`
`FOR
`
`UNITED STATES LETTERS PATENT
`
`METHODS FOR USING A PATIENT SPECIFIC ALIGNMENT DEVICE
`
`Inventor:
`
`Peter M. Bonutti
`
`FLEIT, GIBBONS, GUTMAN,
`BONGINI & BIANCO FL.
`
`21355 East Dixie Highway
`Suite 115
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`Miami, Florida 33180
`Telephone: (305) 830-2600
`Facsimile:
`(305) 830-2605
`
`Attorney Docket No.: 780-A12-012Y-3
`
`
`
`CROSS REFERENCE TO RELATED APPLICATIONS
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`[0001]
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`This application is continuation of US. patent application Serial No. 13/221,033
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`filed August 30, 2011, which is a continuation of US. patent application Serial No. 12/795,935
`
`filed June 8, 2010, which is a continuation of US. patent application Serial No. 11/684,103 filed
`
`March 9, 2007, now US. Patent 7,828,852, which is a continuation of US. patent application
`
`Serial No. 10/681,526 filed October 8, 2003, which is a continuation of US. patent application
`
`Serial No. 10/191,751 filed July 8, 2002, now US. Patent No. 7,104,996, which is a
`
`continuation-in-part of US. patent applications Serial No. 09/976,396 filed October 11, 2001,
`
`now US. Patent No. 6,770,078, Serial No. 09/941,185 filed August 28, 2001, now US. Patent
`
`No. 6,702,821, Serial No. 09/566,070 filed May 5, 2000, now US. Patent No. 6,575,982, Serial
`
`No. 09/737,380 filed December 15, 2000, now US. Patent No. 6,503,267, Serial No. 09/569,020
`
`filed May 11, 2000, now US. Patent No. 6,423,063, Serial No. 09/483,676 filed January 14,
`
`2000, now US. Patent No. 6,468,289, Serial No. 09/798,870 filed March 1, 2000, now US.
`
`Patent No. 6,503,277, Serial No. 09/526,949 filed on March 16, 2000, now US. Patent No.
`
`6,620,181, and Serial No. 09/789,621 filed February 21, 2001, now US. Patent No. 6,635,073.
`
`BACKGROUND
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`[0001] The present invention relates to a new and improved method of performing surgery,
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`and instruments, implants, and other surgical implements that can be used in surgery. The
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`surgery may be of any desired type. The surgery may be performed on joints in a patient's body.
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`The surgery may be performed on any desired joint in a patient's body. Regardless of the type of
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`surgery to be performed, a limited incision may advantageously be utilized.
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`[0002] In some embodiments, this specification relates to limited incision partial or total
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`knee joint replacements and revisions and is the result of a continuation of work which was
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`previously performed in conjunction with the subject matter of US. Patent No. 5,514,143. This
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`specification also contains subject matter which relates to US. Patent Nos. 5,163,949; 5,269,785;
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`5,549,683; 5,662,710; 5,667,520; 5,961,499; 6,059,817; and 6,099,531. Although this
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`specification refers to knee joints, it should be understood that the subject matter of this
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`application is also applicable to joints in many different portions of a patient's body, for example
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`a shoulder, spine, arm, hand, hip or foot of a patient.
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`
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`[0003] During a total or partial knee replacement or revision, an incision is made in a knee
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`portion of a leg of the patient to obtain access to the knee joint. The incision is relatively long to
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`enable instrumentation, such as a femoral alignment guide, anterior resection guide, distal
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`resection guide, femoral cutting guide, and femoral anterior, posterior and chamfer resection
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`guide to be positioned relative to a distal end portion of the femur. In addition, the incision must
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`be relatively large to enable a tibial resection guide to be positioned relative to the proximal end
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`portion of the tibia.
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`[0004] With known procedures of total or partial knee replacement, the incision in the knee
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`portion of the patient is made with the leg of the patient extended (straight) while the patient is
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`lying on his or her back. At this time, the extended leg of the patient is disposed along and rests
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`on a patient support surface. After the incision has been made in the knee portion of the leg of
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`the patient, the leg is flexed and a foot connected with the leg moves along the patient support
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`surface. The knee portion of the flexed leg of the patient is disposed above the patient support
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`surface. This results in the soft tissue in the knee being compressed against the back of the knee
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`joint. This makes it very difficult to access posterior soft tissue to remove bone spurs (ostif1ed),
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`meniscus, posterior capsule, ligaments in the back of the joint, and/or any residual soft tissue or
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`connective tissue that is blocking further flexion.
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`[0005] After the incision has been made and while the leg is flexed with the foot above the
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`patient support surface, the surgeon cannot view arteries, nerves and veins which are sitting just
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`posterior to the knee capsule. Therefore, a surgeon may be very reluctant, or at least very
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`careful, of inserting instruments into the back of the knee joint to remove tissue. This may result
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`in osteophytes, bone spurs and similar types of posterior soft tissue being left in place.
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`[0006] With known techniques, the patella is commonly everted from its normal position.
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`When the patella is everted, the inner side of the patella is exposed and faces outward away from
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`end portions of the femur and tibia. The outer side of the everted patella faces inward toward the
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`end portions of the femur and the tibia. Moving the everted patella to one side of end portions of
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`the femur and tibia tends to increase the size of the incision which must be made in the knee
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`portion of the patient's leg.
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`[0007] After implants have been positioned in the knee portion of the patient's leg, it is
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`common to check for flexion and extension balancing of ligaments by flexing and extending the
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`
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`knee portion with the foot above the support surface. If the ligaments are too tight medially or
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`laterally, they can be released to obtain the desired tension. However, the checking of ligament
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`balance by flexing and extending the leg of the patient, ignores rotational balancing of ligaments.
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`Since the femoral implant is movable relative to the tibial implant, the stability of the knee joint
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`is dependent upon balancing of the ligaments in flexion, extension, and rotation.
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`SUMMARY
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`[0008] The present invention relates to a new and improved method and apparatus for use
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`in performing any desired type of surgery on a joint in a patient's body. The joint may
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`advantageously be a knee joint. However, the method and apparatus may be used in association
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`with surgery on other joints in a patient's body. There are many different features of the present
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`invention which may used either together or separately in association with many different types
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`of surgery. Although features of the present invention may be used with many different surgical
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`procedures, the invention is described herein in conjunction with surgery on a joint in a patient's
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`body.
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`[0010] One of the features of the present invention relates to the making of a limited
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`incision. The limited incision may be in any desired portion of a patient's body. For example,
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`the limited incision may be in a knee portion of a leg of a patient. The limited incision may be
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`made while a lower portion of the leg of the patient is extending downward from the upper
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`portion of the leg of the patient. At this time, a foot connected with the lower portion of the leg
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`of the patient may be below a surface on which the patient is supported. The limited incision
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`may be made while the lower portion of the leg of the patient is suspended from the upper
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`portion of the leg or while the lower portion of the leg and/or the foot of the patient are held by a
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`support device. After the incision has been made, any one of many surgical procedures may be
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`undertaken.
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`[0011] It is believed that in certain circumstances, it may be desired to have a main incision
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`of limited length and a secondary incision of even smaller length. The secondary incision may
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`be a portal or stab wound. A cutting tool may be moved through the secondary incision. An
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`implant may be moved through the main incision.
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`[0012] Once the incision has been made, a patella in a knee portion of the patient may be
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`offset to one side of its normal position. When the patella is offset, an inner side of the patella
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`
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`faces inward toward the end portions of a femur and tibia. If desired, the patella can be cut and
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`realigned in situ, with minimal or no subluxation. Additionally, the cutting and/or realignment
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`can be done while the knee is in flexion, which is the natural position, rather than extension.
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`[0013] Although any one of many known surgical procedures may be undertaken through
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`the limited incision, down sized instrumentation for use in the making of cuts in a femur and/or
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`tibia may be moved through or part way through the incision. The down sized instrumentation
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`may be smaller than implants to be positioned in the knee portion of the patient. The down sized
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`instrumentation may have opposite ends which are spaced apart by a distance which is less than
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`the distance between lateral and medial epicondyles on a femur or tibia in the leg of the patient.
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`[0014] It is contemplated that the down sized instrumentation may have cutting tool guide
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`surfaces of reduced length. The length of the cutting tool guide surfaces may be less than the
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`length of a cut to be made on a bone. A cut on a bone in the patient may be completed using
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`previously cut surfaces as a guide for the cutting tool.
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`[0015] It is contemplated that at least some, if not all, cuts on a bone may be made using
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`light or other electromagnetic radiation, such as infrared radiation, directed onto the bone as a
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`guide. The light directed onto the bone may be in the form of a three dimensional image. The
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`light directed onto the bone may be a beam along which a cutting or milling tool is moved into
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`engagement with the bone.
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`[0016] There are several different orders in which cuts may be made on bones in the knee
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`portion of the leg of the patient. It is believed that it may be advantageous to make the patellar
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`and tibial cuts before making the femoral cuts.
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`[0017] There are many different reasons to check ligament balancing in a knee portion of
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`the leg of a patient. Ligament balancing may be checked while the knee portion of the leg of the
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`patient is flexed and the foot of the patient is below the support surface on which the patient is
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`disposed. Flexion and extension balancing of ligaments may be checked by varying the extent of
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`flexion of the knee portion of the leg of the patient. In addition, rotational stability of the
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`ligaments may be checked by rotating the lower portion of the leg of the patient about its central
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`axis. Balancing of ligaments may also be checked by moving the foot of the patient sideways,
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`rotating the lower portion of the leg of the patient, and/or moving the foot anteriorly or
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`posteriorly.
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`
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`[0018] It is believed that it may be advantageous to utilize an endoscope or a similar
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`apparatus to examine portions of the patient's body which are spaced from the incision. It is also
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`contemplated that images of the knee portion of the patient's leg may be obtained by using any
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`one of many known image generating devices other than an endoscope. The images may be
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`obtained while the patient's leg is stationary or in motion. The images may be obtained to assist
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`a surgeon in conducting any desired type of surgery.
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`[0019] Balancing of the ligaments in the knee portion of a patient's leg may be facilitated
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`by the positioning of one or more transducers between tendons, ligaments, and/or bones in the
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`knee portion. One transducer may be positioned relative to a medial side of a knee joint.
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`Another transducer may be positioned relative to a lateral side of the knee joint. During bending
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`of the knee joint, the output from the transducers will vary as a function of variations in tension
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`forces in the ligaments. This enables the tension forces in ligaments in opposite sides of the knee
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`portion to be compared to facilitate balancing of the ligaments.
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`[0020] Patellar tracking may be checked by the positioning of one or more transducers
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`between the patella and the distal end portion of the femur. If desired, one transducer may be
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`placed between a medial portion of the patella and the distal end portion of the femur. A second
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`transducer may be placed between a lateral portion of the patella and the distal end portion of the
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`femur. Output signals from a transducer will vary as a fianction of variations in force transmitted
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`between the patella and femur during bending of the leg.
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`[0021] The articular surface on the patella may be repaired. The defective original articular
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`surface on the patella may be removed by cutting the patella while an inner side of the patella
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`faces toward a distal end portion of a femur. The step of cutting the patella may be performed
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`while the patella is disposed in situ and is urged toward the distal end portion of the femur by
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`connective tissue. An implant may then be positioned on the patella.
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`[0022] It is contemplated that the size of the incision in the knee or other portion of the
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`patient may be minimized by conducting surgery through a cannula. The cannula may be
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`expandable. To facilitate moving of an implant through the cannula, the implant may be formed
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`in two or more portions. The portions of the implant may be interconnected when the portions of
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`the implant have been positioned in the patient's body. Although the implants disclosed herein
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`
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`are associated with a patient's knee, it should be understood that the implants may be positioned
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`at any desired location in a patient's body.
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`[0023] An implant may be positioned in a recess formed in a bone in a patient. The
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`implant may contain biological resurfacing and/or bone growth promoting materials. The
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`implant may contain mesenchymal cells and/or tissue inductive factors. Alternatively, the
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`implant may be formed of one or more materials which do not enable bone to grow into the
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`implant.
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`[0024] In accordance with one of the features of the present invention, body tissue may be
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`moved or stretched by a device which is expandable. The expandable device may be
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`biodegradable so that it can be left in a patient's body. The expandable device may be expanded
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`to move and/or stretch body tissue and increase a range of motion of a joint. The expandable
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`device may be used to stretch body tissue in which an incision is to be made.
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`[0025] An improved drape system is provided to maintain a sterile field between a surgeon
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`and a patient during movement of the surgeon relative to the patient. The improved drape
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`system includes a drape which extends between the surgeon and a drape for the patient. During
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`surgery on a knee portion of a leg of a patient, the drape system extends beneath a foot portion of
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`the leg of a patient. It is contemplated that the drape system will be utilized during many
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`different types of operations other than surgery on a leg of a patient.
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`[0026] An implant may be movable relative to both a femur and a tibia in a leg of a patient
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`during bending of the leg. The implant may include a single member which is disposed between
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`and engaged by end portions of both the femur and tibia. Alternatively, the implant may include
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`a plurality of members which are disposed in engagement with each other. If desired, one of the
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`members of the plurality of members may be secured to a bone and engaged by a member which
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`is not secured to a bone. The implant may be secured to soft tissue in the knee portion of the
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`patient's leg.
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`[0027] There are many different features to the present invention. It is contemplated that
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`these features may be used together or separately. It is also contemplated that the features may
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`be utilized in association with joints in a patient's body other than a knee joint. For example,
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`features of the present invention may be used in association with surgery on vertebral joints or
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`glenoid joints. However, it is believed that many of the features may be advantageously utilized
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`
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`together during the performance of surgery on a patient's knee. However, the invention should
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`not be limited to any particular combination of features or to surgery on any particular joint in a
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`patient's body. It is contemplated that features of the present invention will be used in
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`association with surgery which is not performed on a joint in a patient's body.
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`BRIEF DESCRIPTION OF THE DRAWINGS
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`[0028] The foregoing and other features of the invention will become more apparent upon a
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`consideration of the following description taken in connection with the accompanying drawings
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`wherein:
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`[0029] Fig. l is a schematic illustration depicting extended and flexed positions of a
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`patient's leg during performance of knee surgery in a known manner;
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`[0030] Fig. 2 is a schematic illustration depicting the manner in which a leg support is used
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`to support an upper portion of a leg of a patient above a support surface on which the patient is
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`disposed in a supine orientation during performance of knee surgery;
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`[0031] Fig. 3 is a schematic illustration depicting the patient's leg after a portion of a drape
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`system has been positioned over the patient, the leg being shown in a flexed condition with the
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`foot below the patient support surface and with an upper portion of the leg supported by the leg
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`support of Fig. 2;
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`[0032] Fig. 4 is a schematic illustration of the patient's leg of Figs. 2 and 3 in an extended
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`condition and of the drape system which extends between a surgeon and the patient;
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`[0033] Fig. 5 is a schematic illustration depicting the manner in which the drape system of
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`Fig. 4 maintains a sterile field during movement of the surgeon relative to the patient;
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`[0034] Fig. 6 is a schematic illustration depicting the manner in which an incision is made
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`in the knee portion of the leg of the patient when the leg is in the position illustrated in Figs. 2
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`and 3;
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`[0035] Fig. 7 is a schematic illustration depicting the manner in which the incision is
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`expanded and a patella is everted with the leg of the patient extended;
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`[0036] Fig. 8 is a schematic illustration depicting the manner in which a drill is utilized to
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`form a passage in a femur in the upper portion of the leg of the patient with the leg in the
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`position illustrated in Figs. 2 and 3 and the patella offset from its normal position;
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`
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`[0037] Fig. 9 is a schematic illustration of the positioning of a femoral alignment guide in
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`the hole formed by the drill of Fig. 8 with the leg of the patient in the position illustrated in Figs.
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`2 and 3;
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`[0038] Fig. 10 is a schematic illustration depicting the position of an anterior resection
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`guide and a stylus relative to the femoral alignment guide of Fig. 9 before an anterior femur cut
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`has been made with the leg of the patient in the position illustrated in Figs. 2 and 3;
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`[0039] Fig. 11 is a schematic illustration, taken generally along the line 11-11 of Fig. 10,
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`further illustrating the relationship of the anterior resection guide and stylus to the distal end
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`portion of the femur;
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`[0040] Fig. 12 is a schematic illustration filrther illustrating the relationship of the anterior
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`resection guide and stylus to the distal end portion of the femur;
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`[0041] Fig. 13 is a schematic illustration depicting the manner in which a cutting tool is
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`moved along a guide surface on the anterior resection guide during making of an anterior femur
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`cut with the leg of the patient in the position illustrated in Figs. 2 and 3;
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`[0042] Fig. 14 is a schematic illustration depicting the relationship of the femoral
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`alignment guide to the femur after making of the anterior femur cut of Fig. 13, the anterior
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`resection guide and stylus being removed from the femoral alignment guide, and the leg of the
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`patient being in the position illustrated in Figs. 2 and 3;
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`[0043] Fig. 15 is a schematic illustration of the anterior femur cut and femoral alignment
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`guide of Fig. 14;
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`[0044] Fig. 16 is a schematic illustration depicting the manner in which the femoral
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`alignment guide is utilized to position a distal resection guide relative to the distal end portion of
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`the femur after making of the anterior femur cut and with the leg of the patient in the position
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`illustrated in Figs. 2 and 3;
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`[0045] Fig. 17 is a schematic illustration depicting the manner in which a distal femur cut is
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`made with a cutting tool after the femoral alignment guide has been removed, the leg of the
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`patient being in the position illustrated in Figs. 2 and 3;
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`[0046] Fig. 18 is a schematic illustration depicting the relationship of the cutting tool and
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`distal resection guide of Fig. 17 to the femur;
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`[0047] Fig. 19 is a schematic illustration depicting the manner in which a femoral cutting
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`guide is positioned on the distal end portion of the femur with the leg of the patient in the
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`position illustrated in Figs. 2 and 3;
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`[0048] Fig. 20 is a schematic illustration fiarther depicting the relationship of the femoral
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`cutting guide to the distal end portion of the femur;
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`[0049] Fig. 21 is a schematic illustration depicting the relationship of a tibial resection
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`guide to the proximal end portion of a tibia in the lower portion of the patient's leg after making
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`the femoral cuts and with the leg of the patient in the position illustrated in Figs. 2 and 3;
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`[0050] Fig. 22 is a schematic illustration of the distal end portion of the femur and the
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`proximal end portion of the tibia after making the femoral and tibial cuts with the leg of the
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`patient in the position illustrated in Figs. 2 and 3 and the patella offset to one side of the incision;
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`[005 1] Fig. 23 is a schematic illustration fiarther depicting the femoral and tibial cuts of Fig
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`22;
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`[0052] Fig. 24 is a schematic illustration depicting the manner in which force is applied
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`against the bottom of the patient's foot by a surgeon's knee with the leg of the patient in the
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`position illustrated in Figs. 2 and 3;
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`[0053] Fig. 25 is a schematic illustration depicting the various directions in which the lower
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`portion of the patient's leg can be moved relative to the upper portion of the patient's leg to
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`expose portions of the bone at the incision in the knee portion of the patient's leg and to check
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`ligament balancing;
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`[0054] Fig. 26 is a schematic illustration depicting the manner in which a tibial punch is
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`positioned relative to a tibial base plate with the leg of the patient in the position illustrated in
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`Figs. 2 and 3;
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`[0055] Fig. 27 is a schematic illustration depicting completed preparation of the tibia for a
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`tibial tray implant with the leg of the patient in the position illustrated in Figs. 2 and 3;
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`[0056] Fig. 28 is a schematic illustration depicting positioning of a tibial bearing insert in
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`the tibial tray of Fig. 27 with the leg of the patient in the position illustrated in Figs. 2 and 3;
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`[0057] Fig. 29 is a schematic illustration depicting femoral and tibial implants with the leg
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`of the patient in the position illustrated in Figs. 2 and 3;
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`10
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`
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`[0058] Fig. 30 is a schematic illustration of an apparatus which may be utilized to move the
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`lower portion of a patient's leg relative to the upper portion of a patient's leg when the patient's
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`leg is in the position illustrated in Figs. 2 and 3;
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`[0059] Fig. 31 is a schematic illustration depicting the manner in which a distal resection
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`guide is connected with a patient's femur by pins which extend through the guide and through
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`skin in the upper portion of the patient's leg into the femur with the leg of the patient in the
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`position illustrated in Figs. 2 and 3;
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`[0060] Fig. 32 is a schematic illustration depicting the manner in which an endoscope may
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`be inserted through an incision in a patient's knee to inspect portions of the patient's knee which
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`are remote from the incision with the leg of the patient in the position illustrated in Figs. 2 and 3;
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`[0061] Fig. 33 is a schematic illustration similar to Fig. 32, depicting the manner in which
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`the endoscope may be inserted through the incision in the patient's knee with the leg of the
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`patient extended;
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`[0062] Fig. 34 is a schematic illustration depicting the manner in which an imaging
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`apparatus may be utilized to generate images of a portion of the patient's leg and the manner in
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`which a robot may be utilized to position cutting tools or other devices relative to the patient's
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`leg with the patient's leg in the position illustrated in Figs. 2 and 3;
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`[0063] Fig. 35 is a schematic illustration depicting the relationship of a cut line to a patella
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`in a knee of the leg of the patient with the leg in the position illustrated in Figs. 2 and 3 and with
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`the patella in the normal position;
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`[0064] Fig. 36 is a schematic illustration depicting the manner in which a cutting tool is
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`moved relative to a guide member to cut the patella of Fig. 35 while the patella is disposed in
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`situ;
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`[0065] Fig. 37 is a schematic illustration depicting the manner in which a tibial alignment
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`shaft and a tibial resection guide are positioned relative to a tibia in a lower portion of a leg of
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`the patient with the leg of the patient in the position illustrated in Figs. 2 and 3;
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`[0066] Fig. 38 is an enlarged fragmentary view of a portion of Fig. 37 and illustrating the
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`construction of the tibial resection guide;
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`11
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`
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`[0067] Fig. 39 is a schematic illustration depicting the relationship between an expandable
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`cannula and an incision in the knee portion of one leg of the patient with the leg of the patient in
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`the position illustrated in Figs. 2 and 3;
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`[0068] Fig. 40 is a schematic illustration depicting the relationship between two separate
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`portions of an implant which are interconnected within the patient's body;
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`[0069] Fig. 41 is a schematic illustration depicting the relationship of transducers to a
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`flexed knee joint of a patient when the leg of the patient is in the position illustrated in Figs. 2
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`and 3;
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`[0070] Fig. 42 is a schematic illustration, generally similar to Fig. 41, illustrating the
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`relationship of the transducers to the knee joint when the leg of the patient is extended;
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`[0071] Fig. 43 is a schematic illustration of a distal end portion of a femur in a leg of a
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`patient with the leg in the position illustrated in Figs. 2 and 3 and illustrating the relationship of
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`an implant to a recess in the end portion of the femur;
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`[0072] Fig. 44 is a schematic sectional View depicting the manner in which a cutting tool is
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`used to form a recess in the end portion of the femur of Fig. 43 with the leg of the patient in the
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`position illustrated in Figs. 2 and 3;
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`[0073] Fig. 45 is a schematic sectional View, taken generally along the line 45 45 of Fig. 43
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`further illustrating the relationship of the implant to the recess;
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`[0074] Fig. 46 is a schematic end View of a proximal end portion of a tibia in a leg of a
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`patient, with the leg in the position illustrated in Figs. 2 and 3, illustrating the relationship of an
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`implant to a recess in the end portion of the tibia;
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`[0075] Fig. 47 is a schematic sectional View depicting the manner in which a cutting tool is
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`used to form the recess in the end portion of the tibia of Fig. 46;
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`[0076] Fig. 48 is a schematic sectional View, taken generally along the line 48 48 of Fig.
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`46, further illustrating the relationship of the implant to the recess;
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`[0077] Fig. 49 is a schematic sectional View illustrating the relationship of another implant
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`to a recess in a bone in a patient's body;
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`[0078] Fig. 50 is a schematic illustration depicting the relationship between a tibial implant
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`and a tibia in the leg of the patient;
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`12
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`
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`[0079] Fig. 51 is a schematic illustration depicting the relationship of expandable devices
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`to the knee portion of a patient's leg;
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`[0080] Fig. 52 is a schematic illustration depicting the manner in which an expandable
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`device may be positioned relative to a knee portion of a patient's leg with the patient's leg in the
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`position illustrated in Figs. 2 and 3;
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`[0081] Fig. 53 is a schematic illustration depicting the manner in which a femoral cutting
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`guide may be mounted on a distal end of a femur in a patient's leg with the patient's leg in the
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`position illustrated in Figs. 2 and 3;
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`[0082] Fig. 54 is a schematic illustration of the manner in which a femoral cutting guide
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`may be mounted on a side surface of a femur in a patient's leg with the patient's leg in the
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`position illustrated in Figs. 2 and 3;
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`[0083] Fig. 55 is a schematic illustration depicting the manner in which light is directed
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`onto a distal end portion of a femur with the patient's leg in the position illustrated in Figs. 2 and
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`3;
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`[0084] Fig. 56 is a schematic illustration depicting the manner in which light is used to
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`guide movement of a cutting tool relative to a distal end portion of a femur with the patient's leg
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`in the position illustrated in Figs. 2 and 3;
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`[0085] Fig. 57 is a schematic illustration depicting the manner in which a cutting tool is
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`moved relative to a secondary incision with a knee portion of a patient's leg in the position
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`illustrated in Figs. 2 and 3;
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`[0086] Fig. 58 is schematic illustration depicting the relationship of transducers to a patella
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`and distal end portion of a femur with the patient's leg in the position illustrated in Figs. 2 and 3;
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`[0087] Fig. 59 is a schematic illustration depicting the relationship between a movable
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`implant, a distal end portion of a femur, and a proximal end portion of a tibia in a knee portion of
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`a leg of a patient;
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`[0088] Fig. 60 is a plan view of a proximal end portion of a tibia depicting the manner in
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`which an implant may be inlaid into a tibia;
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`l3
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`
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`[0089] Fig. 61 is a schematic illustration, generally similar to Fig. 59, depicting the
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`relationship between a movable implant formed by a plurality of members, a distal end portion of
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`a femur, and a proximal end portion of a tibia in a knee portion of a leg of a patient;
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`[0090] Fig. 62 is a schematic illustration, generally similar to Figs. 59 and 61, depicting the
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`relationship between an implant formed by a movable member and a fixed member, a distal end
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`portion of a femur, and a proximal end portion of a tibia in a knee portion of a leg of a patient;
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`[0091] Fig. 63 is a schematic illustration, generally similar to Fig. 59, depicting the manner
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`in which an implant is connected with a ligament in a knee portion of a patient's leg;
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`[0092] Fig. 64 is a schematic illustration, generally similar to Fig. 60, depicting the manner
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`in which an implant is connected with a joint capsule in a knee portion of a patient's leg;
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`[0093] Fig. 65 is a schematic illustration, generally similar to Fig. 60, depicting the manner
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`in which a retainer holds moldable implant material in place on a proximal end portion of a tibia
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`in the knee portion of a leg of the patient;
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`[0094] Fig. 66 is a fragmentary sectional view, taken generally along the line 66-66 of Fig.
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`65 further illustrating the manner in which the retainer holds moldable implant material;
`
`[0095] Fig. 67 is a schematic illustration depicting the manner in which an implant is
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`provided in a knee portion of a leg of a patient to correct defects in a joint and in which an
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`osteotomy wedge is provided to correct defects in bone alignment;
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`[0096] Fig. 68 is a schematic view of the hip region with a guide wire and cannula inserted;
`
`[0097] Fig. 69 is a schematic view of the hip region with an inflatable device inserted;
`
`[0098] Fig. 70A is a side view of a bone removing instrument according to the present
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`invention in a retracted state;
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`[0099] Fig. 70B is a perspective view of the bone removing instrument of Fig. 70A in an
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`expanded state;
`
`[0100] Fig. 71 is a schematic view of the hip region with the bone remover of Fig. 70B
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`inserted and removing the femoral head;
`
`[0101] Fig. 72 is a schematic view of the hip region with the bone remover of Fig. 70B
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`inserted and removing the acetabulum;
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`14
`
`
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`[0102] Fig. 73 is a schematic View of the hip region with a backing of an acetabular
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`component being implanted;
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`[0103] Fig.
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`74A is a sectional View of one embodiment of a liner for an acetabular
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`component;
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`[0104] Fig.
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`74B is a sectional View of another embodiment of a liner for an acetabular
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`component;
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`[0105] Fig.
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`75 is a schematic illustration of a knee joint with an osteotomy performed;
`
`[0106] Fig.
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`76 is a schematic illustration of the access created by the osteotomy of the knee
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`joint of Fig. 75 with the patella not shown for clarity;
`
`[0107] Fig.
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`77 is a schematic illustration of the knee joint of Fig. 75 with the osteotomy
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`repaired;
`
`[0108] Fig.
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`78 is an exploded View of a modular tibial component;
`
`[0109] Fig.
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`79 is a schematic illustration of the modular tibial component of Fig. 78
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`assembled;
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`[011