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`SYSTEM AND METHOD FOR ROBOTIC SURGERY
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`CROSS-REFERENCE TO RELATED APPLICATIONS
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`[0001]
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`This application is a continuation of U.S. patent application Ser. No. 15/787,936, filed
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`on October 19, 2017. U.S. patent application Ser. No. 15/787,936 is a continuation of U.S.
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`patent application Ser. No. 14/958,967, filed December 4, 2015. U.S. patent application Ser. No.
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`14/958,967 is a continuation of U.S. patent application Ser. No. 14/725,070, filed May 29, 2015.
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`U.S. patent application Ser. No. 14/725,070 is a continuation of U.S. patent application Ser. No.
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`14/451,562 filed August 5, 2014. U.S. patent application Ser. No. 14/451,562 is a continuation
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`of U.S. patent application Ser. No. 13/407,968 filed Feb. 29, 2012. U.S. patent application Ser.
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`No. 13/407,968 is a continuation of U.S. patent application Ser. No. 13/407,448 filed Feb. 28,
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`2012. U.S. patent application Ser. No. 13/407,448 is a continuation of U.S. patent application
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`Ser. No. 13/221,033 filed Aug. 30, 2011. U.S. patent application Ser. No. 13/221,033 is a
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`continuation of U.S. patent application Ser. No. 12/795,935 filed Jun. 8, 2010. U.S. patent
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`application Ser. No. 12/795,935 is a continuation of U.S. patent application Ser. No. 11/684,103
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`filed Mar. 9, 2007, now U.S. Pat. No. 7,828,852. U.S. patent application Ser. No. 11/684,103 is a
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`continuation of U.S. patent application Ser. No. 10/681,526 filed Oct. 8, 2003, now U.S. Pat. No.
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`7,635,390. U.S. patent application Ser. No. 10/681,526 is a continuation of U.S. patent
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`application Ser. No. 10/191,751 filed Jul. 8, 2002, now U.S. Pat. No. 7,104,996. U.S. patent
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`application Ser. No. 10/191,751 is a continuation-in-part of U.S. patent application Ser. No.
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`09/976,396 filed Oct. 11, 2001, now U.S. Pat. No. 6,770,078. U.S. patent application Ser. No.
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`10/191,751 is also a continuation-in-part of U.S. patent application Ser. No. 09/941,185 filed
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`Aug. 28, 2001, now U.S. Pat. No. 6,702,821.
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`[0002]
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`U.S. patent application Ser. No. 14/451,562 is also a continuation of U.S. patent
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`application Serial No. 13/859,509,filed April 9, 2013. U.S. patent application Serial No.
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`
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`13/859,509 is a continuation of U.S. patent application Serial No. 10/888,783, filed July 9, 2004.
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`U.S. patent application Serial No. 10/888,783 is a continuation of U.S. patent application Serial
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`No. 10/191,751 filed July 8, 2002 (now U.S. Patent No. 7,104,996); which is a continuation-in-
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`part of each of the following: U.S. patent application Serial No. 09/976,396 filed October 11,
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`2001 (now U.S. Patent No. 6,770,078); and U.S. patent application Serial No. 09/941,185 filed
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`August 28, 2001 (now U.S. Patent No. 6,702,821).
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`BACKGROUND OF THE INVENTION
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`[0003]
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`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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`[0004]
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`In some embodiments, this specification relates to limited incision partial or total
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`knee joint replacements and revisions andis the result of a continuation of work which was
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`previously performed in conjunction with the subject matter of U.S. Patent No. 5,514,143. This
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`specification also contains subject matter which relates to U.S. 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. Althoughthis
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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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`[0005] Duringatotal or partial knee replacementor 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 1s 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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`
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`[0006]
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`With knownproceduresoftotal 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 patientis
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`lying on his or her back. Atthis time, the extended leg of the patient is disposed along andrests
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`on a patient support surface. After the incision has been madein the kneeportion of the leg of
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`the patient, the leg is flexed and a foot connected with the leg movesalong 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 makesit very difficult to access posterior soft tissue to remove bonespurs(ostified),
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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 furtherflexion.
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`[0007]
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`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 whicharesitting just
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`posterior to the knee capsule. Therefore, a surgeon maybe very reluctant, or at least very
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`careful, of inserting instruments into the back of the knee joint to removetissue. This may result
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`in osteophytes, bone spurs and similar types of posterior soft tissue beingleft in place.
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`[0008]
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`With knowntechniques, the patella is commonly everted from its normal position.
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`Whenthe 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 andthe tibia. Moving the everted patella to one side of end portions of
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`the femurandtibia 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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`[0009]
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`After implants have been positioned in the knee portion ofthe patient’s leg, it 1s
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`commonto check for flexion and extension balancing of ligaments by flexing and extending the
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`knee portion with the foot above the support surface. Ifthe 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 extendingthe 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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`
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`SUMMARYOF THE INVENTION
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`[0010]
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`The present invention relates to a new and improved method and apparatus for use in
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`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 usedin 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 usedeither 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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`[0011]
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`Oneof the features of the present invention relates to the making of a limited incision.
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`The limited incision may be in any desired portion of a patient’s body. For example, the limited
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`incision may be in a knee portion of a leg of a patient. The limited incision may be made while a
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`lowerportion of the leg of the patient is extending downward from the upper portion of the leg of
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`the patient. At this time, a foot connected with the lower portion of the leg of the patient may be
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`below a surface on whichthe patient is supported. The limited incision may be made while the
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`lower portion of the leg of the patient is suspended from the upper portion of the leg or while the
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`lower portion of the leg and/or the foot of the patient are held by a support device. After the
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`incision has been made, any one of manysurgical procedures may be undertaken.
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`[0012]
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`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 movedthrough the secondary incision. An
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`implant may be moved through the main incision.
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`[0013]
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`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. Whenthe patella is offset, an inner side of the patella
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`faces inward toward the end portions of a femur andtibia. 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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`
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`[0014]
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`Although any one of many known surgical procedures may be undertaken through the
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`limited incision, down sized instrumentation for use in the making of cuts in a femur and/ortibia
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`may be movedthroughor part way through the incision. The down sized instrumentation may
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`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 whichis less than
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`the distance between lateral and medial epicondyles on a femurortibia in the leg of the patient.
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`[0015]
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`It is contemplated that the down sized instrumentation may havecutting 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 ona bone. A cut on a bonein the patient may be completed using
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`previously cut surfaces as a guide for the cutting tool.
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`[0016]
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`It is contemplated that at least some,if not all, cuts on a bone may be madeusing
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`light or other electromagnetic radiation, such as infrared radiation, directed onto the bone as a
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`guide. Thelight 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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`[0017]
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`There are several different orders in which cuts may be made on bonesin the knee
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`portion of the leg of the patient. It is believed that it may be advantageous to makethe patellar
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`and tibial cuts before making the femoralcuts.
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`[0018]
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`There are many different reasons to check ligament balancing in a knee portion of the
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`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 patientis
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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 checkedby rotating the lower portion of the leg of the patient aboutits 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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`
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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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`[0019]
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`It is believed that it may be advantageousto utilize an endoscope or a similar
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`apparatus to examineportions 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 ofthe 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 maybe obtainedto assist
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`a surgeon in conducting any desired type of surgery.
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`[0020]
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`Balancing ofthe ligaments in the knee portion of a patient’s leg may be facilitated by
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`the positioning of one or more transducers between tendons, ligaments, and/or bones in the knee
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`portion. One transducer maybe positioned relative to a medial side of a knee joint. Another
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`transducer may be positionedrelative to a lateral side of the knee joint. During bendingofthe
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`knee joint, the output from the transducers will vary as a function of variations in tension forces
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`in the ligaments. This enables the tension forces in ligaments in opposite sides of the knee
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`portion to be comparedto facilitate balancing of the ligaments.
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`[0021]
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`Patellar tracking may be checkedby 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 betweena 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 function of variations in force transmitted
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`between the patella and femur during bending oftheleg.
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`[0022]
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`The articular surface on the patella may be repaired. The defective original articular
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`surface on the patella may be removed bycutting the patella while an innerside of the patella
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`faces toward a distal end portion of a femur. Thestep 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 onthe patella.
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`
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`[0023]
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`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 whenthe 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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`are associated with a patient’s knee, it should be understoodthat the implants may be positioned
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`at any desired location in a patient’s body.
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`[0024]
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`An implant may be positioned in a recess formed in a bone in a patient. The implant
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`may contain biological resurfacing and/or bone growth promoting materials. The implant may
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`contain mesenchymalcells and/or tissue inductive factors. Alternatively, the implant may be
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`formed of one or more materials which do not enable bone to grow into the implant.
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`[0025]
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`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/orstretch 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 anincision is to be made.
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`[0026]
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`An improved drape system is provided to maintain a sterile field between a surgeon
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`and a patient during movementof the surgeonrelative to the patient. The improved drape
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`system includes a drape which extends between the surgeon and a drapefor 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 ofa patient.
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`[0027]
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`An implant may be movable relative to both a femuranda tibia in a leg of a patient
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`during bending of the leg. The implant may include a single member whichis disposed between
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`and engaged by endportions 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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`membersofthe plurality of members may be secured to a bone and engaged by a member which
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`
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`is not secured to a bone. The implant may be securedto soft tissue in the knee portion of the
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`patient’s leg.
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`[0028]
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`There are many different features to the present invention. It is contemplated that
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`these features may be used togetheror 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 usedin 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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`together during the performanceof 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 whichis not performed on a joint in a patient’s body.
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`BRIEF DESCRIPTION OF THE DRAWINGS
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`[0029]
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`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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`[0030]
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`Fig. 1 is a schematic illustration depicting extended and flexed positions of a patient’s
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`leg during performance of knee surgery in a known manner;
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`[0031]
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`Fig. 2 is a schematic illustration depicting the mannerin 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 whichthepatientis
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`disposed in a supine orientation during performance of knee surgery;
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`[0032]
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`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 overthe patient, the leg being shownin a flexed condition with the
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`foot below the patient support surface and with an upperportion of the leg supported by the leg
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`support of Fig. 2;
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`
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`[0033]
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`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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`[0034]
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`Fig. 5 is a schematic illustration depicting the manner in which the drape system of
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`Fig. 4 maintainsa sterile field during movementof the surgeonrelative to the patient;
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`[0035]
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`Fig. 6 is a schematic illustration depicting the manner in which an incision is made in
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`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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`[0036]
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`Fig. 7 is a schematic illustration depicting the mannerin whichthe incision is
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`expanded anda patella is everted with the leg of the patient extended;
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`[0037]
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`Fig. 8 is a schematic illustration depicting the manner in whicha drill is utilized to
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`form a passage in a femurin the upperportion 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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`[0038]
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`Fig. 9 is a schematic illustration of the positioning of a femoral alignment guide in the
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`hole formedby the drill of Fig. 8 with the leg of the patient in the position illustrated in Figs. 2
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`and 3;
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`[0039]
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`Fig. 10 is a schematic illustration depicting the position of an anterior resection guide
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`and a stylusrelative to the femoral alignment guide of Fig. 9 before an anterior femurcut has
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`been made with the leg of the patient in the position illustrated in Figs. 2 and 3;
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`[0040]
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`Fig. 11 is a schematic illustration, taken generally along the line 11-11 of Fig. 10,
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`furtherillustrating the relationship of the anterior resection guide andstylusto the distal end
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`portion of the femur;
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`[0041]
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`Fig. 12 is a schematic illustration further illustrating the relationship of the anterior
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`resection guide andstylus to the distal end portion of the femur;
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`
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`[0042]
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`Fig. 13 is a schematic illustration depicting the manner in whicha cutting toolis
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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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`[0043]
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`Fig. 14 is a schematic illustration depicting the relationship of the femoral alignment
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`guide to the femur after making of the anterior femur cut of Fig. 13, the anterior resection guide
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`and stylus being removed from the femoral alignment guide, andthe leg of the patient being in
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`the position illustrated in Figs. 2 and 3;
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`[0044]
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`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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`[0045]
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`Fig. 16 is a schematic illustration depicting the manner in which the femoral
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`alignment guideis 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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`[0046]
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`Fig. 17 is a schematic illustration depicting the manner in which a distal femurcutis
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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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`[0047]
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`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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`[0048]
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`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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`[0049]
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`Fig. 20 is a schematic illustration further depicting the relationship of the femoral
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`cutting guide to the distal end portion of the femur;
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`10
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`
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`[0050]
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`Fig. 21 is a schematic illustration depicting the relationship ofa tibial resection guide
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`to the proximal end portion ofa tibia in the lower portion of the patient’s leg after making the
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`femoral cuts and with the leg of the patient in the position illustrated in Figs. 2 and 3;
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`[0051]
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`Fig. 22 is a schematic illustration of the distal end portion of the femur and the
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`proximal end portion ofthe tibia after making the femoral andtibial 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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`[0052]
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`Fig. 23 is a schematic illustration further depicting the femoral andtibial cuts of
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`Fig 22;
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`[0053]
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`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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`[0054]
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`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 movedrelative to the upper portion of the patient’s leg to
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`expose portions of the boneat the incision in the knee portion of the patient’s leg and to check
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`ligament balancing;
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`[0055]
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`Fig. 26 is a schematic illustration depicting the manner in whicha tibial punch 1s
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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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`[0056]
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`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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`[0057]
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`Fig. 28 is a schematic illustration depicting positioning ofa tibial bearing insert in the
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`tibial tray of Fig. 27 with the leg of the patient in the position illustrated in Figs. 2 and 3;
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`11
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`
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`[0058]
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`Fig. 29 is a schematic illustration depicting femoral andtibial implants with the leg of
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`the patient in the position illustrated in Figs. 2 and 3;
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`[0059]
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`Fig. 30 is a schematic illustration of an apparatus which may beutilized 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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`[0060]
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`Fig. 31 is a schematic illustration depicting the manner in whicha 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 upperportion 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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`[0061]
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`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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`[0062]
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`Fig. 33 is a schematic illustration similar to Fig. 32, depicting the manner in which
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`the endoscope maybe inserted through the incision in the patient’s knee with the leg of the
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`patient extended;
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`[0063]
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`Fig. 34 is a schematic illustration depicting the manner in which an imaging apparatus
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`may be utilized to generate images of a portion of the patient’s leg and the manner in which a
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`robot may be utilized to position cutting tools or other devices relative to the patient’s leg with
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`the patient’s leg in the position illustrated in Figs. 2 and 3;
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`[0064]
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`Fig. 35 is a schematic illustration depicting the relationship ofa cut line to a patella in
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`a knee of the leg of the patient with the leg in the position illustrated in Figs. 2 and 3 and with the
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`patella in the normal position;
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`12
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`
`
`[0065]
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`Fig. 36 is a schematic illustration depicting the manner in whicha cutting toolis
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`movedrelative to a guide memberto cut the patella of Fig. 35 while the patella is disposed in
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`situ;
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`[0066]
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`Fig. 37 is a schematic illustration depicting the manner in whicha tibial alignment
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`shaft and a tibial resection guide are positioned relative to a tibia in a lowerportion 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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`[0067]
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`Fig. 38 is an enlarged fragmentary view ofa portion of Fig. 37 andillustrating the
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`construction of the tibial resection guide;
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`[0068]
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`Fig. 39 is a schematic illustration depicting the relationship between an expandable
`
`cannula and an incision in the knee portion of one leg of the patient with the leg of the patient in
`
`the position illustrated in Figs. 2 and 3;
`
`[0069]
`
`Fig. 40 is a schematic illustration depicting the relationship between two separate
`
`portions of an implant which are interconnected within the patient’s body;
`
`[0070]
`
`Fig. 41 is a schematic illustration depicting the relationship of transducersto a flexed
`
`knee joint of a patient whenthe leg of the patientis in the position illustrated in Figs. 2 and 3;
`
`[0071]
`
`Fig. 42 is a schematic illustration, generally similar to Fig. 41, illustrating the
`
`relationship of the transducers to the knee joint whenthe leg of the patient is extended;
`
`[0072]
`
`Fig. 43 is a schematic illustration of a distal end portion of a femurin a leg of a
`
`patient with the leg in the position illustrated in Figs. 2 and 3 andillustrating the relationship of
`
`an implant to a recess in the end portion of the femur;
`
`[0073]
`
`Fig. 44 is a schematic sectional view depicting the manner in which a cutting tool is
`
`used to form a recess in the end portion of the femur of Fig. 43 with the leg of the patient in the
`
`position illustrated in Figs. 2 and 3;
`
`13
`
`
`
`[0074]
`
`Fig. 45 is a schematic sectional view, taken generally along the line 45-45 of Fig. 43
`
`furtherillustrating the relationship of the implant to the recess;
`
`[0075]
`
`Fig. 46 is a schematic end view of a proximal endportion of a tibia in a leg of a
`
`patient, with the leg in the position illustrated in Figs. 2 and 3, illustrating the relationship of an
`
`implant to a recess in the end portion ofthe tibia;
`
`[0076]
`
`Fig. 47 is a schematic sectional view depicting the manner in which a cutting tool is
`
`used to form the recess in the end portion ofthetibia of Fig. 46;
`
`[0077]
`
`Fig. 48 is a schematic sectional view, taken generally along the line 48-48 of Fig. 46,
`
`furtherillustrating the relationship of the implant to the recess;
`
`[0078]
`
`Fig. 49 is a schematic sectional view illustrating the relationship of another implant to
`
`a recess in a bone in a patient’s body;
`
`[0079]
`
`Fig. 50 is a schematic illustration depicting the relationship between a tibial implant
`
`and a tibia in the leg of the patient;
`
`[0080]
`
`Fig. 51 is a schematic illustration depicting the relationship of expandable devicesto
`
`the knee portion of a patient’s leg;
`
`[0081]
`
`Fig. 52 is a schematic illustration depicting the manner in which an expandable
`
`device may be positioned relative to a knee portion of a patient’s leg with the patient’s leg in the
`
`position illustrated in Figs. 2 and 3;
`
`[0082]
`
`Fig. 53 is a schematic illustration depicting the manner in which a femoral cutting
`
`guide may be mounted on a distal end of a femurin a patient’s leg with the patient’s leg in the
`
`position illustrated in Figs. 2 and 3;
`
`14
`
`
`
`[0083]
`
`Fig. 54 is a schematic illustration of the manner in which a femoral cutting guide may
`
`be mounted onaside surface of a femurin a patient’s leg with the patient’s leg in the position
`
`illustrated in Figs. 2 and 3;
`
`[0084]
`
`Fig. 55 is a schematic illustration depicting the manner in whichlightis directed onto
`
`a distal end portion of a femur with the patient’s leg in the position illustrated in Figs. 2 and 3;
`
`[0085]
`
`Fig. 56 is a schematic illustration depicting the manner in whichlight is used to guide
`
`movementofa cutting tool relative to a distal end portion of a femur with the patient’s leg in the
`
`position illustrated in Figs. 2 and 3;
`
`[0086]
`
`Fig. 57 is a schematic illustration depicting the manner in whicha cutting toolis
`
`movedrelative to a secondary incision with a knee portion of a patient’s leg in the position
`
`illustrated in Figs. 2 and 3;
`
`[0087]
`
`Fig. 58 is schematic illustration depicting the relationship of transducersto a patella
`
`and distal end portion of a femur with the patient’s leg in the position illustrated in Figs. 2 and 3;
`
`[0088]
`
`Fig. 59 is a schematic illustration depicting the relationship between a movable
`
`implant, a distal end portion of a femur, and a proximal end portion of a tibia in a knee portion of
`
`a leg of a patient;
`
`[0089]
`
`Fig. 60 is a plan view ofa proximal end portion of a tibia depicting the mannerin
`
`which an implant may be inlaid intoatibia;
`
`[0090]
`
`Fig. 61 is a schematic illustration, generally similar to Fig. 59, depicting the
`
`relationship between a movable implant formedby a plurality of members, a distal end portion of
`
`a femur, and a proximal end portion of a tibia in a knee portion ofa leg of a patient;
`
`15
`
`
`
`[0091]
`
`Fig. 62 is a schematic illustration, generally similar to Figs. 59 and 61, depicting the
`
`relationship between an implant formed by a movable memberanda fixed member, a distal end
`
`portion of a femur, and a proximal end portion ofa tibia in a knee portion of a leg of a patient;
`
`[0092]
`
`Fig. 63 is a schematic illustration, generally similar to Fig. 59, depicting the manner
`
`in which an implant is connected with a ligamentin a knee portion of a patient’s leg;
`
`[0093]
`
`Fig. 64 is a schematic illustration, generally similar to Fig. 60, depicting the manner
`
`in which an implant is connected with a joint capsule in a knee portion of a patient’s leg;
`
`[0094]
`
`Fig. 65 is a schematic illustration, generally similar to Fig. 60, depicting the manner
`
`in which a retainer holds moldable implant material in place on a proximal end portion ofa tibia
`
`in the knee portion of a leg of the patient;
`
`[0095]
`
`Fig. 66 is a fragmentary sectional view, taken generally along the line 66-66ofFig.
`
`65 further illustrating the manner in which the retainer holds moldable implant material;
`
`[0096]
`
`Fig. 67 is a schematic illustration depicting the manner in which an implantis
`
`provided in a knee portion of a leg of a patient to correct defects in a joint and in which an
`
`osteotomy wedgeis provided to correct defects in bone alignment;
`
`[0097]
`
`Fig. 68 is a schematic view of the hip region with a guide wire and cannula inserted;
`
`[0098]
`
`Fig. 69 is a schematic view ofthe hip region with an inflatable device inserted;
`
`[0099]
`
`Fig. 70A is a side view of a bone removing instrument according to the present
`
`invention in a retractedstate;
`
`[00100]
`
`Fig. 70B is a perspective view of the bone removing instrument of Fig. 70A in an
`
`expandedstate;
`
`16
`
`
`
`[0100]
`
`Fig. 71 is a schematic view of the hip region with the bone removerof Fig. 70B
`
`inserted and rem