US 20060271105 A1
Devices and methods are disclosed for securing soft tissue to bone, and particularly for axially anchoring suture which attaches the soft tissue to adjacent bone structure.
1. A suture anchoring device, comprising:
an anchor housing having an outer wall;
a compressible plug member disposed within said housing and extending proximally of said housing;
a channel extending through said plug member for accommodating a length of suture; and
a cap member for enclosing a proximal end of said housing;
wherein said plug member is compressed in order to anchor the length of suture when said cap member is engaged with said housing.
2. A suture anchoring device, comprising:
an anchor body having an interior threaded wall;
a suture return member associated with said body for returning a distally extending length of suture in a proximal direction;
a length of fiber having a first end secured to a distal portion of said body, and a second end extending from an end of said body, said fiber being wrapped about the interior threaded wall of said body a plurality of times;
whereby when said length of fiber is pulled in a predetermined direction, the wrapped fiber becomes tightly engaged about said suture to anchor said suture.
3. The suture anchoring device as recited in
4. The suture anchoring device as recited in
a first plate having a suture receiving aperture disposed therein;
a second plate having a suture receiving aperture disposed therein, and
a connection between said first and second plates which is designed to break when a predetermined force is applied thereto;
wherein axial displacement of one of said plates relative to the other of said plates creates a tortuous path for a length of suture passing therethrough.
5. A suture anchoring device, comprising:
an outer tube having a lumen extending axially therethrough;
a length of suture extending distally through said outer tube, about a suture return member, and proximally back through said outer tube; and
an inner expandable member extending axially through said lumen, between portions of said length of suture, said inner expandable member being actuatable to a radially expanded state in order to compress and clamp said length of suture in place.
6. The suture anchoring device as recited in
7. The suture anchoring device as recited in
8. The suture anchoring device as recited in
This application is a continuation application of co-pending U.S. patent application Ser. No. 10/299,171 to Seth Foerester, et al. filed Nov. 19, 2002, the subject matter being incorporated herein by reference in its entirety.
The present invention relates to devices and methods for repairing soft tissue, and more particularly to devices and methods for arthroscopic repair of a torn rotator cuff.
It is an increasingly common problem for tendons and other soft, connective tissues to tear or to detach from associated bone. One such type of tear or detachment is a “rotator cuff” tear, wherein the supraspinatus tendon separates from the humerus, causing pain and loss of ability to elevate and externally rotate the arm. Complete separation can occur if the shoulder is subjected to gross trauma, but typically, the tear begins as a small lesion, especially in older patients.
To repair a torn rotator cuff, the typical course today is to do so surgically, through a large incision. This approach is presently taken in almost 99% of rotator cuff repair cases. There are two types of open surgical approaches for repair of the rotator cuff, one known as the “classic open” and the other as the “mini-open”. The classic open approach requires a large incision and complete detachment of the deltoid muscle from the acromion to facilitate exposure. The cuff is debrided to ensure suture attachment to viable tissue and to create a reasonable edge approximation. In addition, the humeral head is abraded or notched at the proposed soft tissue to bone reattachment point, as healing is enhanced on a raw bone surface. A series of small diameter holes, referred to as “transosseous tunnels”, are “punched” through the bone laterally from the abraded or notched surface to a point on the outside surface of the greater tuberosity, commonly a distance of 2 to 3 cm. Finally, the cuff is sutured and secured to the bone by pulling the suture ends through the transosseous tunnels and tying them together using the bone between two successive tunnels as a bridge, after which the deltoid muscle must be surgically reattached to the acromion. Because of this maneuver, the deltoid requires postoperative protection, thus retarding rehabilitation and possibly resulting in residual weakness. Complete rehabilitation takes approximately 9 to 12 months.
The mini-open technique, which represents the current growing trend and the majority of all surgical repair procedures, differs from the classic approach by gaining access through a smaller incision and splitting rather than detaching the deltoid. Additionally, this procedure is typically performed in conjunction with arthroscopic acromial decompression. Once the deltoid is split, it is retracted to expose the rotator cuff tear. As before, the cuff is debrided, the humeral head is abraded, and the so-called “transosseous tunnels”, are “punched” through the bone or suture anchors are inserted. Following the suturing of the rotator cuff to the humeral head, the split deltoid is surgically repaired.
Although the above described surgical techniques are the current standard of care for rotator cuff repair, they are associated with a great deal of patient discomfort and a lengthy recovery time, ranging from at least four months to one year or more. It is the above described manipulation of the deltoid muscle together with the large skin incision that causes the majority of patient discomfort and an increased recovery time.
Less invasive arthroscopic techniques are beginning to be developed in an effort to address the shortcomings of open surgical repair. Working through small trocar portals that minimize disruption of the deltoid muscle, a few surgeons have been able to reattach the rotator cuff using various bone anchor and suture configurations. The rotator cuff is sutured intracorporeally and an anchor is driven into bone at a location appropriate for repair. Rather than thread the suture through transosseous tunnels which are difficult or impossible to create arthroscopically using current techniques, the repair is completed by tying the cuff down against bone using the anchor and suture. Early results of less invasive techniques are encouraging, with a substantial reduction in both patient recovery time and discomfort.
Unfortunately, the skill level required to facilitate an entirely arthroscopic repair of the rotator cuff is inordinately high. Intracorporeal suturing is clumsy and time consuming, and only the simplest stitch patterns can be utilized. Extracorporeal knot tying is somewhat less difficult, but the tightness of the knots is difficult to judge, and the tension cannot later be adjusted. Also, because of the use of bone anchors to provide a suture fixation point in the bone, the knots that secure the soft tissues to the anchor by necessity leave the knot bundle on top of the soft tissues. In the case of rotator cuff repair, this means that the knot bundle is left in the shoulder capsule where it can be felt by the patient postoperatively when the patient exercises the shoulder joint. So, knots tied arthroscopically are difficult to achieve, impossible to adjust, and are located in less than optimal areas of the shoulder. Suture tension is also impossible to measure and adjust once the knot has been fixed. Consequently, because of the technical difficulty of the procedure, presently less than 1% of all rotator cuff procedures is of the arthroscopic type, and is considered investigational in nature.
Another significant difficulty with current arthroscopic rotator cuff repair techniques is shortcomings related to currently available suture anchors. Suture eyelets in bone anchors available today, which like the eye of a needle are threaded with the thread or suture, are small in radius, and can cause the suture to fail at the eyelet when the anchor is placed under high tensile loads.
There are various bone anchor designs available for use by an orthopedic surgeon for attachment of soft tissues to bone. The basic commonality between the designs is that they create an attachment point in the bone for a suture that may then be passed through the soft tissues and tied, thereby immobilizing the soft tissue. This attachment point may be accomplished by different means. Screws are known for creating such attachments, but existing designs suffer from a number of disadvantages, including their tendency to loosen over time, requiring a second procedure to later remove them, and their requirement for a relatively flat attachment geometry.
Another approach is to utilize the difference in density in the cortical bone (the tough, dense outer layer of bone) and the cancellous bone (the less dense, airy and somewhat vascular interior of the bone). There is a clear demarcation between the cortical bone and cancellous bone, where the cortical bone presents a kind of hard shell over the less dense cancellous bone. The aspect ratio of the anchor is such that it typically has a longer axis and a shorter axis and usually is pre-threaded with a suture. These designs use a hole in the cortical bone through which an anchor is inserted. The hole is drilled such that the shorter axis of the anchor will fit through the diameter of the hole, with the longer axis of the anchor being parallel to the axis of the drilled hole. After deployment in to the cancellous bone, the anchor is rotated 90B so that the long axis is aligned perpendicularly to the axis of the hole. The suture is pulled, and the anchor is seated up against the inside surface of the cortical layer of bone. Due to the mismatch in the dimensions of the long axis of the anchor and the hole diameter, the anchor cannot be retracted proximally from the hole, thus providing resistance to pull-out. These anchors still suffer from the aforementioned problem of eyelet design that stresses the sutures.
Still other prior art approaches have attempted to use a “pop rivet” approach. This type of design requires a hole in the cortical bone into which a split shaft is inserted. The split shaft is hollow, and has a tapered plug leading into its inner lumen. The tapered plug is extended out through the top of the shaft, and when the plug is retracted into the inner lumen, the tapered portion causes the split shaft to be flared outwardly, ostensibly locking the device into the bone.
Other methods of securing soft tissue to bone are known in the prior art, but are not presently considered to be feasible for shoulder repair procedures, because of physicians' reluctance to leave anything but a suture in the capsule area of the shoulder. The reason for this is that staples, tacks, and the like could possibly fall out and cause injury during movement. As a result ofthis constraint, the attachment point often must be located at a less than ideal position. Also, the tacks or staples require a substantial hole in the soft tissue, and make it difficult for the surgeon to precisely locate the soft tissue relative to the bone.
As previously discussed, any of the anchor points for sutures mentioned above require that a length of suture be passed through an eyelet fashioned in the anchor and then looped through the soft tissues and tied down to complete the securement. Much skill is required, however, to both place the sutures in the soft tissues, and to tie knots while working through a trocar under endoscopic visualization.
What is needed, therefore, are new approaches for repairing the rotator cuff or fixing other soft tissues to bone, wherein both the bone and suture anchors reside completely below the cortical bone surface, there is no requirement for the surgeon to tie a knot to attach the suture to the bone anchor, and wherein suture tension can be adjusted and possibly measured. The procedures associated with the new approaches should be better for the patient than existing procedures, should save time, be uncomplicated to use, and be easily taught to practitioners having skill in the art.
Accordingly, the inventors have developed new and novel approaches for securing soft tissue to bone, and particularly for axially anchoring suture which attaches the soft tissue to adjacent bone structure.
More particularly, in one aspect of the invention there is disclosed a suture anchoring device, comprising an anchor housing having an outer wall, a compressible plug member disposed within the housing and extending proximally of the housing, and a channel extending through the plug member for accommodating a length of suture. A cap member is provided for enclosing a proximal end of the housing. In operation, the compressible plug member is compressed in order to anchor the length of suture when the cap member is engaged with the housing.
In another aspect of the invention, there is disclosed a suture anchoring device which comprises an anchor body having an interior threaded wall, as well as a suture return member associated with the body, such as a pin, for returning a distally extending length of suture in a proximal direction. A length of fiber is provided, having a first end secured to a distal portion of the body, and a second end extending from an end of the body, the fiber being wrapped about the interior threaded wall of the body a plurality of times. In operation, when the length of fiber is pulled in a predetermined direction, the wrapped fiber becomes tightly engaged about the suture to anchor the suture.
In yet another aspect of the invention, there is provided a suture anchoring device, which comprises an anchor body having an outer wall, and a suture return member disposed at a distal end of the anchor body, for receiving a length of suture extending distally through the body, and returning a portion of the suture length in a proximal direction. A passage extends along an interior surface of the wall for accommodating the length of suture. The passage tapers in width in a proximal direction, for the purpose of permitting the suture to be moved axially when pulled in a first direction, for approximating a portion of soft tissue to which the suture was attached to adjacent bone, and anchoring the suture axially in place when the suture is pulled in an opposing direction.
In still another aspect of the invention, there is provided a suture anchoring device, comprising an anchor body having an outer wall, as well as a lumen for accommodating a length of suture within the outer wall. A plurality of members are disposed within the anchor body for contacting the length of suture and creating a tortuous path therefor, in order to anchor the length of suture in place. The device further comprises a member radially extending from the body for anchoring the device in adjacent bone.
In another aspect of the invention, there is provided a suture anchoring device, which comprises an axially extending spring, as well as a suture return member or pin disposed distally of said spring. A length of suture extends axially within the spring and about the suture return member. An actuator is disposed at a proximal end of the device for actuating the spring to a compressed state wherein the suture becomes clamped within the spring.
In yet another aspect of the invention, there is provided a suture anchoring device, which comprises a suture return member and a length of suture extending axially through the device about the suture return member. A plurality of axially stacked, spaced plates, comprising leaf springs, are disposed proximally of the suture return member. The aforementioned length of suture extends through apertures in each of the plates. A mandrel is provided for moving the plurality of stacked plates between a first generally planar orientation, wherein the suture is free to move axially therethrough, and a second folded orientation, wherein the suture is axially clamped within the apertures.
In still another aspect of the invention, there is provided a suture anchoring device, which comprises a body, a core disposed within the body, and a length of suture attached to a piece of soft tissue and extending into the body. A portion of the length of suture is wrapped about the core and attached to a distal end thereof. The core is rotatable to adjustably tension the length of suture, and may be rotationally locked in order to anchor the length of suture in place.
In another aspect of the invention, there is provided a suture anchoring device, which comprises an outer tube, as well as a first plate having a suture receiving aperture disposed therein. A second plate has a suture receiving aperture disposed therein. A connection between the first and second plates is designed to break when a predetermined force is applied thereto. The system is designed so that axial displacement of one of the plates relative to the other of the plates causes application of the predetermined force, to separate the plates, and thus create a tortuous path for a length of suture passing therethrough.
In still another aspect of the invention, there is provided a suture anchoring device. This device comprises an outer tube having a lumen extending axially therethrough, and a length of suture extending distally through the outer tube, about a suture return member, and proximally back through the outer tube. An inner expandable member extends axially through the lumen, between portions of the length of suture, the inner expandable member being actuatable to a radially expanded state in order to compress and clamp the length of suture in place. In one embodiment, the inner expandable member comprises a split elastomeric tube, while in a second embodiment, the inner expandable member comprises a spring coil.
The invention, together with additional features and advantages thereof, may best be understood by reference to the following description taken in conjunction with the accompanying illustrative drawing.
FIG 1A is a partial sectional view through the left shoulder of a human as seen from the front showing the use of a minimally invasive soft tissue to bone attachment system, or suture anchor system, of the present invention;
The present invention provides improved knotless suture anchor devices and methods for anchoring a length of suture with respect to a body cavity. In the exemplary embodiments described herein, the inventive devices are used to anchor a length of suture to a bone structure, specifically the humeral bone of the human shoulder. The length of suture is desirably looped through soft tissue, such as a rotator cuff tendon, to approximate and fix the soft tissue with respect to the body cavity (e.g., bone structure). It should be understood, however, that the suture anchor apparatus described herein may be utilized to secure a length of suture to body cavities other than in a bone structure, and may even be used to anchor the suture outside of a body cavity, or merely to a predetermined location within the body. In this regard, the various inventive embodiments include an anchor body within which the length of suture may be anchored without knots. If the anchor body is to be implanted within the body cavity, structure on its exterior or coupled therewith may also be provided for securing the anchor body therein.
As mentioned, the present invention is particularly well-suited for repairing rotator cuff injuries by re-attaching the rotator cuff tendon to the outside of the humeral head. The invention permits minimally invasive surgeries on such injuries and greatly facilitates rapid and secure fixation of the rotator cuff tendon to the humeral head. It should be understood that the same principles described herein apply to the repair of other injuries in which soft tissue is to be re-attached to a bone structure.
With reference first to FIG 1A, a generally tubular trocar 30 provides a conduit through the soft tissue of the shoulder for passage of the suture anchor system 20 of the present invention. Per convention, the trocar has a proximal end outside of the patient that the surgeon manipulates, and a distal probe or end that enters the body and through which the surgery is performed. Typically, the surgeon makes an incision or stab wound through the outer dermal layers of sufficient size to permit passage of the trocar 30 through the skin and the deltoid muscle, into proximity with the humeral head 24. Various trocars and techniques for creating the approach passageway are known and may be utilized with the present invention. In addition, more than one incision and conduit may be necessary to perform the several suturing and anchoring steps.
After establishing one or more direct conduits to the humeral head 24, the surgeon passes a length of suture through the soft tissue of the rotator cuff tendon 22 so that a loop 32 of suture material is embedded therein, as seen in
The exemplary suture anchor system 20 as illustrated is particularly suitable for anchoring a suture to a body cavity, specifically the humeral head 24 as shown. When anchoring sutures to such a bone structure, a conventional technique is to first form a blind hole or cavity 40 through the cortical layer 42 and into the soft cancellous matter 44, as seen in
The suture anchor 46 performs two functions: anchoring itself within the body cavity and anchoring the sutures therein. In the embodiment as illustrated in
The present invention illustrates a particular anchoring member 48, although any similar expedient will work. For example, a different toggle-like anchoring member may be used such as shown in-co-pending application Ser. No. 09/876, 488 filed on Mar. 2, 2001, expressly incorporated by reference herein. Alternatively, an anchoring structure that expands into contact with the cancellous matter 44 or a body resembling a screw may also be used. In short, the present invention is not considered to be limited by the particular anchoring structure that secures the suture locking portion to the bone or other body cavity.
The second function of the suture anchor 46 is the anchoring or fixation of the suture with respect to the suture anchor itself, without the use of knots. Desirably, the particular manner of anchoring the suture with respect to the suture anchor 46 permits easy adjustment of the length of suture between the suture anchor 46 and the loop 32 formed in the soft tissue prior to anchoring the suture. This adjustment allows the surgeon to establish the proper tension in the length of suture for effective repair of the soft tissue, and reattachment of the rotator cuff tendon 22 in the illustrated embodiment. So, for example,
Although not shown, the remaining steps in the procedure involve withdrawing portions of the suture anchor from the surgical site as seen in
Although the present invention is described primarily in conjunction with the repair of a torn rotator cuff, the apparatus and method could also be used in arthroscopic repair at other sites, such as the knee, elbow, or hip, for example, as well as in conjunction with other surgical techniques, such as traditional open or mini-open surgical procedures.
Now with reference to
In operation, as shown in
Now with reference to
In operation, the suture length 34 is disposed in the insert 68, from a proximal direction, and wrapped around the primary pin 72, as shown in
Now with reference to
A somewhat similar embodiment to that of
Once the bone lock feature has been deployed, a predetermined applied tensile force proximally on the inner member 122 will cause separation of a proximal portion 142 from the remaining portion of the inner member 122 at the designed point of weakness 128, as shown in
Yet another suture anchoring device 46f, which may be called a “spring-lock” anchor, is illustrated in
Then, when it is desired to anchor the suture in place, the driver 148 is retracted proximally, in the direction of arrow 160, as shown in
Not illustrated, but contemplated within the scope of the invention, is the inclusion of a compressible sleeve around which the spring 154 may be wrapped, and through which the suture 34 may be threaded. When the spring collapses, the sleeve also collapses on the suture, thereby locking it in place.
Now, with reference to
When the tensioning step has been completed as desired, the mandrel 172 is withdrawn proximally, thereby releasing the leaf springs 164, so that they may return to their undeformed state, as shown in
In operation, a driver (not shown) having a hex head engages a hexagonal aperture 188, and rotates the core 182, in order to further wrap the suture 34 about the core, and to thus tension the suture 34 and approximate the tendon 22 to adjacent bone (not shown). When the suture 34 is tensioned as desired, the core is rotationally locked in place, to thereby anchor the suture in place. During the tensioning step, the fins 184 function to snag the suture and to act as bearings for the core 182.
Another embodiment of a suture anchoring device 46i is shown in
As shown in
Yet another suture anchoring device 46 jis shown in
Yet another embodiment of a suture anchoring device 46 k is illustrated in
Finally, another alternative suture anchoring embodiment 461 is illustrated in
The apparatus and method of the present invention may be embodied in other specific forms without departing from its spirit or essential characteristics. The described embodiments are to be considered in all respects only as illustrative and not restrictive. The scope of the invention is, therefore, indicated by the appended claims rather than by the foregoing description. All changes which come within the meaning and range of equivalency of the claims are to be embraced within their scope.