegments 310 e can be assembled by threading the male threadedsection 325 e of a first threadedsegment 310 e into the female threadedsection 335 e of a second threadedsegment 310 e. In one embodiment, after threading the male threadedsection 325 e of a first threadedsegment 310 e through the female threadedsection 335 e of a second threadedsegment 310, the male threadedsection 325 e and a portion of themale mating section 320 e can move within anarticulation chamber 333 e. In various embodiments thearticulation chamber 333 e is sized and configured to allow motion in one, two, three or more planes. In one embodiment thearticulation chamber 333 e is sized and configured to allow rotation between adjacent first andsecond segments 310 e. In one embodiment the male threadedsection 325 e and the female threadedsection 335 e is designed such that as they reach the last half (½) to quarter (¼) turn there is a small amount of interference between the male and female portions to help secure the threadedsegments 310 e together. As the adjacent threadedsegments 310 e are forced past this interference the male threadedsection 325 e drops into thearticulation chamber 333 e. In one embodiment thearticulation chamber 333 e is an undercut area in thefemale mating section 330 e of the mating part. The adjacent threadedsegments 310 e then cannot be disassembled by pulling axially but must be unthreaded and forced past the point of interference again. This feature keeps the adjacent threadedsegments 310 e together unless they are deliberately disassembled. In one embodiment there is a slight taper on both themale mating section 320 e andfemale mating section 330 e which keeps the adjacent threadedsegments 310 e locked together tightly and reduces or eliminates play between the adjacent threadedsegments 310 e when they are assembled with a tensionedelongate member 350. - With reference to
FIGS. 52A-C , in one embodiment a threadedsegment 310 f has amale mating section 320 f, a male threadedsection 325 f, afemale mating section 330 f, a female threadedsection 335 f, anarticulation chamber 333 f, and achannel 340 f and is similar to threadedsegment 310 e but also comprises a step surface 324 f on themale mating section 320 f that allows adjacent threadedsegments 310 f to bend more in one direction than another, and can also serve as a stop when the threadedsegments 310 f of an intramedullary structure 300 f are bent. This allows the bent intramedullary structure to be pushed into the intramedullary canal without the threadedsegments 310 f seating. The assembled intramedullary structure 300 f is bent by pulling the threadedsegments 310 f apart longitudinally and then bending or rotating the threadedsegments 310 f with respect to each other. In one embodiment the threadedsegments 310 f are designed such that bending mainly occurs in one direction. With reference toFIGS. 53A-C in one embodiment a pair of threadedsegments 310 f are bent with respect to each other. With reference toFIGS. 54A-C in one embodiment, a pair of threadedsegments 310 f are in axial alignment with respect to each other in a straightened configuration. - In one embodiment a
snap ring segment 310 g of a segmentedintramedullary structure 300 can be configured to connect with an adjacentsnap ring segment 310 g with asnap ring 323 g. In various embodiments, thesnap ring 323 g is a separate and moveable component from the two adjacentsnap ring segments 310 g, allowing a range of relative movement between the two adjacentsnap ring segments 310 g. In one embodiment thesnap ring 323 g is moveable with respect to both the adjacentsnap ring segments 310 g. Thesnap ring segment 310 g inFIGS. 55A-E is illustrated without asnap ring 323 g. For some illustrations of an embodiment of asnap ring 323 g, seeFIGS. 56B , 56D, 57B and 57D. - In one embodiment the
snap ring segment 310 g includes adistal end 326, aproximal end 336, amale mating section 320 g, afemale mating section 330 g, and a central lumen or channel 340 g extending through a longitudinal axis of thesnap ring segment 310 g. In the illustrated embodiment inFIGS. 55A-E , themale mating section 320 g is at thedistal end 326 and thefemale mating section 330 g is at theproximal end 336. In another embodiment, themale mating section 320 g can be at theproximal end 336 and thefemale mating section 330 g is at thedistal end 326. The external surfaces of themale mating section 320 g are configured to interface with the internal surfaces of thefemale mating section 330 g, along thechannel 340 g. - In one embodiment a
snap segment 310 g hasmale mating section 320 g with aflat feature 321 g and ataper feature 322 g and afemale mating section 330 g with aflat feature 331 g and ataper feature 332 g which are configured to allow bending in one plane when at least partially distracted. In one embodiment asnap ring segment 310 g can have one or moreflat features snap ring segments 310 g to relative motion between thesegments 310 g in a single plane or an axis substantially parallel to theflat feature FIG. 56B ) along aflat feature 321 g in acompressed configuration 306 is no more than about zero degrees, 0.5 degrees, 1 degree, 2 degrees, 3 degrees, or 5 degrees or less. In various embodiments, a maximumrotational displacement angle 305 along aflat feature 321 g in adistracted configuration 308 or abent configuration 307 can be no more than about 0.5 degrees, 1 degree, 5 degrees, 15 degrees, or 20 degrees or less. - In one embodiment a
snap ring segment 310 g can have ataper feature snap ring segments 310 g with each other when in a straightened, rigid or an axially compressed configuration. In various embodiments, a maximumrotational displacement angle 305 along ataper feature 322 g in acompressed configuration 306 can be no more than about zero degrees, 0.5 degrees, 1 degree, 2 degrees, 3 degrees, or 5 degrees or less. - In one embodiment a
snap ring segment 310 g can have one or moreflat features 321 g and one or more taper features 322 g along the surfaces defining central lumen or channel 340 g that are configured to allow bending between adjacent segments of the segmentedintramedullary structure 300 in only a single plane when the adjacent segments are at least partially distracted and/or bent with respect to each other. In various embodiments, a maximumrotational displacement angle 305 along ataper feature 322 g in abent configuration 307 can be 1 degree, 3 degrees, 5 degrees, 10 degrees, 20 degrees, 30 degrees, 45 degrees, or 60 degrees or less. - In one embodiment corresponding taper features 322 g, 332 g enable easier engagement of the adjacent
snap ring segments 310 g when they are compressed together. In one embodiment themale mating section 320 g includes one or more taper features 322 g configured to interface with one or more taper features 332 g on thefemale mating section 330 g. - In
various embodiments segments 310 can have various features along thechamber 340 and the outside surfaces. In various embodiments, surfaces may have chamfers, radii, or other transition structures. As illustrated in one embodiment illustrated atFIG. 55B , starting at theproximal end 336 of thechamber 340 g, thesnap ring segment 310 gfemale mating section 330 g has aproximal chamber edge 360 and aproximal chamber surface 362. In some embodiments, the proximal chamber surfaces 362 can be substantially linear and inclined from the longitudinal axis to provide a frusto-conical chamber increasing in inside diameter in the proximal direction. - In one embodiment a
first articulation chamber 333 g has proximal transverse stop orsurface 364, a firstarticulation wall surface 366, and adistal surface 368. An optionalsecond articulation chamber 334 g has proximal stop orsurface 372, a secondarticulation wall surface 374, and a distal stop orsurface 376. The stop surfaces onarticulation chambers - The
chamber 340 g surface continues to extend from thefemale mating section 330 g into themale mating section 320 g withlumen surface 378, which extends toward thedistal end 326 of thesnap ring segment 310 g. In one embodiment the exterior of themale mating section 320 g has adistal end surface 380, adistal lip wall 382, a distal snapring articulation surface 384, a snap ringarticulation wall surface 386, a proximal snapring articulation surface 388,step surface 324 g, a proximalstep surface edge 392, a distal maleexterior surface 390 and a distal maleexterior surface edge 394. In various embodiments, the distal male exterior surfaces 390 can be a linear orflat feature 321 g parallel to the longitudinal axis or ataper feature 322 g, inclined with respect to the longitudinal axis and decreasing in a transverse dimension in the distal direction. - With reference to
FIGS. 56A-E in one embodiment, a pair ofsnap ring segments 310 g in abent configuration 307 are rotated with respect to each other in the side view inFIGS. 56A-56B but remain substantially axially aligned in the front view inFIGS. 56C-56D . With reference toFIGS. 57A-E in one embodiment, a pair ofsnap ring segments 310 g are in axial alignment with respect to each other in acompressed configuration 306. In one embodiment thesnap ring 323 g allows thesnap ring segments 310 g to be assembled together easily and retains thesnap ring segments 310 g together so they do not fall apart when the assembly is distracted. -
FIGS. 58A-58D illustrate embodiments ofsegments 310 in various configurations.FIG. 58A illustrates an embodiment of a pair ofsegments 310 that are detached.FIG. 58B illustrates an embodiment of a pair ofsegments 310 that are in an assembled but distractedconfiguration 308.FIG. 58C illustrates an embodiment of a pair ofsegments 310 that are in abent configuration 307.FIG. 58B illustrates an embodiment of a pair ofsegments 310 that are in acompressed configuration 306. In one embodiment asnap ring 323 g is disposed on a snap ringarticulation wall surface 386 of amale mating section 320 g of a firstsnap ring segment 310 g. The firstsnap ring segment 310 g can be pushed or advanced in to a secondsnap ring segment 310 g, deflecting thesnap ring 323 g into a radially reduced configuration that snaps back into a radially expanded configuration inside afirst articulation chamber 333 g or asecond articulation chamber 334 g. In one embodiment, thesnap ring 323 g permanently connects theadjacent segments 310 g together so that theadjacent segments 310 g do not detach from each other. - In one embodiment the
snap ring 323 g (seeFIGS. 56A-58D ) provides for ease of assembly of adjacentsnap ring segments 310 g. Thesnap ring 323 g can also lock to retain adjacentsnap ring segments 310 g together so they do not fall apart when the segmentedintramedullary structure 300 is distracted, moved or subjected to tensile forces. In one embodiment asnap ring segment 310 g can be distracted or pulled apart axially to allow two or moresnap ring segments 310 g to bend in one plane. In one embodiment asnap ring segment 310 g can be distracted or pulled apart axially to allow two or moresnap ring segments 310 g to bend about one axis. - In one embodiment the
snap ring 323 g is an annular or arcuate length of a resilient material such as stainless steel, Nitinol, Titanium, a Titanium alloy, or other material with an open section configured to allow a certain range of bending or flexing or temporary deformation of thesnap ring 323 g in order to snap thesnap ring 323 g in to a location. In oneembodiment snap ring 323 g is a C-shaped ring and serves to create an interference fit between adjacentsnap ring segments 310 g to permanently join them together. In various embodiments snaprings 323 g are sized proportionately depending on the size of thesnap ring segments 310 g being joined. In one embodiment thesnap ring 323 g has a feature for assisting in the removal of thesnap ring 323 g from the location. In one embodiment asnap ring 323 g is disposed to be rotatable, and axially slideable along the snap ringarticulation wall surface 386 at least between the distal snapring articulation surface 384 and the proximal snapring articulation surface 388. In one embodiment asnap ring 323 g is configured to stop or limit motion against one or more surfaces in one ormore articulation chambers snap ring 323 g can be configured to stop against a surface in order to connect adjacentsnap ring segments 310 g while limiting the relative motion between the adjacentsnap ring segments 310 g. For example, in various embodiments asnap ring 323 g is configured to stop against aproximal surface 364 of afirst articulation chamber 333 g and a distalsnap ring surface 384 to prevent adjacentsnap ring segments 323 g from detaching from each other as illustrated inFIGS. 56B , 56D and 58B. - In one embodiment a
snap ring 323 g is configured to stop against adistal surface 368 of afirst articulation chamber 333 g and a proximal snapring articulation surface 388 to limit the compression of adjacentsnap ring segments 323 g. In one embodiment adistal end surface 380 of amale mating section 320 g contacts adistal surface 376 of asecond articulation chamber 334 g to limit the compression of adjacentsnap ring segments 323 g. - In one embodiment the
step surface 324 g is slideably and/or rotationally moveable with respect to thedistal chamber surface 362 and thedistal chamber edge 360. For example, in an embodiment with twoadjacent segments 310, there is a proximal segment and a distal segment. In one embodiment of a compressed configuration, the distal maleexterior surface edge 394 of the proximal segment is close to or in complementary contact withdistal chamber edge 360 of the distal segment. In articulating the proximal segment and the distal segment between the compressed and the bent configurations (seeFIGS. 57B and 56B , respectively), thedistal lip wall 382 of the proximal segment'smale mating section 320 g moves in a proximal direction through thesecond articulation chamber 334 g with respect to the distal segment. Thedistal lip wall 382 of the proximal segment'smale mating section 320 g can move in a proximal direction through thesecond articulation chamber 334 g and into thefirst articulation chamber 333 g. As the proximal segment moves away from the distal segment, thetapered features 322 g open up and get wider to allow the proximal segment to rotate or bend substantially within a plane parallel toflat features 321 g in the male andfemale mating sections bent configuration 306, the proximalstep surface edge 392 of the proximal segment is close to or in contact withdistal chamber edge 360 of the distal segment. - In various embodiments, interaction between features on the interior and/or exterior surfaces of
adjacent segments 310 can be configured to adjust or determine the axial distraction range of motion and/or rotational bending range of motion of thesegments 310 with respect to each other. For example, in various non-limiting embodiments theaxial displacement length 304 and/or therotational displacement angle 305 can be altered by changing tapers, radii, dimensions of parts, or features, such as changing thesnap ring 323 g thickness, changing the distance between the proximalstep surface edge 392 and the distal maleexterior surface edge 394 on asnap ring segment 310 g, changing the distance between the proximalsnap ring surface 388 and the distalsnap ring surface 384 on asnap ring segment 310 g, or changing thefirst articulation chamber 333 g height (distance fromproximal surface 364 and distal surface 368). - Referring to
FIGS. 58B-58D , operation of the segmentedintramedullary structure 300 implant is best illustrated. InFIG. 58B , a first,proximal segment 310 g is interlocked with a second,distal segment 310 g, and placed under axial traction. Proximal movement of theproximal segment 310 g causes surface 384 to advancesnap ring 323 g to the proximal limit of travel withinfirst articulation chamber 333 g. At that point, further relative axial distraction of the two segments is limited bystop surface 364. In this distractedconfiguration 308, the twosegments 310 may be inclined with respect to each other, enabling the assembled implant to be bent into acurved configuration 307, such as for implantation around a curve, and to facilitate removal as will be discussed below. - In one embodiment during implantation, the implant needs to be able to be placed under axial compression as it is advanced around a curve. This is permitted as seen in
FIG. 58C , with the distally facing proximalstep surface edge 392 engaging proximally facingproximal chamber edge 360 to permit axial compression without axial shortening of the implant, and simultaneously permit axial compression while permitting the implant to retain a curve. - Once the implant has reached the approximately linear configuration of the intramedullary canal, distally facing proximal
step surface edge 392 disengages laterally from proximally facingproximal chamber edge 360 as the angle between the twosegments 310 decreases. This enables theproximal segment 310 g to axially advance further intodistal segment 310 g under further axial compression such as by pushing distally on a deployment tool, as illustrated inFIG. 58D . As seen therein, the complementary internal surfaces of the twosegments 310 urge the axially compressed construct into a linear or substantially linear predetermined configuration. - Thus, the implant has a first length, when under axial tension as illustrated in
FIG. 58B . The implant can be shortened to a second length upon application of an axially compressive force, while the implant is in a nonlinear configuration as illustrated inFIG. 58C . The implant can be further axially shortened to a third length by applying an axially compressive force while the implant is in a substantially linear configuration as seen inFIG. 58D . Preferably, the implant is thereafter locked in the axially compressed and linear configuration ofFIG. 58D such as by applying axial tension on a tighteningelongate member 350 as is discussed elsewhere herein. - When removal is desired, proximal traction on a
proximal segment 310 may be applied as will be discussed in additional detail below. Once theproximal segment 310 has broken free of any bony ingrowth that may have occurred, it will advance proximally to the proximal limit of travel as illustrated inFIG. 58B . This enables further proximal traction on theproximal segment 310 to be transferred on thenext segment 310 in the distal direction along the length of theimplant 300. In this manner, a proximal, removal force can be transmitted directly fromsegment 310 tosegment 310 along the length of theimplant 300, in addition to or in place of reliance on the tensioningelongate member 350 extending through central lumen or channel 340 g. - In one embodiment a segmented
intramedullary structure 300 comprises asegment construct 303. The segment construct 303 comprises two ormore segments 310 including adistal end segment 400 and aproximal end segment 500. In various embodiments,segments 310 can also comprise one ormore transition segments 314 and/oruniform segments 316 disposed between thedistal end segment 400 and theproximal end segment 500. - In one
embodiment transition segment 314 has a varying outer nominal diameter or width dimension, and is configured to provide a transition betweensegments 310 with different outer nominal diameter or width dimensions. A plurality oftransition segments 314 may be used to transition across nominal dimensions in incremental transition steps. For example, in the illustrated embodiment ofFIGS. 56A-H , twotransition segments 314 are used to transition from a nominal width or diameter dimension from theproximal end segment 500 to auniform segment 316. In various embodiments, different combinations oftransition segments 314 can be used to transition between a plurality ofnominal segment 310 dimensions. In one embodiment, the nominal dimension changes can be gradual, such as with a smooth taper. In one embodiment one ormore transition segments 314 taper distally and serve to gradually reduce the outer diameter of thesegment construct 303. For example, in one embodiment, threetransition segments 314 can be used to transition the body of the segment construct 303 down from an 11 mm diameter of one embodiment of aproximal end segment 500 to one embodiment of auniform segment 316 nominal diameter of 8.0 mm diameter. Thetransition segments 314 can include an 11 to 10mm transition segment 314, a 10 to 9 mm, and a 9 to 8mm transition segment 314. - In one
embodiment uniform segment 316 has a uniform outer nominal diameter or width dimension. In one embodiment auniform segment 316 has a fixed diameter. In one embodiment auniform segment 316 is a straight segment. In one embodiment auniform segment 316 is a curved segment. In various embodimentsdistal end segment 400 andproximal end segment 500 are configured with a male mating section 320 or a female mating section 330 that corresponds to the mating structure of anadjacent segment 310. In various embodiments theproximal end segment 500 and/or thedistal end segment 400 can have a transition in nominal outer dimension width or diameter. In one embodiment thedistal end segment 400 tapers distally. - The segment construct 303 is configured to be changeable between a relatively flexible,
bent configuration 307 for insertion or extraction through a hole in an intramedullary canal and a relatively rigid, or less flexiblecompressed configuration 306 to provide a relatively stable anchor or fixation feature for the treatment of bone.FIGS. 59A-H illustrate various views of an embodiment of a segmentedintramedullary structure 300 in acompressed configuration 306.FIG. 59G is a schematic perspective partially exploded view of the segmentedintramedullary structure 300 with aelongate member 350 extending between aproximal end 301 anddistal end 302 of theintramedullary structure 300 through thechannels 340 of thesegments 310. -
FIG. 60 illustrates various embodiments of segmentedintramedullary structures 300 in variousbent configurations 307 with various lengths, diameters, materials anddistal end segments 400 with various embodiments of distal fixation structures. Although certain embodiments of proximal and distal fixation structures inproximal end segments 500 anddistal end segments 400 may show one fixation embodiment, any of the disclosed fixation structures can be mixed or used in combination with other or the same type of fixation structures on the proximal, distal, and/or intermediate portion of any embodiment of segmentedintramedullary structures 300.FIGS. 61-63 illustrate various embodiments ofdistal end segments 400 of segmentedintramedullary structures 300 with various embodiments of distal fixation structures. -
FIG. 61 illustrates one embodiment of a cross-screw distalfixation structure segment 410 of an intramedullary structure has one or more pre-formed orpre-drilled cross throughbores 112 for a surgeon to use in securing the distal end in the bone by using one or more bone screws 113 through the bone and into one or more cross-holes at various angles to anchor and secure the distal end of the implant in the bone. In various embodiments,bone screw 113 is the same or similar to lockingbolt 54 and/or lockingbolt 60. In oneembodiment bone screw 113 is a locking screw. In oneembodiment bone screw 113 is a self-tapping screw. In oneembodiment bone screw 113 uses an internal hex interface for driving the screw. In variousembodiments bone screw 113 can have a major diameters and lengths and screwing interfaces configured for a particular application. In various embodiments abone screw 113 has a major diameter of 4 mm, 5 mm, 6 mm, or other diameters. In various embodiments a bone screw has a length in the range of approximately 16 to 120 mm. In one embodiment at least onebone screw 113 is used in at least one throughbore 112 at thedistal end segment 400. In one embodiment at least onebone screw 113 is used in at least one throughbore 112 at theproximal end segment 500. In various embodiments, one, two, three, four or more throughholes 112 are provided in anysegment 310. In one embodiment athroughbore 112 is a tunnel in asegment 310. In oneembodiment throughbore 112 may merge with anotherthroughbore 112 to form a multi-conduit pathway.Different throughbores 112 may be used or optionally provided for options in fixing the device to bone. -
FIG. 62 illustrates one embodiment of a polymerdistal fixation segment 412 of anintramedullary structure 300 that includes a strong, solid polymer tip. In one embodiment the polymer is implantable-grade polyetheretherketone (PEEK), or other similar materials. One advantage of a polymer distalfixation structure segment 412 is that the surgeon can pierce the polymerdistal fixation segment 412 in any angle or direction to provide cross-screw fixation between the bone and implant. In one embodiment one or more bone screws 113 are used to provide structure between one side of the cortical bone, through the polymerdistal fixation segment 412, and into the other side of the cortical bone. For example, seeFIGS. 39B and 40B . In one embodiment the polymerdistal fixation segment 412 is fixed to theintramedullary structure 300 with apin 413. In one embodiment the polymerdistal fixation segment 412 has one or more markers placed in it for radiopaque monitoring of the fixation process. In one embodiment themarker 414 is near a distal end of the polymerdistal fixation segment 412. In one embodiment the marker can be a ring or other structure or shape for visualization under monitoring devices such as fluoroscopy. - With respect to
FIG. 63 , one embodiment of a radially-expandabledistal fixation segment 415 of an intramedullary structure can be called “hinged fingers.” In one embodiment, radially-expandabledistal fixation segment 415 is the same or has similar features to an embodiment of the radially-expandabledistal end segment 114 described above. In one embodiment, a radially-expandabledistal fixation segment 415 comprises two or more rigid members 416 (also called hinged fingers) that can open up like a flower when the ball (or actuator 417) at the end of theelongate member 350 is pulled up proximally through the intramedullary structure. One embodiment includes three or morerigid members 416. In one embodiment therigid members 416 do not bend. One embodiment has metalrigid members 416. In one embodiment one or more hingedfinger members 416 have a surface texture configured to improve fixation to bone. In one embodiment the surface texture is grooves. In one embodiment, theball 417 is attached to the distal end of theelongate member 350. When theelongate member 350 is pulled proximally toward theproximal end 301 of the segmentedintramedullary structure 300 the ball moves proximally until the hingedfingers 416 seat on sufficiently stable bone in or around the intramedullary canal. In one embodiment theball 417 can move off the central longitudinal axis of the intramedullary device since theelongate member 350 is flexible, allowing theball 417 to apply pressure to actuate the various hingedfingers 416 until a sufficient number of hingedfingers 416 is properly anchored, irrespective of irregular bony geometry in the intramedullary canal. This self-centering aspect of theball 417 andelongate member 350 is another advantage of the present embodiment. - In one embodiment
distal end segment 400 has aproximal end 401 and adistal end 402. In one embodimentdistal end segment 400 has a male or female end portion configured for attachment with an adjacent,proximal segment 310. In one embodiment theproximal end 401 of thedistal end segment 400 has afemale mating section 430 similar to any embodiment of a female mating section 330 in asegment 310. In one embodimentdistal end segment 400 has achannel 440 extending longitudinally therethrough. In oneembodiment channel 440 is similar tochannel 340 in asegment 310. In oneembodiment channel 440 is configured to align with and work in conjunction withchannel 340 in one ormore segments 310 and anelongate member 350. In one embodiment adistal end segment 400 is configured to distally anchor an elongate mechanism, such as atensioning rod 14, threaded rod, orelongate member 350. - In one embodiment
elongate member 350 is flexible. In one embodimentelongate member 350 comprises abraided cable 352. In one embodimentelongate member 350 comprises a metal cable. In one embodimentelongate member 350 comprises a braided Titanium cable. In one embodimentelongate member 350 serves as a post-reaming guide for placing the segmentedintramedullary structure 300 into anintramedullary canal 40 of abone 42. In one embodiment theelongate member 350 is inserted through an entry point in the cortical bone in to theintramedullary canal 40 and distally past afracture site 44 in abone 42. - In one embodiment
elongate member 350 comprises aferrule 356 at the distal end of theelongate member 350. In oneembodiment ferrule 356 is attached to the distal end of thebraided cable 352. In oneembodiment ferrule 356 is crimped to the distal end of thebraided cable 352. In oneembodiment ferrule 356 is welded to the distal end of thebraided cable 352. In oneembodiment ferrule 356 is crimped and welded to the distal end of thebraided cable 352. In oneembodiment ferrule 356 serves as a stop at the end of theelongate member 350. In oneembodiment ferrule 356 is a Titanium alloy. - In one embodiment
elongate member 350 comprises abraided cable 352 at least partially disposed within a lumen of atube 354. SeeFIGS. 65 and 65A . In one embodiment thetube 354 is flexible. In one embodiment thetube 354 is a Nitinol tube. In one embodiment thetube 354 has an outer diameter of 0.085″, an inner diameter of 0.065″, and a wall thickness of 0.010″. In one embodiment thetube 354 stiffens theelongate member 350 to facilitate the insertion of the segmentedintramedullary structure 300 over theelongate member 350, across thefracture site 44. In one embodiment the super elastic properties of Nitinol can prevent or minimize the permanent deformation of theelongate member 350 if bending of theelongate member 350 at thefracture site 44 occurs. In one embodiment thetube 354 runs from the distal end of theelongate member 350 to just below theproximal end segment 500 when the segmentedintramedullary structure 300 is fully compressed. - In one embodiment the
elongate member 350 is tensioned to compress theimplant segments 310 together to form a relatively rigid construct. In one embodiment the proper placement of the segmentedintramedullary structure 300 can be confirmed with fluoroscopy prior to the tensioning of theelongate member 350. In one embodiment theelongate member 350 is manually tensioned. In one embodiment theelongate member 350 is manually tensioned by pulling proximally on theelongate member 350 with respect to the segmentedintramedullary structure 300. In one embodiment theelongate member 350 is tensioned or further tensioned with acable tensioner assembly 200. In one embodiment, when fully tensioned, theelongate member 350 is locked in place with acollet screw 280 in theproximal end segment 500. In one embodiment anend cap 290 is placed and then theelongate member 350 is cut flush with the top of theend cap 290. In one embodiment, when theelongate member 350 is fully tensioned and the segmentedintramedullary structure 300 becomes rigid, thetube 354 is enclosed by the segmentedintramedullary structure 300 and is no longer is loaded. In various embodiments,distal end segment 400 can be any of the embodiments of a distal end segment. In one embodiment illustrated atFIG. 64 , thedistal end segment 400 can be a cross-screw distalfixation structure segment 410. - In one embodiment the
proximal end segment 500 has aproximal end 501 and adistal end 502 with a channel 540 extending between theproximal end 501 anddistal end 502.FIGS. 66-68 illustrate one embodiment of aproximal end segment 500. In one embodiment theproximal end segment 500 has aproximal section 510 near theproximal end 501. In one embodiment theproximal end segment 500 has adistal section 520 near thedistal end 502. In one embodiment theproximal end segment 500 has athroughbore section 530 between theproximal end 501 anddistal end 502. In one embodimentdistal section 520 has a male or female end portion configured for attachment with an adjacent,distal segment 310. In one embodiment thedistal end 502 ofproximal end segment 500 has adistal section 520 similar to any embodiment of a male mating section 320 in asegment 310. In various embodimentsproximal end segment 500 is has similar features asproximal end segment 110 described above. - In one embodiment the
proximal end segment 500 is slightly curved such that itsproximal end 501 reaches cortical bone proximal to thefracture site 44 while its distal end is in theintramedullary canal 40. In oneembodiment throughbore section 530 has four through-holes, orthroughbores 112, to allow for placement of one, two, three or fourbone screws 113 at theproximal end 301 of the segmentedintramedullary structure 300. In one embodiment, two of thethroughbores 112 are oriented forbone screws 113 placed from the right, and two of thethroughbores 112 are oriented forbone screws 113 placed from the left. - In one embodiment a
cable collet anchor 272 is permanently fixed within theproximal section 510. In embodimentcable collet anchor 272 is permanently fixed within theproximal section 510 with a pin (not illustrated) in a pin hole 511, which can be welded in place after insertion. In embodimentcable collet anchor 272 is permanently fixed within theproximal section 510 by welding. In embodimentcable collet anchor 272 is permanently fixed within theproximal section 510 with an interference fit between the two components. In embodimentcable collet anchor 272 is integral, or unitary, with theproximal section 510. - In one embodiment the
cable collet anchor 272 is configured to interface with acable tensioner assembly 200. In oneembodiment interface 512 provides a notch or other feature to facilitate the interfacing or connection between thecable collet anchor 272 and thecable tensioner assembly 200. In one embodiment acable tensioner assembly 200 is used to tighten, or increase tension in aelongate member 350 in order to make the segmentedintramedullary structure 300 less flexible, such as during device implantation. In one embodiment acable tensioner assembly 200 is used to loosen, or decrease tension in aelongate member 350 in order to make the segmentedintramedullary structure 300 more flexible, such as during device extraction. - In one embodiment the
cable collet anchor 272 is threaded to mate with thecollet screw 280 with achannel 281 configured to gripelongate member 350 with a plurality offlexible fingers 284. In one embodiment thecable collet anchor 272 has one or moretapered walls 276 to force the plurality offlexible fingers 284 to close around theelongate member 350 as thecollet screw 280 is tightened by rotating it distally. In one embodiment the outer surface of theflexible fingers 284 are tapered distally. In one embodiment the outer surface of theflexible fingers 284 are substantially cylindrical. In various embodiments thecollet screw 280 can have three, four, five or moreflexible fingers 284. The illustratedcollet screw 280 atFIG. 69 has threeflexible fingers 284. In one embodiment adriver shaft 252 of acollet driver 250 can used to tighten or loosen thecable collet screw 280 by interfacing with a cablecollet screw interface 283. In one embodiment cablecollet screw interface 283 has a shapedinner wall 286. In various embodiments shapedinner wall 286 is a hex shape, or other keyed type shape. In one embodiment cablecollet screw interface 283 has a shaped outer wall. In one embodiment the shaped outer wall is a hexagonal shape, such as with a nut. - In one embodiment an
end cap 290 serves to prevent bone formation over the device entry point. In various embodiments theend cap 290 can be configured to attach at thedistal end 501 of theproximal end segment 500. In various embodiments, theend cap 290 can be offered in various lengths to allow the surgeon to position the end of theend cap 290 so that it is just below the cortical margin. In various embodiments, theend cap 290 can have an additional length of +0 mm, +5 mm, +10 mm, +15 mm, or +20 mm. In oneembodiment end cap 290 has external threads that mate with internal threads on theproximal end segment 500. In oneembodiment end cap 290 has internal threads that mate with external threads on theproximal end segment 500. In oneembodiment end cap 290 has a reversible snap fit connection with theproximal end segment 500. In one embodiment, once theend cap 290 is in place, theelongate member 350 is cut flush with the proximal surface of theend cap 290. - Procedures for Manufacturing, Assembling or Installing a Segmented Intramedullary Structure
- In various embodiments, steps for installing a segmented intramedullary structure may include optional steps, and steps that can be taken in or out of sequence. Different combinations of steps may be used depending on the segmented intramedullary structure used, patient anatomy, the treatment being provided, and/or medical practitioner preference. As noted above,
FIGS. 14-22 schematically illustrate various embodiments of procedures for installing an embodiment of a segmented intramedullary nail into the intramedullary canal of a long bone. The following embodiments of procedures can be used alone, in conjunction with, or in combination with the embodiments of the procedure described with respect toFIGS. 14-22 and described elsewhere herein.FIGS. 70-78 schematically illustrate various embodiments of procedures for installing an embodiment of a segmented intramedullary nail into the intramedullary canal of a long bone. - In one embodiment a technique for implanting a segmented
intramedullary structure 300 can include any of the following general steps, such as reaming a canal in tissue to a diameter larger than the diameter of the selected segmentedintramedullary structure 300, inserting aelongate member 350 into the prepared canal, placing the selected segmentedintramedullary structure 300 over theelongate member 350, pulling on theelongate member 350 to compress thesegments 310 together, placing proximal and distal end locking screws 113, tensioning theelongate member 350 with acable tensioner assembly 200, locking theelongate member 350 by tightening acable collet screw 280 within theproximal end segment 500, threading anend cap 290 onto the proximal end of the segmentedintramedullary structure 300, or cutting theelongate member 350 flush with theend cap 290 with a cable cutter instrument. In one embodiment the technique for implanting a segmented intramedullary structure involves reaming a canal in tissue to a diameter at least 1.0 mm larger than the diameter of the selected segmentedintramedullary structure 300. - In various embodiments of techniques for implanting a segmented
intramedullary structure 300, various instruments can be used. Some non-limiting examples of optional instruments that can be used include a guide wire, a ball-tip guide wire, a Kelly clamp, an exchange tube, a drill bit, a cable tensioner, a reamer, a flexible reamer set, a tissue protector, a guidewire T-handle, an obturator, an implant length gauge, a proximal screw guide, a drill sleeve, a broach trial, a curved broach trial, a screw driver, a cannulated screw driver, a slap hammer, a back slapper, and a cable cutter. - In one embodiment, pre-operative planning includes measuring
intramedullary canal 40 diameter and/or length in abone 42. In one embodiment a radiographic canal ruler can be used to measureintramedullary canal 40 diameter and/or length in abone 42. -
FIG. 70 illustrates one embodiment of an approach to an access site for the implantation or removal of a segmentedintramedullary structure 300. In the illustrated embodiment, thebone 42 is a humerus, but the approach can be with any long bone and can occur at a distal or proximal end of thebone 42. In one embodiment, a patient is placed in a supine and in a semi-recumbent position (e.g., traditional “beach chair” position or tilted with the thorax “bumped” 30-40 degrees). A surgeon can split the deltoid fibers longitudinally, taking care to avoid the axillary nerve. In one embodiment, anaccess hole 46 is created at the access site. The surgeon can create an entry hole oraccess hole 46 just distal to the insertion of the supraspinatus, below the greater tuberosity. - In one embodiment illustrated at
FIG. 71 , the surgeon can insert the tip of abroach 604 into thebone 42 at an approximately 45 degree angle to the bone surface, at least 1 cm distal to the rotator cuff insertion. In one embodiment the geometry of the cutting surfaces of the broach 604 matches the proximal geometry of the segmentedintramedullary structure 300 to ensure properly sized proximal opening in the bone. In one embodiment, an 11 mmdiameter access hole 46 is used. Optionally, a guide wire and/or cone reamer can be used to open theaccess hole 46 prior to insertion of thebroach 604. The surgeon advances thebroach 604 into themedullary canal 40. - In one embodiment illustrated at
FIG. 72 , the surgeon can advance aguide wire 606 into theintramedullary canal 40, manually reduce thefracture 44, then advance the guide wire tip past thefracture site 44. In one embodiment theguide wire 606 has a 2 mm outer diameter. In one embodiment theguide wire 606 includes a ball tip at its distal end. In one embodiment the surgeon can confirm the position of theguide wire 606 using fluoroscopy as needed. In one embodiment the surgeon centers the ball-tip of theguide wire 606 at the distal end of theintramedullary canal 40. - In one embodiment illustrated at
FIG. 73 , the surgeon can measure the proper implant length. While maintaining fracture reduction with the distal ball tip of theguide wire 606 in proper position, the surgeon can place a Kelly clamp at a point as close as possible to the cortical entry point nearaccess hole 46. The surgeon can proximally withdraw theguide wire 606 approximately 1 cm from thebone 42, and estimate the segmentedintramedullary structure 300 length by measuring the exposed guide wire 606 (indicated by the arrow with reference number 608) using the a device length gauge. The surgeon can record the length or select an appropriate segmentedintramedullary structure 300 and insert theguide wire 606 back into theintramedullary canal 40 and remove the Kelly clamp. - In one embodiment illustrated at
FIG. 74 , the surgeon can ream theintramedullary canal 40. In various embodiments, one ormore reamers 608 can be used. In one embodiment, beginning with a small diameterflexible reamer 608, such as in one example, a 6 mmflexible reamer 608, the surgeon can ream the medullary canal by placing thereamer 608 over theguide wire 606 and advancing it into the canal while maintaining fracture reduction. In one embodiment noguide wire 606 is required. In one embodiment the surgeon can use a tissue protector to prevent soft tissue damage while reaming. In one embodiment the surgeon can gradually increasereamers 608 diameters (for example, thereamers 608 can increase in diameter by 0.5 mm increments) until “chatter” is heard for thereamer 608, indicating the proper implant diameter. In one embodiment this diameter should correspond to preoperative estimates using radiographs or a radiographic canal ruler. Based on pre-op planning, thefinal reamer 608 diameter should be at least 1.0 mm larger than the nominal or central diameter of the chosen segmentedintramedullary structure 300 to minimize the potential for fracture site distraction. In one embodiment the surgeon can place an obturator over the end of theguide wire 606 to hold it in position. The surgeon can remove thelast reamer 608 by sliding it along theguide wire 606. Once thereamer 608 is out of thebone 42, the surgeon can remove the obturator andreamer 608. - In one embodiment illustrated at
FIG. 75 , the surgeon can select the diameter and length of the segmentedintramedullary structure 300 based on thelast reamer 608 diameter combined with the previously measured canal length. The surgeon can insert an exchange tube 610 over theguide wire 606, remove theguide wire 606 and insert theelongate member 350. The surgeon can confirm theelongate member 350 position under fluoroscopy. The surgeon can remove the exchange tube 610, being careful to maintain the position of theelongate member 350. - In one embodiment illustrated at
FIG. 76 , one embodiment of a segmentedintramedullary structure 300 being inserted in a bent configuration in to a sectional view of abone 42 according to an embodiment of the present invention.FIG. 76 illustrates one embodiment of an additional optional step in the method of inserting a segmentedintramedullary structure 300 in a bent configuration in to anintramedullary canal 40 of along bone 42 with aninserter guide 612. In one embodiment, aninserter guide 612 is a flexible, low friction strip with a width approximately equal to the width or diameter of the segmentedintramedullary structure 300. Theinserter guide 612 is inserted into theaccess hole 46 in thelong bone 42 leading into theintramedullary canal 40. - In one embodiment illustrated at
FIG. 77 , the surgeon can insert a segmentedintramedullary structure 300 into thebone 42. In one embodiment the surgeon can attach a proximal fixation screw guide-interface 104, or proximal drill guide, onto theproximal end 301 of the segmentedintramedullary structure 300. In one embodiment the surgeon can use a locking bolt with a quick connect mechanism. The surgeon can advance the segmentedintramedullary structure 300 over the proximal end of theelongate member 350. With the segmentedintramedullary structure 300 in a flexed or bent configuration, the surgeon can advance the segmentedintramedullary structure 300 over theelongate member 350 into themedullary canal 40. The surgeon can cake care to maintain theelongate member 350 position across thefracture 44 while advancing the segmentedintramedullary structure 300 over theelongate member 350. In one embodiment the surgeon can optionally slightly rotate theproximal end 301 of the segmentedintramedullary structure 300 to assist with insertion. The surgeon can sink the most proximal portion of the segmentedintramedullary structure 300 at least 5 mm below the bone cortex and confirm position with fluoroscopy. In one embodiment the surgeon can apply preliminary tension to theelongate member 350 by manually pulling on the proximal end of the exposedelongate member 350 to compress thesegments 310 of the segmentedintramedullary structure 300 together. The surgeon can take caution not to bend or kink theelongate member 350 near the segmentedintramedullary structure 300. - In one embodiment illustrated at
FIG. 78 , the surgeon can fixate the segmentedintramedullary structure 300 with respect to thebone 42. In one embodiment the surgeon can fixate the segmentedintramedullary structure 300 with respect to thebone 42 with proximal and distal bone screws 113. In other embodiments, other fixation techniques can be used. The surgeon can confirm that the proximal portion of the IFS is flush or slightly below the cortex of thebone 42. The surgeon can create an incision in line with the mostproximal screw throughbore 112. In one embodiment twoproximal throughbores 112 are configured for left-sided or right-sided access, and are close enough in proximity to have both bone screws 113 inserted through a single incision, approximately 5 mm long. The surgeon can bluntly dissect the incision to the cortex, taking care to avoid the axillary nerve and any of its arborized branches. The surgeon can spread the tissues and insert a proximal fixation screw guide-interface 104 until it contacts thebone 42. In one embodiment self-tappingbone screws 113 can be inserted with the proximal fixation screw guide-interface 104 through thebone 42 and into thethroughbores 112 of the segmentedintramedullary structure 300. In one embodiment the proximal fixation screw guide-interface 104 includes a 3.2 mm proximal drill sleeve. The surgeon can maintain the position of the proximal fixation screw guide-interface 104 against thebone 42 and use a drill bit to drill through the near and far cortices of thebone 42. In one embodiment the drill bit is a 3.2 mm calibrated drill bit. In surgeon can optionally stop drilling immediately after penetrating the far cortex of thebone 42. The surgeon can measure the necessary length for thebone screw 113 using the drill bit, a calibrated drill bit, or a calibrated measuring device. In various embodiments, thebone screw 113 can include diameters and length appropriate for the application. In some embodiments, thebone screw 113 has a diameter of 4.0 mm, 5.0 mm, or 6.0 mm, and a length in a range from about 16 mm to about 120 mm. The surgeon can select abone screw 113 and insert it through the selected throughbore 112 of the segmentedintramedullary structure 300 with a screw driver. In one embodiment the screw driver is a hex driver. The surgeon can repeat the procedure for the more distally-positionedproximal bone screw 113. In one embodiment, the more distally-positionedproximal bone screw 113 can be inserted before the more proximally-positionedproximal bone screw 113. The surgeon can reconfirmfracture 44 reduction with a visualization technique, such as fluoroscopy. The surgeon can ensure the segmentedintramedullary structure 300segments 310 are mostly compressed by manually tensioning theelongate member 350 as necessary by pulling on the proximal end of theelongate member 350. In one embodiment the surgeon avoids locking the segmentedintramedullary structure 300 with distraction between the bone segments at thefracture 44. - In one embodiment, the surgeon can place the patient's elbow on a mayo stand to support it to reduce distraction between bone segments at the
fracture 44. The surgeon can utilize an AP view of the distal humerus and make a longitudinal incision over the segmentedintramedullary structure 300distal throughbores 112. The surgeon can identify the biceps fascia, split the fascia and deliver the drill tip to thebone 42. The surgeon can take caution to ensure drill tip placement so as to avoid inadvertent medialization of the drill tip. In one embodiment the surgeon can drill the holes in the bone for the distal bone screws 113. In one embodiment the surgeon can use self-tapping distal bone screws 113. In one embodiment the surgeon can insert the bone screws 113 using a freehand technique. - In one embodiment illustrated at
FIG. 78 , the surgeon can tension theelongate member 350 in the segmentedintramedullary structure 300, which compresses thesegments 310 with acable tensioner assembly 200. In one embodiment the surgeon can ensure that thecable tensioner assembly 200 is ready to accept theelongate member 350 by loosening the tensioning threadedknob 240 until it stops. In one embodiment the loosening of the tensioning knob is counter-clockwise. In another embodiment the loosening of the tensioning knob is clockwise. The surgeon can insert thecable collet screw 280 into the distal end of thecable tensioner assembly 200 and press thecable collet screw 280 to firmly seat it on thecable tensioner assembly 200. The surgeon can slide thecable tensioner assembly 200 over the exposedelongate member 350 and attachcable tensioner assembly 200 to the proximal fixation screw guide-interface 104. In one embodiment the proximal fixation screw guide-interface 104 is already in place. In one embodiment the proximal fixation screw guide-interface 104 andcable tensioner assembly 200 can attach using a quick connect mechanism. - In one embodiment segmented
intramedullary structure 300elongate member 350 tensioning occurs in two steps: 1) tensioning of theelongate member 350, and 2) locking of theelongate member 350 with thecable collet screw 280. In one embodiment, when thecable tensioner assembly 200 is securely connected to the proximal fixation screw guide-interface 104—segmentedintramedullary structure 300 construct. The surgeon can tighten thecollet driver 250 knob by turning it 1-2 turns clockwise to partially advance the lockingcollet threads 282 of thecable collet screw 280 into theproximal end 301 of the segmentedintramedullary structure 300. This step ensures proper threading of thecable collet screw 280 into thecable collet anchor 272 of the segmentedintramedullary structure 300. Thecable collet screw 280 should not be fully tightened yet. The surgeon can confirm the segmentedintramedullary structure 300 position and fracture 44 reduction using fluoroscopy. The surgeon can apply tension to theelongate member 350 by rotating the tensioning threadedknob 240 clockwise until the tension indicator markings 247 reaches the 100 pound mark. In one embodiment the surgeon does not exceed 125 pounds of tension. Tensioningelongate member 350 should apply compression across thefracture site 44, such that the gap is reduced or eliminated between thefracture 44 fragments. Tensioningelongate member 350 should also reduce or eliminate gaps between thesegments 310. The surgeon can confirm the position of the segmentedintramedullary structure 300 and confirmfracture 44 reduction using a C-arm or fluoroscopy. The surgeon can locks the tensionedelongate member 350 within the segmentedintramedullary structure 300 by tightening thecable collet screw 280 by rotating thecollet driver 250, which rotates thedriver shaft 252, clockwise to fully “seat” thecable collet screw 280. - In one embodiment, after the
cable collet screw 280 has been secured, the surgeon can release thecable tensioner assembly 200 by loosening the tensioning threadedknob 240 until it stops. This will release thecable tensioner assembly 200 from theelongate member 350. The surgeon can release the quick connect outer ring to remove thecable tensioner assembly 200 and proximal fixation screw guide-interface 104 from the segmentedintramedullary structure 300. - In one embodiment the surgeon can select an
appropriate end cap 290 and slide it distally over the exposedelongate member 350. The surgeon can thread theend cap 290 into place using an end cap driver. The surgeon can confirm the position of the segmentedintramedullary structure 300 using fluoroscopy. The surgeon can use cable cutters to cut theelongate member 350 as close to theproximal end 301 of the segmentedintramedullary structure 300 as possible. In one embodiment the surgeon can cut theelongate member 350 as close to the proximal end of theend cap 290 as possible. The surgeon can close the wound in layers. - In various embodiments, different combinations of
segments 310 can be assembled or manufactured into a custom segmentedintramedullary structure 300 based on specific parameters of the bone in which the segmentedintramedullary structure 300 will be implanted. In various embodiments, different combinations ofsegments 310 can be used or combined in a modular fashion to assemble custom made segmentedintramedullary structures 300 based on the bone and application for the structure. In various embodiments the overall configuration or shape of the segmentedintramedullary structure 300 may be straight, substantially straight, or curved along any onesegment 310 or any sets ofsegments 310 depending on the selection of parts from an array of parts with various shapes, sizes and features. Eachsegment 310 can be substantially straight or curved, and any set ofsegments 310 can have interfaces providing for angles betweenadjacent segments 310. In various embodiments,segments 310 can also comprise one ormore transition segments 314 and/oruniform segments 316 disposed between thedistal end segment 400 and theproximal end segment 500.Segments 310 can be selected based on features thesegments 310 have for use based on an evaluation of parameters of the bone for implantation. Parameters, as discussed herein, can include bone or intramedullary canal diameter, length, width, height, curvature (if any), deviation from linear, fracture geometry, bone geometry, tissue geometry, anatomical features such as abnormalities or other features, to name a few. In various embodiments, different combinations of embodiments ofsegments 314 and/oruniform segments 316 can be disposed between different embodiments of adistal end segment 400 and different embodiments of aproximal end segment 500. Referring to one embodiment illustrated inFIG. 79 , different non-limiting embodiments of aproximal end segment throughbores 112, locking mechanisms, and more can be selected depending on parameters of the bone or patient in which the structure is to be implanted. Similarly, different non-limiting embodiments of adistal end segment uniform segments 316 can be used, with different sizes arranged with complementary interfaces. In one optional embodiment variousuniform segments 316 may be used with complementary interfaces but have different outer body parameters, such as diameter, texture or other alignment or bone engagement or bone ingrowth enhancing structure. Likewise, any combination oftransition segments 314 can be used, with different sizes arranged with complementary interfaces. Various combinations oftransition segments 314 may be used for a continuous transition along a number oftransition segments 314, or can vary in taper with increases in diameter or width as desired depending on the sequence ofsegment 310 assembly. - In one method of assembly, manufacture, or construction of the segmented
intramedullary structure 300, a surgeon could assemble a modular or custom segmentedintramedullary structure 300 while in the operating room. In one embodiment an evaluation of bone parameters using any imaging or assessment technique can be used, then a series ofsegments 310 could be assembled using a selected or suitable series and number ofsegments 310 based on the bone evaluation. In one embodiment asegment 310 may be selected based on the best fitting curvature, orientation, and/orthroughbores 112 for a surgical approach to the bone.Different segments 310 can be selected for accommodating for a fracture, increased stability, screw placement, and other aspects relating to features and parameters of the device with the bone. - Typically, at least a proximal segment, a distal segment and an intermediate segment will be assembled to form a final construct. Depending upon the desired length of the assembled implant, at least two, or three or five or more intermediate segments may be used. Each of the intermediate segments is provided with a proximal interface, for engaging a proximally adjacent segment, and a distal interface for engaging a distally adjacent segment. The proximal and or distal interfaces may be provided with a retention lock such as a snap ring as has been described elsewhere herein or other complementary retention structure. The retention lock permits the physician to connect two adjacent segments together while assembling the implant, and also to preserve the implant removal feature discussed below.
- In the modular, customizable device, the distal end segment may be provided with a proximally extending tightening element such as a pull or push element, rotatable shaft or other structure for locking the finished implant in its implanted configuration. Each of the intermediate segments is provided with an axially extending lumen, for receiving the tightening element therethrough. During assembly, the physician feeds the axially extending tightening element from the distal most segment through each successive intermediate segment until the desired length is reached. The proximal segment is provided with a lock, for locking the tightening element. The tightening element may be provided with an initial length which exceeds the length of the assembled implant. The proximal excess of the tightening element can be cut off or otherwise detached and discarded to conform to the length of the implant. Alternatively, it may be left subcutaneously so that it can be retrieved and used as a guide to the implant for future revision surgery. Alternatively, the tightening element may be provided in a modular configuration, with a portion of the tightening element carried by each segment, so that it is effectively assembled as each successive segment is connected to the implant.
- Procedures for Extracting or Removing a Segmented Intramedullary Structure
- In one embodiment an implanted segmented
intramedullary structure 300 can be removed from the patient. In one embodiment an implanted segmentedintramedullary structure 300 can be removed from the patient by reversing some of the steps used in implantation. In one embodiment the surgeon can access theaccess hole 46 in the bone with an incision and moving tissue out of the way. Visualization techniques, such as fluoroscopy, or manual palpation of the tissue can be used to locatebone screw 113 extraction sites. Use of minimally invasive, percutaneous, or open surgical techniques can be used to access the access site and screw sites in the patient. In one embodiment theend cap 290 is removed. In one embodiment the bone screws 113 are removed. In one embodiment thecable collet screw 280 is loosened. In one embodiment thecable collet screw 280 is loosened with a collet screw removal tool. In one embodiment thecable collet screw 280 is loosened with acable tensioner assembly 200 operated in a manner to reduce tension in theelongate member 350. In one embodiment, the proximal end of theelongate member 350 is grasped with a tool for extracting theelongate member 350. In one embodiment extraction ofelongate member 350 pulls thedistal end segment 400 of the segmentedintramedullary structure 300 in a proximal direction toward theaccess hole 46. In one embodiment thecable collet screw 280 is loosened, moved proximally alongelongate member 350, and tightened back on theelongate member 350 to grasp theelongate member 350 at a more proximal location. In one embodiment a loosenedelongate member 350releases segments 310 in the segmentedintramedullary structure 300 from the compressed configuration, allowing thesegments 310 to distract or move with respect to each other. In one embodiment the tension inelongate member 350 is reduced enough to allowadjacent segments 310 in the segmentedintramedullary structure 300 to move into abent configuration 307 sufficient for extraction of at least onesegment 310 though theaccess hole 46. In oneembodiment segments 310 are removed frombone 42 sequentially. In one embodiment, it is possible that the segmentedintramedullary structure 300 is attached to patient tissue or bone, or that some bone cement or adhesives were used around the implanted device, or other additional anchoring mechanisms. In one embodiment theproximal end 301 of the segmentedintramedullary structure 300 may be tapped or vibrated with a hammer or device configured to shake or vibrate the segmentedintramedullary structure 300 at a frequency, such as a resonant frequency, to assist in the removal of the segmentedintramedullary structure 300 from thebone 42. In one embodiment extraction of a segmentedintramedullary structure 300 includes providing sufficient force to break onesegment 310 free from the surrounding bone at a time. For example, the force required to shear the bone ingrowth into one segment, such as the mostproximal segment 310, is less than the force required to shear the bony ingrowth throughout the length of the entire segmentedintramedullary structure 300 at once. For example, resistance to removal may correlate to surface area of the implant being removed. If one segment is broken free at a time, the resistance to overcome removal would be proportionate to the surface area of that one segment instead of the entire implant. In one embodiment the shear force to free onesegment 310 is less than the shear force to freemultiple segments 310 at the same time. In one embodiment extraction of a segmentedintramedullary structure 300 includes attaching a removal device to the mostproximal segment 310 and pulling the mostproximal segment 310 proximally. In one embodiment the removal device is a slap hammer, and the slap hammer is attached to the mostproximal segment 310 and actuated with sufficient force to free the mostproximal segment 310 from thebone 42. In various embodiments the snap ring or other locking structure permits distraction between adjacent segments of at least about 0.5 mm, generally at least about 1 mm or 2 mm but often no more than about 5 mm or 10 mm. As a result, a loosenedsegment 310 may be proximally retracted to the limit of its travel. Further proximal force applied to thesegment 310 will be transferred by the locking structure to the next adjacent distal segment so that it may be broken free from surroundingbone 42. The process can be repeated to remove allsegments 310 from thebone 42. - Thus, an improved intramedullary structure has been provided as described above. While the structure has been described in terms of certain specific embodiments, there is no intention to limit the invention to the same. It will be understood that the foregoing is only illustrative of the principles of the invention, and that various modifications, alterations, and combinations can be made by those skilled in the art without departing from the scope and spirit of the invention. Accordingly, it is not intended that the invention be limited, except as by the appended claims.
Claims (14)
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US8430879B2 (en) | 2013-04-30 |
US20090228007A1 (en) | 2009-09-10 |
JP2010522046A (en) | 2010-07-01 |
US20130006245A1 (en) | 2013-01-03 |
AU2008228710A1 (en) | 2008-09-25 |
WO2008116175A3 (en) | 2008-11-06 |
EP2129309A2 (en) | 2009-12-09 |
US20090228008A1 (en) | 2009-09-10 |
US8128627B2 (en) | 2012-03-06 |
US20080287951A1 (en) | 2008-11-20 |
WO2008116175A2 (en) | 2008-09-25 |
CN101636119A (en) | 2010-01-27 |
US8496658B2 (en) | 2013-07-30 |
CA2678911A1 (en) | 2008-09-25 |
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