Methods and apparatuses for attaching tissue to orthopaedic implants

This application claims the benefit of U.S. Provisional Patent Application Ser. No. 60/916,414, entitled METHODS AND APPARATUSES FOR ATTACHING SOFT TISSUE TO ORTHOPAEDIC IMPLANTS, filed on May 7, 2007, and U.S. patent application Ser. No. 12/115,763, entitled METHODS AND APPARATUSES FOR ATTACHING SOFT TISSUE TO ORTHOPAEDIC IMPLANTS, filed on May 6, 2008, the entire disclosures of which are expressly incorporated by reference herein.

1. Field of the Disclosure

The present disclosure relates to methods and apparatuses for attaching tissue to orthopaedic implants. More particularly, the present disclosure relates to methods and apparatuses for attaching tissue to a proximal tibial implant and a proximal femoral implant.

2. Description of the Related Art

Orthopaedic implants are commonly used to replace at least a portion of a patient's joint to restore the use of the joint or to increase the use of the joint. For example, orthopaedic implants may be used to restore the patient's joint following deterioration due to aging or illness or following traumatic injury.

The present disclosure provides methods and apparatuses for attaching tissue structures to orthopaedic implants. The tissue structures may include soft tissue structures, such as muscles, ligaments, capsules, and tendons. The tissue structures may also include bone, including bone that retains a natural connection to muscles, ligaments, capsules, or tendons. In one exemplary embodiment, the methods and apparatuses are used to attach a tissue structure to a proximal tibial implant. In another exemplary embodiment, the methods and apparatuses are used to attach a tissue structure to a proximal femoral implant.

According to an exemplary embodiment of the present invention, a segmental tibial orthopaedic implant configured for attachment to a tissue structure is provided. The segmental tibial orthopaedic implant includes a body and at least one washer. The body includes an anterior surface, a posterior surface, a lateral surface, a medial surface, a proximal end, and a distal end, the proximal end of the body including a bearing surface configured to support articulation with a distal femoral component, and the anterior surface of the body including a porous material. The at least one washer includes a clamping surface, the at least one washer rotatably coupled to the body with the clamping surface facing the anterior surface of the body, wherein the at least one washer is configured to clamp the tissue structure between the clamping surface and the anterior surface of the body.

According to another exemplary embodiment of the present invention, a segmental tibial orthopaedic implant configured for attachment to a tissue structure is provided. The segmental tibial orthopaedic implant includes a body, a medial washer, and a lateral washer. The body includes an anterior surface, a posterior surface, a lateral surface, a medial surface, a proximal end, and a distal end, the proximal end of the body including a bearing surface configured to support articulation with a distal femoral component. The medial washer is coupled to the body, the medial washer configured to clamp a medial tissue structure against the anterior surface of the body. The lateral washer is coupled to the body in spaced relation to the medial washer, the lateral washer configured to clamp a lateral tissue structure against the anterior surface of the body.

According to yet another exemplary embodiment of the present invention, a segmental femoral orthopaedic implant configured for attachment to a tissue structure is provided. The segmental femoral orthopaedic implant includes a body, a neck, and a protrusion. The body includes an anterior surface, a posterior surface, a lateral surface, a medial surface, a proximal end, and a distal end, the lateral surface of the body including a porous material. The neck extends medially from the body, the neck configured to support a head for articulation with an acetabular component. The protrusion projects medially from the body beneath the neck, the protrusion defining at least one suture throughbore.

According to yet another exemplary embodiment of the present invention, a method is provided for attaching a tissue structure to a segmental femoral orthopaedic implant. The method includes the steps of providing the segmental femoral orthopaedic implant comprising a body, a neck that extends from the body, and a protrusion that projects from the body beneath the neck, the protrusion defining at least one suture throughbore; implanting the segmental femoral orthopaedic implant in a patient such that the neck and the protrusion extend medially from the body; and securing the tissue structure to the protrusion.

According to yet another exemplary embodiment of the present invention, a segmental femoral orthopaedic implant configured for attachment to a tissue structure is provided. The segmental femoral orthopaedic implant includes a body, a neck, a proximal washer, and a distal washer. The body includes an anterior surface, a posterior surface, a lateral surface, a medial surface, a proximal end, and a distal end, the lateral surface of the body including a porous material. The neck extends medially from the body, the neck configured to support a head for articulation with an acetabular component. The proximal washer is coupled to the body, the proximal washer configured to resist movement of a proximal tissue structure in a first direction. The distal washer is coupled to the body distally of the proximal washer, the distal washer configured to resist movement of a distal tissue structure in a second direction that differs from the first direction.

According to still yet another exemplary embodiment of the present invention, an orthopaedic implant configured for attachment to a tissue structure is provided. The orthopaedic implant includes a body and at least one washer rotatably coupled to the body. The body includes an anterior surface, a posterior surface, a lateral surface, a medial surface, a proximal end, and a distal end, the proximal end of the body configured for articulation with an adjacent anatomical structure, and at least one of the anterior, posterior, lateral, and medial surfaces of the body including a porous material. The at least one washer is configured to clamp the tissue structure against the porous material of the body, the at least one washer maintaining a fixed axial spacing from the body as the at least one washer is rotated relative to the body from a first rotational position to a second rotational position.

According to still yet another exemplary embodiment of the present invention, an orthopaedic implant configured for attachment to a tissue structure is provided. The orthopaedic implant includes a body, a first washer, a second washer, and a fastener. The body includes an anterior surface, a posterior surface, a lateral surface, a medial surface, a proximal end, and a distal end, the proximal end of the body configured for articulation with an adjacent anatomical structure, the body defining a bore. The first washer includes a first body portion and a first engagement arm, the first body portion configured to extend into the bore of the implant, the first engagement arm separated a first distance from the body of the implant when the first body portion is received in the bore and configured to clamp the tissue structure against the body of the implant. The second washer includes a second body portion and a second engagement arm, the second body portion configured to extend into the same bore of the implant as the first body portion of the first washer, the second engagement arm separated a second distance from the body of the implant when the second body portion is received in the bore and configured to clamp the tissue structure against the body of the implant, the second distance exceeding the first distance. The fastener is configured to extend into the bore of the implant to couple either of the first and second washers to the body of implant.

According to still yet another exemplary embodiment of the present invention, a method is provided for attaching a tissue structure to an orthopaedic implant. The method includes the steps of: providing a body including an anterior surface, a posterior surface, a lateral surface, a medial surface, a proximal end, and a distal end, the proximal end of the body configured for articulation with an adjacent anatomical structure; providing a porous plate including at least one suture throughbore; securing the tissue structure to the plate; and after the securing step, coupling the plate to the body.

The above-mentioned and other features of the disclosure, and the manner of attaining them, will become more apparent and will be better understood by reference to the following description of embodiments of the disclosure taken in conjunction with the accompanying drawings, wherein:

FIG. 1 is a perspective view of a proximal tibial implant according to an exemplary embodiment of the present disclosure;

FIG. 2 is another perspective view of the proximal tibial implant of FIG. 1 ;

FIG. 3 is a side elevational view of the proximal tibial implant of FIG. 1 ;

FIG. 4 is an anterior elevational view of the proximal tibial implant of FIG. 1 ;

FIG. 5 is another side elevational view of the proximal tibial implant of FIG. 1 ;

FIG. 6 is an anterior elevational view of the proximal tibial implant of FIG. 1 , further including a medial rotating fixation structure and a lateral rotating fixation structure, each having a washer and a fastener;

FIG. 7 is a cross-sectional view of the washer and the fastener of FIG. 6 ;

FIG. 8 is an alternative cross-sectional view of the washer and the fastener of FIG. 6 ;

FIG. 9 is an anterior elevational view of a proximal tibial implant according to another exemplary embodiment of the present disclosure;

FIG. 10 is an exploded perspective view of a proximal tibial implant according to yet another exemplary embodiment of the present disclosure;

FIG. 11 is a perspective view of a proximal tibial implant according to yet another exemplary embodiment of the present disclosure;

FIG. 12 is a cross-sectional view of the proximal tibial implant of FIG. 11 , taken along line 12 - 12 of FIG. 11 ;

FIG. 13 is a perspective view of a proximal femoral implant according to an exemplary embodiment of the present disclosure;

FIG. 14 is another perspective view of the proximal femoral implant of FIG. 13 ;

FIG. 15 is an anterior/posterior elevational view of the proximal femoral implant of FIG. 13 ;

FIG. 16 is a medial elevational view of the proximal femoral implant of FIG. 15 , taken along line 16 - 16 of FIG. 15 ;

FIG. 17 is an inferior plan view of the proximal femoral implant of FIG. 15 , taken along line 17 - 17 of FIG. 15 ;

FIG. 18 is a side elevational view of a proximal tibial implant according to still yet another exemplary embodiment of the present disclosure;

FIG. 19 is an anterior elevational view of the proximal tibial implant of FIG. 18 ;

FIG. 20 is a posterior elevational view of the proximal tibial implant of FIG. 18 ;

FIG. 21 is a perspective view of the proximal tibial implant of FIG. 18 ;

FIG. 22 is a perspective view of a proximal femoral implant according to another exemplary embodiment of the present disclosure;

FIG. 23 is an anterior elevational view of a proximal tibial implant according to an exemplary embodiment of the present disclosure including a tissue attachment plate;

FIG. 24 is an anterior elevational view of the proximal tibial implant of FIG. 23 shown without the tissue attachment plate;

FIG. 25 is a cross-sectional view of the proximal tibial implant of FIG. 24 , taken along line 25 - 25 of FIG. 24 ;

FIG. 26 is an anterior elevational view of the proximal tibial implant of FIG. 23 , further including a medial rotating fixation structure and a lateral rotating fixation structure, each having a washer and a fastener;

FIG. 27 is a perspective view of the washer of FIG. 26 ;

FIG. 28 is a cross-sectional view of the washer and the fastener of FIG. 26 ;

FIG. 29 is an anterior elevational view of the proximal tibial implant of FIG. 23 , further including a bar in place of the washers of FIG. 26 ;

FIG. 30 is a perspective view of the bar of FIG. 29 ;

FIG. 31 is a perspective view of the proximal tibial implant of FIG. 26 , further including a set screw and a snap ring;

FIG. 32 is a cross-sectional view of the proximal tibial implant of FIG. 31 , taken along line 32 - 32 of FIG. 31 ;

FIG. 33 is a perspective view of the proximal tibial implant of FIG. 26 , further including a set screw;

FIG. 34 is a cross-sectional view of the proximal tibial implant of FIG. 33 , taken along line 34 - 34 of FIG. 33 ;

FIG. 35 is a perspective view of a proximal femoral implant according to another exemplary embodiment of the present disclosure;

FIG. 36 is a perspective view of the proximal femoral implant of FIG. 35 , further including a proximal rotating fixation structure and a distal rotating fixation structure;

FIG. 36A is a lateral elevational view of the proximal femoral implant of FIG. 36 , illustrating the proximal and distal rotating fixation structures in different positions than in FIG. 36 ;

FIG. 37 is a partial cross-sectional anterior/posterior elevational view of the proximal femoral implant of FIG. 36 ;

FIG. 38 is an elevational view of the proximal rotating fixation structure of FIG. 36 ;

FIG. 39 is a perspective view of the proximal rotating fixation structure of FIG. 36 ;

FIG. 40 is an exploded perspective view of the proximal rotating fixation structure of FIG. 36 ;

FIG. 41 is a perspective view of the distal rotating fixation structure of FIG. 36 ;

FIG. 42 is an exploded perspective view of the distal rotating fixation structure of FIG. 36 ;

FIG. 43 is a partial cross-sectional view of the proximal femoral implant and the distal rotating fixation structure of FIG. 36 ;

FIG. 43A is a view similar to FIG. 43 showing an alternative distal rotating fixation structure;

FIG. 44 is an anterior/posterior elevational view of a proximal femoral implant according to yet another exemplary embodiment of the present disclosure including a first mechanism for controlling the alignment of proximal and distal fixation structures relative to the implant;

FIG. 45 is an anterior/posterior elevational view of the proximal femoral implant of FIG. 44 including a second mechanism for controlling the alignment of the proximal and distal fixation structures relative to the implant;

FIG. 46 is an anterior/posterior elevational view of the proximal femoral implant of FIG. 44 including a third mechanism for controlling the alignment of the proximal and distal fixation structures relative to the implant;

FIG. 47 is an anterior/posterior elevational view of the proximal femoral implant of FIG. 44 including a fourth mechanism for controlling the alignment of the proximal and distal fixation structures relative to the implant;

FIG. 48 is an exploded perspective view of a proximal femoral implant according to still yet another exemplary embodiment of the present disclosure including a proximal fixation structure and a distal fixation structure, each fixation structure having a washer, a fastener, and a set screw;

FIG. 49 is a perspective view of the proximal and distal washers of FIG. 48 ;

FIG. 50 is a perspective view of the fastener of FIG. 48 ;

FIG. 51 is an exploded perspective view of a proximal femoral implant according to still yet another exemplary embodiment of the present disclosure;

FIG. 52 is an anterior/posterior elevational view of the proximal femoral implant of FIG. 51 ;

FIG. 53 is a cross-sectional view of the proximal femoral implant of FIG. 51 , taken along line 53 - 53 of FIG. 51 ;

FIG. 54 is an anterior/posterior elevational view of a proximal fixation structure coupled to the proximal femoral implant of FIG. 51 ; and

FIG. 54A is a view similar to FIG. 54 showing an alternative proximal fixation structure.

Corresponding reference characters indicate corresponding parts throughout the several views. The exemplifications set out herein illustrate embodiments of the disclosure and such exemplifications are not to be construed as limiting the scope of the invention in any manner.

Referring to FIGS. 1-5 , proximal tibial implant 30 is shown and may be used to restore mechanical and biological fixation of tissue structures associated with a knee joint of a patient to enhance the stability of the knee joint, to restore knee joint function, and to enhance knee joint kinematics. The tissue structures may include soft tissue structures, such as muscles, ligaments, capsules, and tendons. The tissue structures may also include bone, including bone that retains a natural connection to muscles, ligaments, capsules, or tendons. Typically, proximal tibial implant 30 may be used in a patient requiring complete metaphyseal removal of the proximal tibia. Proximal tibial implant 30 of FIG. 1 includes body 32 having proximal end 42 and distal end 40 , femoral bearing plate or surface 34 , and mating structure 36 . Body 32 also includes an anterior surface, a posterior surface opposite the anterior surface, a lateral surface, and a medial surface opposite the lateral surface.

Body 32 may be formed from relatively light-weight material, such as titanium, a cobalt chromium alloy, or another suitable biocompatible material, for example, thereby making it easier for the patient to lift and extend the knee joint, particularly in procedures which require extensive removal of muscle proximate the knee joint. In one embodiment, bearing surface 34 may be formed as a modular component of proximal tibial implant 30 to provide more interoperative options. In an exemplary embodiment, bearing surface 34 is formed of a wear-resistant material to minimize debris from articulation with an adjacent anatomical component of the knee joint, such as a distal femoral component (not shown). Mating structure 36 may be formed complementary to a meniscal component (not shown) of the knee joint to provide either a mobile or a non-mobile bearing connection between proximal tibial implant 30 and the meniscal component.

As shown in FIG. 1 , proximal tibial implant 30 also includes rotational adjustment tabs 38 at distal end 40 of proximal tibial implant 30 to allow for in vivo rotational adjustment of proximal tibial implant 30 relative to another implant or to the remaining structure of the tibia. Rotational adjustment tabs 38 may generally extend distally from body 32 along a lateral and/or a medial side of proximal tibial implant 30 . A plurality of tabs 38 may be utilized or a single tab 38 may be utilized.

Proximal tibial implant 30 further includes tissue attachment plate 44 . In an exemplary embodiment, attachment plate 44 is positioned on at least an anterior surface of proximal tibial implant 30 . Attachment plate 44 may be integrally formed with proximal tibial implant 30 . Alternatively, attachment plate 44 may be formed as a modular component of proximal tibial implant 30 . The modular attachment plate 44 may be positioned in a recess (not shown) on the anterior surface of proximal tibial implant 30 and fastened to body 32 . Attachment plate 44 may generally have a relatively thin anterior to posterior thickness, e.g., as low as approximately 1 mm to as high as approximately 5 mm, such as to define a relatively slim profile. In an embodiment, attachment plate 44 does not protrude from proximal tibial implant 30 to avoid potentially interfering with other anatomical structures. For example, the anterior surface of attachment plate 44 may sit substantially flush with the remainder of the anterior surface of proximal tibial implant 30 . Alternatively, in another embodiment, attachment plate 44 may sit proud of proximal tibial implant 30 to enhance the attachment to tissue structures. For example, the anterior surface of attachment plate 44 may extend 0.5 mm, 1 mm, or more, beyond proximal tibial implant 30 .

Attachment plate 44 provides a direct connection between a tissue structure and proximal tibial implant 30 . For example, a patellar tendon, which joins a lower edge of a patella (not shown) of the knee joint with a tibial tubercle of a tibia, may be mechanically fixed directly to attachment plate 44 of proximal tibial implant 30 . Also, the patellar tendon may be biologically fixed via ingrowth into attachment plate 44 of proximal tibial implant 30 . Such fixation of the patellar tendon to proximal tibial implant 30 enhances usability of the knee joint. For example, when a patient jumps into the air or allows the tibia to hang without any support, the fixation of the patellar tendon to proximal tibial implant 30 prevents dislocation of the components of the prosthetic knee joint and facilitates normal functioning of the prosthetic knee joint after the jump or once the tibia is again supported. In one example, a rotating hinged knee includes a distal femoral component with a post extending through a meniscal component and into proximal tibial implant 30 . During a jump or when the tibia is unsupported, the patellar tendon effectively prevents the post from extending too far from proximal tibial implant 30 and ensures that the post returns to proper engagement with proximal tibial implant 30 once normal functioning is resumed.

As described further below, attachment plate 44 includes at least one porous surface 45 , such as a surface to facilitate ingrowth of tissue structures. In one embodiment, porous surface 45 may be formed of a material having a cellular structure which resembles bone and approximates the physical and mechanical properties of bone, thereby enabling rapid and extensive tissue infiltration and strong attachment of tissue structures thereto. For example, the material may be a highly porous biomaterial having a porosity as low as 55, 65, or 75 percent and as high as 80, 85, or 90 percent. An example of such a material is produced using Trabecular Metal™ technology that is generally available from Zimmer, Inc., of Warsaw, Ind. Trabecular Metal™ is a trademark of Zimmer Technology, Inc. Such a material may be formed from a reticulated vitreous carbon foam substrate which is infiltrated and coated with a biocompatible metal, such as tantalum, by a chemical vapor deposition (“CVD”) process in the manner disclosed in detail in U.S. Pat. No. 5,282,861, the disclosure of which is expressly incorporated herein by reference. In addition to tantalum, other metals such as niobium or alloys of tantalum and niobium with one another or with other metals may also be used.

Generally, the porous tantalum structure includes a large plurality of ligaments defining open spaces therebetween, with each ligament generally including a carbon core covered by a thin film of metal such as tantalum, for example. The open spaces between the ligaments form a matrix of continuous channels having no dead ends, such that growth of cancellous bone and/or soft tissue through the porous tantalum structure is uninhibited. The porous tantalum may include up to 75%-85% or more void space therein. Thus, porous tantalum is a lightweight, strong porous structure which is substantially uniform and consistent in composition, and closely resembles the structure of natural cancellous bone. The porous tantalum structure may be made in a variety of densities in order to selectively tailor the structure for particular applications. In particular, as discussed in the above-incorporated U.S. Pat. No. 5,282,861, the porous tantalum may be fabricated to virtually any desired porosity and pore size, and can thus be matched with the surrounding natural bone in order to provide an improved matrix for bone ingrowth and mineralization. Such porous material also facilitates ingrowth of soft tissue for enhanced attachment of soft tissue structures to proximal tibial implant 30 . For example, fibers and struts which extend from porous surface 45 are generally rough which facilitates holding a soft tissue structure in such a manner that damage and disengagement of the soft tissue structure is discouraged. The porous material may have a generally corrugated surface to further facilitate biological fixation of soft tissue structures thereto.

According to an exemplary embodiment of the present invention, porous surface 45 of attachment plate 44 may be impregnated with and/or coated with biologically active agents. Suitable biologically active agents include, for example, antibiotics, to reduce the chances of infection and to promote healing, and growth factors, to promote ingrowth into porous surface 45 of attachment plate 44 .

As shown in FIGS. 3-5 , proximal tibial implant 30 further includes fastener or suture apertures 46 in the anterior surface of body 32 aligned with corresponding throughbores 48 that extend posteriorly through body 32 of proximal tibial implant 30 . Throughbores 48 generally extend straight through proximal tibial implant 30 from the anterior surface to the posterior surface. Also, body 32 may include apertures 46 a which are generally skewed through body 32 . Apertures 46 a may include corresponding throughbores 48 a that form a curved path through body 32 , as opposed to a straight path through body 32 as formed by throughbores 48 . Advantageously, apertures 46 a and their respective curved throughbores 48 a may accommodate curved suture needles. In addition, apertures 46 , 46 a , may be counterbored, as shown, for example, in FIG. 3 . Counterbored apertures 46 , 46 a , increase the space available to insert a suture needle into the corresponding throughbores 48 , 48 a , without having to widen throughbores 48 , 48 a , entirely across the depth of body 32 , which could reduce the strength of body 32 . Like curved throughbores 48 a , counterbored apertures 46 , 46 a , may accommodate curved suture needles in the corresponding throughbores 48 , 48 a . Apertures 46 , 46 a , may have a generally rounded shape to facilitate prevention of suture or fastener breakage during an operation.

In operation, a surgeon may attach a tissue structure, such as a muscle, a ligament, a capsule, a tendon, and/or bone, for example, to proximal tibial implant 30 . First, the surgeon positions the tissue structure in contact with attachment plate 44 . At least one suture is then threaded through apertures 46 , 46 a , and the corresponding throughbores 48 , 48 a , to maintain contact between the tissue structure and attachment plate 44 . In contrast to sutures, a surgeon may also use surgical tape or surgical cables, for example. The surgeon may select any or all apertures 46 , 46 a , and throughbores 48 , 48 a , to at least temporarily secure the tissue structure to attachment plate 44 of proximal tibial implant 30 . In one embodiment, the sutures may be biodegradable after a period of time in which the tissue structure is permanently attached to proximal tibial implant 30 via ingrowth of the tissue structure into porous surface 45 of attachment plate 44 . The close proximity of apertures 46 , 46 a , to attachment plate 44 facilitates more direct contact between the tissue structure and attachment plate 44 .

Referring next to FIGS. 6-8 , an alternative embodiment proximal tibial implant 30 A is shown and is substantially identical to proximal tibial implant 30 , described above with reference to FIGS. 1-5 , except as described below. Proximal tibial implant 30 A includes body 32 , bearing surface 34 , mating structure 36 , rotational adjustment tabs 38 , distal end 40 , and proximal end 42 . Proximal tibial implant 30 A also includes attachment plate 44 A which is similar to attachment plate 44 , described above with reference to FIGS. 1-5 , except as described below. For example, attachment plate 44 A on the anterior surface of proximal tibial implant 30 A includes porous surface 45 to facilitate ingrowth of a tissue structure.

Proximal tibial implant 30 A also includes medial fixation structure 200 and lateral fixation structure 202 . Medial fixation structure 200 includes washer 50 and fastener 52 , and lateral fixation structure 202 includes washer 50 ′ and fastener 52 ′. Washers 50 , 50 ′, may be attached atop attachment plate 44 A by inserting fasteners 52 , 52 ′, through any apertures 46 provided in body 32 . It is within the scope of the present invention that washers 50 , 50 ′, may be labeled to ensure that washer 50 is inserted into body 32 medially of washer 50 ′. Also, each washer 50 , 50 ′, and/or fastener 52 , 52 ′, may be sized or shaped to fit into a particular aperture 46 to ensure that washer 50 is inserted into body 32 medially of washer 50 ′. Washers 50 , 50 ′, are rotatably attached to attachment plate 44 A such that washers 50 , 50 ′, are rotatable from a first rotational position, shown in phantom in FIG. 6 , in which a tissue structure is not engaged with washers 50 , 50 ′, to a second rotational position, shown in solid lines in FIG. 6 , in which a tissue structure may be securely clamped against attachment plate 44 A of proximal tibial implant 30 A with washers 50 , 50 ′. In one embodiment, as shown in FIG. 7 , washer 50 includes a plurality of teeth 54 to further facilitate holding engagement of the tissue structure against attachment plate 44 A with washer 50 . In another embodiment, as shown in FIG. 8 , washer 50 includes a porous material similar to porous surface 45 described above to facilitate ingrowth of the tissue structure into both washer 50 and attachment plate 44 A, thereby facilitating a secure hold on the tissue structure.

In operation, a surgeon may attach tissue structures to proximal tibial implant 30 A. The tissue structures may include soft tissue structures, such as muscles, ligaments, capsules, and tendons. The tissue structures may also include bone, including bone that retains a natural connection to muscles, ligaments, capsules, or tendons. First, the surgeon positions the tissue structure in contact with attachment plate 44 A. At least one optional washer 50 , 50 ′, may then be rotated from the first rotational position into the second rotational position, as shown in FIG. 6 , to clamp and mechanically fix the tissue structure to attachment plate 44 A beneath washers 50 , 50 ′. Each washer 50 , 50 ′, may include a locking mechanism to lock washers 50 , 50 ′, in the clamped, second rotational position. In an exemplary procedure, a surgeon pulls or otherwise manipulates a tissue structure, such as a portion of a calf muscle or the patellar tendon, for example, in close proximity to attachment plate 44 A, and then uses washers 50 , 50 ′, to clamp the tissue structure against porous surface 45 of attachment plate 44 A, such that the tissue structure is mechanically fixed to proximal tibial implant 30 A beneath washers 50 , 50 ′. Washers 50 , 50 ′, may be positioned to pull the tissue structure from a medial, lateral, proximal, and/or distal side of proximal tibial implant 30 A.

To further maintain contact between the tissue structure and attachment plate 44 A, the surgeon may thread at least one suture through apertures 46 , 46 a , and the corresponding throughbores 48 , 48 a , to create a “sling” around proximal tibial implant 30 A. The surgeon may select any or all apertures 46 , 46 a , and the corresponding throughbores 48 , 48 a , to secure the tissue structure to proximal tibial implant 30 A. In one embodiment, the sutures may be biodegradable after a period of time in which the tissue structure is permanently attached to proximal tibial implant 30 A via ingrowth of the tissue structure into porous surface 45 of attachment plate 44 A. The close proximity of apertures 46 , 46 a , to attachment plate 44 A facilitates more direct contact between the tissue structure and attachment plate 44 A and encourages ingrowth of the tissue structure into porous surface 45 of attachment plate 44 A. According to an exemplary embodiment of the present disclosure, sutures are used in combination with washers 50 , 50 ′, to biologically and mechanically fix the tissue structure to proximal tibial implant 30 A.

Referring next to FIG. 9 , another embodiment proximal tibial implant 30 B is shown and may be substantially identical to proximal tibial implant 30 , described above with reference to FIGS. 1-5 , or proximal tibial implant 30 A, described above with reference to FIGS. 6-8 , except as described below. Proximal tibial implant 30 B includes body 32 , bearing surface 34 , mating structure 36 , rotational adjustment tabs 38 , distal end 40 , and proximal end 42 . Proximal tibial implant 30 B also includes attachment plate 44 B which is similar to attachment plate 44 , described above with reference to FIGS. 1-5 , or attachment plate 44 A, described above with reference to FIGS. 6-8 , except as described below. For example, attachment plate 44 B on the anterior surface of proximal tibial implant 30 B includes porous surface 45 to facilitate ingrowth of a tissue structure.

As shown in FIG. 9 , apertures 46 , 46 a , in body 32 are at least partially offset from porous surface 45 of attachment plate 44 B, as opposed to extending through attachment plate 44 B and being surrounded by porous surface 45 , as shown in FIG. 1 . In this embodiment, contact between the fragile sutures that extend through apertures 46 , 46 a , and the rough, uneven porous surface 45 , may be reduced and/or eliminated, thereby minimizing the risk that the sutures will weaken or tear. Attachment plate 44 B may include contours 58 which substantially mimic the shape of apertures 46 , 46 a , on one side, extending porous surface 45 adjacent to and in close proximity to each aperture 46 , 46 a , on one side. Contours 58 encourage contact between the tissue structure and porous surface 45 on one side of apertures 46 , 46 a , while still reducing and/or eliminating contact between the fragile sutures and porous surface 45 on the other side of apertures 46 , 46 a.

In operation, a surgeon may attach a tissue structure to proximal tibial implant 30 B. First, the surgeon positions the tissue structure in contact with attachment plate 44 B. At least one suture is then threaded through apertures 46 , 46 a , and the corresponding throughbores 48 , 48 a , to maintain contact between the tissue structure and attachment plate 44 B. The surgeon may select any or all apertures 46 , 46 a , and the corresponding throughbores 48 , 48 a , to secure the tissue structure to proximal tibial implant 30 B. In one embodiment, the sutures may be biodegradable after a period of time in which the tissue structure is permanently attached to proximal tibial implant 30 B via ingrowth of the tissue structure into porous surface 45 of attachment plate 44 B. The close proximity of apertures 46 , 46 a , to attachment plate 44 B facilitates more direct contact between the tissue structure and attachment plate 44 B. At the same time, providing a non-porous area around at least a portion of each aperture 46 , 46 a , may reduce contact between the sutures and the rough, uneven porous surface 45 , which could tear the sutures.

Referring next to FIG. 10 , yet another embodiment proximal tibial implant 30 C is shown and may be substantially identical to proximal tibial implant 30 , described above with reference to FIGS. 1-5 , proximal tibial implant 30 A, described above with reference to FIGS. 6-8 , or proximal tibial implant 30 B, described above with reference to FIG. 9 , except as described below. Proximal tibial implant 30 C includes body 32 , bearing surface 34 , mating structure 36 , rotational adjustment tabs 38 , distal end 40 , and proximal end 42 . Proximal tibial implant 30 C also includes attachment plate 44 C which may be similar to attachment plate 44 , described above with reference to FIGS. 1-5 , attachment plate 44 A, described above with reference to FIGS. 6-8 , or attachment plate 44 B, described above with reference to FIG. 9 , except as described below. For example, attachment plate 44 C on the anterior surface of proximal tibial implant 30 C includes porous surface 45 to facilitate ingrowth of a tissue structure.

As shown in FIG. 10 , attachment plate 44 C is a modular component, which may be attached to body 32 via fastener 64 inserted through attachment plate 44 C and into a corresponding aperture 66 in body 32 , for example. Fastener 64 may be a screw, bolt, anchor mechanism, a mechanism which expands once inserted into body 32 , or any other suitable fastening mechanism. Body 32 includes recess 60 formed in an anterior surface of body 32 that is sized and configured to accept attachment plate 44 C in a close-fitting engagement. Recess 60 in body 32 also provides clearance for extension 61 of attachment plate 44 C which includes groove 62 . In one embodiment, attachment plate 44 C may include a smooth posterior surface to facilitate the close-fitting engagement with recess 60 . In another embodiment, the posterior surface of attachment plate 44 C and/or the surface of recess 60 may include a porous surface substantially identical to porous surface 45 described above.

In operation, a surgeon may attach a tissue structure to proximal tibial implant 30 C with attachment plate 44 C already attached to body 32 . First, the surgeon positions the tissue structure in contact with attachment plate 44 C. At least one suture is then threaded through apertures 46 , 46 a , and the corresponding throughbores 48 , 48 a , to maintain contact between the tissue structure and attachment plate 44 C. The surgeon may select any or all apertures 46 , 46 a , and the corresponding throughbores 48 , 48 a , to secure the tissue structure to proximal tibial implant 30 C. Furthermore, the surgeon may thread at least one suture through groove 62 and around extension 61 of attachment plate 44 C and through distal aperture 46 b in body 32 to further facilitate mechanical fixation and stabilization of modular attachment plate 44 C to body 32 and/or the tissue structure to attachment plate 44 C. In one embodiment, the sutures may be biodegradable after a period of time in which the tissue structure is permanently attached to proximal tibial implant 30 C via ingrowth of the tissue structure into porous surface 45 of attachment plate 44 C. The close proximity of apertures 46 , 46 a , 46 b , to attachment plate 44 C facilitates more direct contact between the tissue structure and attachment plate 44 C, thereby enhancing the ingrowth of the tissue structure into porous surface 45 of attachment plate 44 C.

Alternatively, in certain embodiments, the surgeon may first attach the tissue structure to the modular attachment plate 44 C and then secure attachment plate 44 C to body 32 , thereby providing potential for tensioning the tissue structure prior to securement of attachment plate 44 C to body 32 . For example, the surgeon may tie the tissue structure onto attachment plate 44 C by tying a suture through apertures 63 and/or along groove 62 . To further maintain contact between the tissue structure and proximal tibial implant 30 C, the surgeon may position the tissue structure between the modular attachment plate 44 C and body 32 and then clamp attachment plate 44 C onto body 32 using fastener 64 . Providing a porous surface on the posterior surface of attachment plate 44 C and/or the surface of recess 60 would further facilitate ingrowth of the tissue structure into proximal tibial implant 30 C. In this embodiment, the anterior surface of attachment plate 44 C may be non-porous to avoid interfering with surrounding tissue, including skin. In one embodiment, attachment plate 44 C is formed of a material which allows tissue and blood vessels to grow through the plate. In this manner, attachment plate 44 C may secure a soft tissue structure, such as the patellar tendon, to proximal tibial implant 30 C and then a muscle, such as a calf muscle, may be wrapped over the anterior surface of attachment plate 44 C to facilitate blood flow through attachment plate 44 C, thereby reducing the potential of subcutaneous irritation and necrosis of the soft tissue structures.

Referring next to FIGS. 11-12 , yet another embodiment proximal tibial implant 30 D is shown and may be substantially identical to proximal tibial implant 30 , described above with reference to FIGS. 1-5 , proximal tibial implant 30 A, described above with reference to FIGS. 6-8 , proximal tibial implant 30 B, described above with reference to FIG. 9 , or proximal tibial implant 30 C, described above with reference to FIG. 10 , except as described below. Proximal tibial implant 30 D includes body 32 , bearing surface 34 , mating structure 36 , rotational adjustment tabs 38 , distal end 40 , and proximal end 42 . Proximal tibial implant 30 D also includes attachment plate 44 D which may be similar to attachment plate 44 , described above with reference to FIGS. 1-5 , attachment plate 44 A, described above with reference to FIGS. 6-8 , attachment plate 44 B, described above with reference to FIG. 9 , or attachment plate 44 C, described above with reference to FIG. 10 , except as described below. For example, attachment plate 44 C on the anterior surface of proximal tibial implant 30 D includes porous surface 45 to facilitate ingrowth of a tissue structure. Attachment plate 44 D may be a modular component and attached to body 32 via suitable fasteners (not shown), an adhesive material, an interference fit, or, alternatively, attachment plate 44 D may be integrally formed with body 32 .

As shown in FIG. 12 , body 32 includes apertures 46 , corresponding throughbores 48 , posterior recesses 68 , and anterior recesses 70 . It is within the scope of the present invention that recesses 68 , 70 , may be formed on one or both medial and lateral sides of body 32 . Posterior recesses 68 may be formed toward the posterior side of body 32 but maintain proximity to the anterior side of body 32 . Anterior recesses 70 may be formed on the anterior side of body 32 adjacent to attachment plate 44 D. The corresponding throughbore 48 of each aperture 46 extends width W from anterior recess 70 to a corresponding posterior recess 68 .

In operation, a surgeon may attach a tissue structure to proximal tibial implant 30 D. First, the surgeon positions the tissue structure in contact with attachment plate 44 D. At least one suture is then threaded through apertures 46 and the corresponding throughbores 48 to maintain contact between the tissue structure and attachment plate 44 D. The surgeon may select any or all apertures 46 and the corresponding throughbores 48 to secure the tissue structure to proximal tibial implant 30 D. In one embodiment, the sutures may be biodegradable after a period of time in which the tissue structure is permanently attached to proximal tibial implant 30 D via ingrowth of the tissue structure into porous surface 45 of attachment plate 44 D. The close proximity of apertures 46 to attachment plate 44 D facilitates more direct contact between the tissue structure and attachment plate 44 D. Moreover, recesses 68 , 70 , facilitate easier suture passage through apertures 46 and the corresponding throughbores 48 due to the thinness of throughbores 48 (width W). Also, recesses 68 , 70 , facilitate passage of a curved suture needle through throughbores 48 due to the thinness of throughbores 48 (width W).

Referring next to FIGS. 18-21 , yet another embodiment proximal tibial implant 30 E is shown and may be substantially identical to proximal tibial implant 30 , described above with reference to FIGS. 1-5 , proximal tibial implant 30 A, described above with reference to FIGS. 6-8 , proximal tibial implant 30 B, described above with reference to FIG. 9 , proximal tibial implant 30 C, described above with reference to FIG. 10 , or proximal tibial implant 30 D, described above with reference to FIGS. 11-12 , except as described below. Proximal tibial implant 30 E includes body 32 , bearing surface 34 , mating structure 36 , rotational adjustment tabs 38 , distal end 40 , and proximal end 42 . Proximal tibial implant 30 E also includes attachment plate 44 E which may be similar to attachment plate 44 , described above with reference to FIGS. 1-5 , attachment plate 44 A, described above with reference to FIGS. 6-8 , attachment plate 44 B, described above with reference to FIG. 9 , attachment plate 44 C, described above with reference to FIG. 10 , or attachment plate 44 D, described above with reference to FIGS. 11-12 , except as described below. For example, attachment plate 44 E on the anterior surface of proximal tibial implant 30 E includes porous surface 45 to facilitate ingrowth of a tissue structure.

As shown in FIG. 19 , attachment plate 44 E surrounds some, but not all, suture apertures 46 . As discussed above with reference to FIG. 9 , reducing and/or eliminating contact between the sutures that extend through apertures 46 and the rough, uneven porous surface 45 of attachment plate 44 E reduces the likelihood that the sutures will weaken or tear.

In operation, a surgeon may attach a tissue structure to proximal tibial implant 30 E. First, the surgeon positions the tissue structure in contact with attachment plate 44 E. At least one suture is then threaded through apertures 46 and the corresponding throughbores 48 to maintain contact between the tissue structure and attachment plate 44 E. The surgeon may select any or all apertures 46 and the corresponding throughbores 48 to secure the tissue structure to proximal tibial implant 30 E. In one embodiment, the sutures may be biodegradable after a period of time in which the tissue structure is permanently attached to proximal tibial implant 30 E via ingrowth of the tissue structure into porous surface 45 of attachment plate 44 E. The close proximity of apertures 46 to attachment plate 44 E facilitates more direct contact between the tissue structure and attachment plate 44 E. At the same time, providing a non-porous area around at least some apertures 46 , 46 a , reduces contact between the sutures and the rough, uneven porous surface 45 , which could tear the sutures.

Referring next to FIGS. 23-34 , still yet another embodiment proximal tibial implant 30 F is shown and may be substantially identical to proximal tibial implant 30 , described above with reference to FIGS. 1-5 , proximal tibial implant 30 A, described above with reference to FIGS. 6-8 , proximal tibial implant 30 B, described above with reference to FIG. 9 , proximal tibial implant 30 C, described above with reference to FIG. 10 , proximal tibial implant 30 D, described above with reference to FIGS. 11-12 , or proximal tibial implant 30 E, described above with reference to FIGS. 18-21 , except as described below. Proximal tibial implant 30 F includes body 32 , bearing surface 34 , mating structure 36 , rotational adjustment tabs 38 , distal end 40 , and proximal end 42 . Proximal tibial implant 30 E also includes attachment plate 44 F which may be similar to attachment plate 44 , described above with reference to FIGS. 1-5 , attachment plate 44 A, described above with reference to FIGS. 6-8 , attachment plate 44 B, described above with reference to FIG. 9 , attachment plate 44 C, described above with reference to FIG. 10 , attachment plate 44 D, described above with reference to FIGS. 11-12 , or attachment plate 44 E, described above with reference to FIGS. 18-21 , except as described below. For example, attachment plate 44 F on the anterior surface of proximal tibial implant 30 F includes porous surface 45 to facilitate ingrowth of a tissue structure. As shown by comparing FIGS. 23 and 24 , attachment plate 44 F is a modular component set into recess 43 of body 32 and attached to body 32 , such as via diffusion bonding.

Referring to FIG. 26 , proximal tibial implant 30 F also includes medial fixation structure 200 F and lateral fixation structure 202 F. Proximal tibial implant 30 F includes medial bore 204 that is sized to receive medial fixation structure 200 F and lateral bore 206 that is sized to receive lateral fixation structure 202 F, as shown in FIG. 23 . It is within the scope of the present invention that fixation structures 200 F, 202 F, may be labeled to ensure that medial fixation structure 200 F is inserted into body 32 medially of lateral fixation structure 202 F. Also, each fixation structure 200 F, 202 F, may be sized or shaped to fit into only its corresponding bore 204 , 206 , to ensure that medial fixation structure 200 F is inserted into body 32 medially of lateral fixation structure 202 F. Walls 214 , 216 , that define bores 204 , 206 , respectively, may include various features to cooperate with fixation structures 200 F, 202 F. For example, walls 214 , 216 , may define a polygonal, or non-circular, bore 204 , 206 , such as the octagonal bores 204 , 206 , shown in FIG. 23 . As another example, walls 214 , 216 , may include internal threads 210 and/or shoulder 248 , as shown in FIG. 32 . Proximal tibial implant 30 F also includes cross bores 208 , 209 , which are described further below.

Medial fixation structure 200 F is illustrated in FIG. 28 and includes washer 50 F and fastener 52 F. Washer 50 F is an essentially L-shaped structure that includes body portion 226 F and tissue engagement arm 228 F that extends substantially perpendicular to body portion 226 F. As shown in FIG. 27 , tissue engagement arm 228 F of washer 50 F is slightly arcuate to match the contour of body 32 . Body portion 226 F of washer 50 F defines bore 240 F that is configured to receive fastener 52 F. Fastener 52 F may include any suitable fastening mechanism, including an anchor or a mechanism that expands once inserted into body 32 of proximal tibial implant 30 F. For example, fastener 52 F may be a screw or bolt having external thread 244 F and head 246 F, as shown in FIG. 28 .

A plurality of teeth 54 F extends from washer 50 F, and specifically from tissue engagement arm 228 F of washer 50 F. Teeth 54 F may be arranged in various patterns. For example, teeth 54 F may be aligned in columns and rows, teeth 54 F may be aligned diagonally, or teeth 54 F may be distributed randomly across the surface of washer 50 F. Adjacent teeth 54 F may be separated by approximately 1 mm, 2 mm, 3 mm, or more, for example. According to an exemplary embodiment of the present disclosure, and as shown in FIG. 27 , each tooth 54 F includes at least one face, referred to herein as blocking face 232 F, that extends substantially normal to engagement arm 228 F of washer 50 F and/or body 32 of proximal tibial implant 30 F, as discussed in more detail below. Blocking faces 232 F of teeth 50 F may all face the same direction, as shown in FIG. 27 , or blocking faces 232 F of teeth 50 F may face different directions.

Lateral fixation structure 202 F includes washer 50 F′ and fastener 52 F′. Washer 50 F′ may be substantially identical to washer 50 F described above with respect to FIGS. 27-28 , or washer 50 F′ may be a mirror image of washer 50 F, for example. Also, fastener 52 F′ may be substantially identical to fastener 52 F described above with respect to FIG. 28 .

In operation, a surgeon may attach a tissue structure to proximal tibial implant 30 F. Prior to permanently attaching the tissue structure to proximal tibial implant 30 F, the surgeon may gather and temporarily attach the tissue structure to proximal tibial implant 30 F. In one embodiment, the surgeon first gathers or collects the desired tissue structure. Then, the surgeon positions at least one suture or other surgical fastener through aperture 76 and its associated throughbore to temporarily hold the tissue structure in place. Because the attachment through aperture 76 may be only temporary, aperture 76 need not be surrounded by porous surface 45 .

Next, the surgeon positions the tissue structure in contact with attachment plate 44 F and clamps the tissue structure against attachment plate 44 F using fixation structures 200 F, 202 F. An exemplary method of clamping the tissue structure with fixation structures 200 F, 202 F, is set forth in the following paragraphs.

First, the surgeon selects desired fixation structures 200 F, 202 F, from a set provided. The set may include, for example, washers 50 F, 50 F′, of various sizes and washers 50 F, 50 F′, having various arrangements of teeth 54 F, 54 F′. According to an exemplary embodiment of the present disclosure, body portions 226 F, 226 F′, of washers 50 F, 50 F′, and/or fasteners 52 F, 52 F′, may be provided in various lengths to alter the final distance between engagement arms 228 F, 228 F′, of washers 50 F, 50 F′, and body 32 of proximal tibial implant 30 F. This distance may impact the clamping force applied by washers 50 F, 50 F′, to the tissue structure and the space available for the tissue structure. Therefore, depending on the desired clamping force, the amount of tissue to be attached, and other considerations, the distance between engagement arms 228 F, 228 F′, of washers 50 F, 50 F′, and body 32 of proximal tibial implant 30 F may vary. For example, the distance between engagement arms 228 F, 228 F′, of washers 50 F, 50 F′, and body 32 of proximal tibial implant 30 F may vary between approximately 1 mm, 2 mm, 3 mm, 4 mm, 5 mm, or more.

Next, the surgeon aligns the selected washers 50 F, 50 F′, relative to body 32 and inserts washers 50 F, 50 F′, into bores 204 , 206 , of proximal tibial implant 30 F. The surgeon may rotate each washer 50 F, 50 F′, at various angles relative to body 32 , as shown in FIG. 26 . According to an exemplary embodiment of the present disclosure, the surgeon may align washers 50 F, 50 F′, to substantially cover the tissue structure with engagement arms 228 F, 228 F′, of washers 50 F, 50 F′. In other words, the surgeon may align washers 50 F, 50 F′, to maximize contact between engagement arms 228 F, 228 F′, of washers 50 F, 50 F′, and the tissue structure. For example, as shown in FIG. 26 , medial washer 50 F may be angled relative to body 32 to cross over a medial gastrocnemius flap that is wrapped across proximal tibial implant 30 F. According to another exemplary embodiment of the present disclosure, the surgeon may rotate washers 50 F, 50 F′, to resist movement or retraction of the tissue structure with teeth 54 F, 54 F′, and specifically blocking faces 232 F, 232 F′, of teeth 54 F, 54 F′. In the illustrated embodiment, each washer 50 F, 50 F′, may be rotated to eight different positions due to the octagonal shape of bores 204 , 206 , and the corresponding octagonal shape of body portion 226 F, 226 F′, of washers 50 F, 50 F′. The number of available positions may be increased or decreased by varying the shape of bores 204 , 206 , and washers 50 F, 50 F′.

After aligning washers 50 F, 50 F′, with proximal tibial implant 30 F, the surgeon secures washers 50 F, 50 F′, to proximal tibial implant 30 F using fasteners 52 F, 52 F′, and set screws 250 F, 250 F′. Referring to the illustrated embodiment of FIG. 32 , fasteners 52 F, 52 F′, are first inserted through bores 240 F, 240 F′, of washers 50 F, 50 F′, and posteriorly into bores 204 , 206 , in body 32 of proximal tibial implant 30 F. Eventually, external threads 244 F, 244 F′ of fasteners 52 F, 52 F′, engage internal threads 210 of bores 204 , 206 . In this arrangement, heads 246 F, 246 F′, of fasteners 52 F, 52 F′, prevent washers 50 F, 50 F′, from withdrawing from bores 204 , 206 , and shoulders 248 of walls 214 , 216 , prevent washers 50 F, 50 F′, from retracting into bores 204 , 206 . Therefore, each washer 50 F, 50 F′, is able to maintain a fixed axial spacing from body 32 . Also, the keyed engagement between octagonal body portions 226 F, 226 F′, of washers 50 F, 50 F′, and octagonal walls 214 , 216 , prevent washers 50 F, 50 F′, from spinning freely in bores 204 , 206 . Fasteners 52 F, 52 F′, may be secured in bores 204 , 206 , at a desired depth by inserting set screws 250 F, 250 F′, medially and laterally into cross bores 208 , 209 , in body 32 of proximal tibial implant 30 F to contact the posteriorly extending fasteners 52 F, 52 F′. Optionally, set screws 250 F, 250 F′, may include snap rings 224 F, 224 F′, as shown in FIG. 32 , to enhance the connection between set screws 250 F, 250 F′, and body 32 of proximal tibial implant 30 F.

According to an exemplary embodiment of the present disclosure, the tissue structure should be held tightly in contact with the anterior attachment plate 44 F of proximal tibial implant 30 F beneath washers 50 F, 50 F′. More particularly, the tissue structure should be held tightly in contact with the anterior attachment plate 44 F of proximal tibial implant 30 F beneath engagement arms 228 F, 228 F′, of washers 50 F, 50 F′. Thus, the bottom surfaces of engagement arms 228 F, 228 F′, of washers 50 F, 50 F′, act as clamping surfaces. According to another exemplary embodiment of the present disclosure, washers 50 F, 50 F′, should permit adequate circulation and fluid flow through the tissue structure. Thus, teeth 54 F, 54 F′, on washers 50 F, 50 F′, may be oriented to resist movement of the tissue structure, but adjacent teeth 54 F, 54 F′, may be separated to permit blood and fluid to flow between adjacent teeth 54 F, 54 F′. For example, adjacent teeth 54 F, 54 F′, may be separated by approximately 1 mm, 2 mm, 3 mm, or more. Also, as shown in FIG. 31 , washers 50 F, 50 F′, themselves are separated on the anterior surface of proximal tibial implant 30 F to permit blood and fluid to flow between washers 50 F, 50 F′. Optionally, if washers 50 F, 50 F′, provide too much or too little clamping pressure against the tissue structure, fixation structures 200 F, 202 F, may be removed and replaced with fixation structures 200 F, 202 F, of a different size. For example, if washers 50 F, 50 F′, provide too much clamping pressure against the tissue structure, fixation structures 200 F, 202 F, may be removed and replaced with fixation structures 200 F, 202 F, having longer body portions 226 F, 226 F′, and/or longer fasteners 52 F, 52 F′. Washers 50 F, 50 F′, provide a mechanical fixation between the tissue structure and proximal tibial implant 30 F. Over time, the tissue structure may grow into attachment plate 44 F. Thus, the tissue structure may be both biologically and mechanically affixed to proximal tibial implant 30 F.

In certain situations, the surgeon may replace the two individual washers 50 F, 50 F′, of FIG. 26 with the single bar 260 F shown in FIGS. 29-30 . Bar 260 F spans medially-laterally across anterior attachment plate 44 F from bore 204 to bore 206 . Bar 260 F may be secured to body 32 using the same fasteners 52 F, 52 F′, that are used to secure washers 50 F, 50 F′, to body 32 . Like washers 50 F, 50 F′, bar 260 F includes a plurality of teeth 262 F that are configured to engage and clamp the tissue structure against anterior attachment plate 44 F. Bar 260 F may have a straight configuration or a bowed configuration, as shown in FIG. 30 .

Also, the surgeon may secure the tissue structure to the porous attachment plate 44 F by threading sutures through any or all apertures 46 , 46 a , and the corresponding throughbores 48 , 48 a . In one embodiment, the sutures may be biodegradable after a period of time in which the tissue structure is permanently attached to proximal tibial implant 30 F via ingrowth of the tissue structure into attachment plate 44 F.

Referring next to FIGS. 13-17 , proximal femoral implant 80 is shown and may be used to restore mechanical and biological fixation of tissue associated with a hip joint of a patient to enhance the stability of the hip joint, to restore hip joint function, and to enhance hip joint kinematics. Proximal femoral implant 80 may typically be used in a patient requiring complete metaphyseal removal of the proximal femur.

Proximal femoral implant 80 includes body 82 having proximal end 92 and distal end 90 . Body 32 also includes an anterior surface, a posterior surface opposite the anterior surface, a lateral surface, and a medial surface opposite the lateral surface. As shown in FIG. 16 , proximal femoral implant 80 defines a generally slender profile with no protruding edges or structures in the anterior or posterior directions. The slender profile also tapers proximally toward proximal end 92 from distal end 90 which facilitates soft tissue closure after a procedure is completed and prevention of potential damage to subcutaneous tissue. Also, proximal femoral implant 80 may include a modular or integral neck 84 configured to mate with a corresponding femoral head component (not shown) of a prosthetic hip joint. In turn, the femoral head component may articulate against a natural or a prosthetic acetabulum (not shown).

Proximal femoral implant 80 further includes anteversion adjustment tabs 88 at distal end 90 to allow for in vivo rotational adjustment of proximal femoral implant 80 relative to a prosthetic femoral stem component or the natural femur. Anteversion adjustment tabs 88 may generally extend distally from body 82 along a lateral and/or a medial side of proximal femoral implant 80 . A plurality of tabs 88 may be utilized or a single tab 88 may be utilized.

The medial side of proximal femoral implant 80 includes medial protrusion 86 that projects medially from body 82 . More particularly, medial protrusion 86 projects radially from the substantially cylindrical body 82 . According to an exemplary embodiment of the present invention, medial protrusion 86 projects approximately 6 mm, 8 mm, 10 mm, 12 mm, 14 mm, 16 mm, or more, from the substantially cylindrical body 82 . Medial protrusion 86 includes porous surface 96 , which may be an inlay of porous material substantially identical to porous surface 45 described above. Porous surface 96 may be formed integrally with medial protrusion 86 or, alternatively, porous surface 96 may be formed on a plate which is attached to medial protrusion 86 . Medial protrusion 86 also includes a plurality of apertures 98 having corresponding throughbores 99 ( FIG. 16 ) that extend anteriorly-posteriorly through medial protrusion 86 . Medial protrusion 86 serves to replicate the lesser trochanter of the natural proximal femur. Therefore, like the natural lesser trochanter, medial protrusion 86 , and the corresponding throughbores of apertures 98 extending therethrough, may provide a secure attachment to tissue structures located medially of proximal femoral implant 80 , including the iliopsoas muscles. Also, as shown in FIG. 17 , medial protrusion 86 buttresses neck 84 , which may provide additional support to proximal femoral implant 80 when implanted into a hip joint.

The lateral side of proximal femoral implant 80 includes lateral ingrowth pads 102 , 104 , attached to body 82 via fasteners 103 , 105 , respectively. Although each lateral ingrowth pad 102 , 104 , is shown with only a single fastener 103 , 105 , respectively, each lateral ingrowth pad 102 , 104 , may be configured to receive multiple fasteners. The use of multiple fasteners prevents lateral ingrowth pads 102 , 104 , from rotating and/or spinning freely relative to body 82 .

Each lateral ingrowth pad 102 , 104 , may include porous surface 109 , 107 , respectively. Porous surface 109 , 107 , may be substantially identical to porous surface 45 described above. Lateral ingrowth pads 102 , 104 , may be constructed entirely of a porous material. For example, lateral ingrowth pad 102 is illustrated in FIGS. 13-15 as being constructed entirely of a porous material, such that porous surface 109 substantially covers lateral ingrowth pad 102 . Alternatively, lateral ingrowth pads 102 , 104 , may include a porous material bonded to or coated onto a solid metal substrate. For example, lateral ingrowth pad 104 is illustrated in FIGS. 13-15 as being constructed of porous material bonded to a solid metal substrate, such that porous surface 107 is positioned adjacent to porous surface 106 of body 82 . Also, lateral ingrowth pads 102 , 104 , may be slightly angled to follow the path of body 82 . For example, as shown in FIG. 15 , the proximal end of lateral ingrowth pad 102 is more medially positioned than the distal end of lateral ingrowth pad 102 . The angle of lateral ingrowth pad 102 , in particular, facilitates prevention of potential irritation of subcutaneous tissue surrounding the proximal lateral portion of proximal femoral implant 80 after implantation.

The lateral side of proximal femoral implant 80 further includes lateral porous surface 106 positioned beneath lateral ingrowth pads 102 , 104 . Like medial porous surface 96 , lateral porous surface 106 may be substantially identical to porous surface 45 described above. For example, like porous surface 45 , lateral porous surface 106 may be impregnated with and/or coated with biologically active agents. Porous surface 106 may substantially wrap around the proximal lateral end of body 82 from an anterior to a posterior side of body 82 to provide optimal attachment surfaces for tissue structures, as described below. Although porous surface 106 is illustrated as a continuous surface that extends along the lateral side of body 82 from proximal end 92 toward distal end 90 , it is within the scope of the present disclosure that porous surface 106 may include multiple, distinct porous segments on the lateral side of body 82 .

As shown in FIGS. 15-17 , the lateral side of body 82 further includes a plurality of lateral apertures 108 having corresponding throughbores that extend through body 82 from an anterior side to a posterior side. Also, lateral protrusion 94 extends laterally from body 82 and includes aperture 100 having a corresponding throughbore 101 .

In operation, a surgeon may attach tissue structures to proximal femoral implant 80 . The tissue structures may include soft tissue structures, such as muscles, ligaments, capsules, and tendons. The tissue structures may also include bone, including bone that retains a natural connection to muscles, ligaments, capsules, or tendons. Prior to permanently attaching the tissue structures to proximal femoral implant 80 , the surgeon may gather and temporarily attach the tissue structures to proximal femoral implant 80 . In one embodiment, the surgeon first gathers or collects the desired tissue structures. Then, the surgeon positions at least one suture or other surgical fastener through aperture 100 and the corresponding throughbore 101 ( FIG. 17 ) in lateral protrusion 94 to temporarily hold the tissue structures in place. Because the attachment through throughbore 101 may be only temporary, lateral protrusion 94 of proximal femoral implant 80 need not include a porous surface.

To attach a tissue structure to the medial side of proximal femoral implant 80 , a surgeon positions the tissue structure in contact with porous surface 96 on medial protrusion 86 . At least one suture or other surgical fastener, such as surgical tape or surgical cable, is then threaded through one or both apertures 98 and through corresponding throughbores 99 to secure the tissue structure to proximal femoral implant 80 and to maintain contact between the tissue structure and porous surface 96 . In one embodiment, the sutures may be biodegradable after a period of time in which the tissue structure is permanently attached to proximal femoral implant 80 via ingrowth of the tissue structure into porous surface 96 . The close proximity of apertures 98 to porous surface 96 facilitates more direct contact between the tissue structure and porous surface 96 , thereby enhancing ingrowth of the tissue structure into porous surface 96 . In an exemplary embodiment, the tissue structure is an iliopsoas muscle which, when attached to proximal femoral implant 80 , enhances stability of the hip joint. In this embodiment, medial apertures 98 provide locations from which tissue structures are pulled into contact with the medial side of proximal femoral implant 80 , similar to the natural lesser trochanter.

To attach a tissue structure to the lateral side of proximal femoral implant 80 , the surgeon positions the tissue structure in contact with porous surface 106 . At least one suture or other surgical fastener is then threaded through at least one aperture 108 and the corresponding throughbore proximate to porous surface 106 to secure the tissue structure to proximal femoral implant 80 and to maintain contact between the tissue structure and porous surface 106 . In one embodiment, the sutures may be biodegradable after a period of time in which the tissue structure is permanently attached to proximal femoral implant 80 via ingrowth of the tissue structure into porous surface 106 . The close proximity of apertures 108 to porous surface 106 facilitates more direct contact between the tissue structure and porous surface 106 . In an exemplary embodiment, the tissue structure is an abductor muscle, including at least one of the gluteus maximus, the gluteus medius, the gluteus minimus, and the tensor fascia lata, and/or a quadriceps muscle which, when attached to proximal femoral implant 80 , enhances the kinematics of the hip joint. In this embodiment, lateral apertures 108 provide locations from which tissue structures are pulled into contact with the lateral side of proximal femoral implant 80 and facilitate providing a sling around proximal femoral implant 80 to maximize hip joint function and kinematics.

To further attach a tissue structure to the lateral side of proximal femoral implant 80 , the surgeon may tighten lateral ingrowth pads 102 , 104 , against body 82 of proximal femoral implant 80 . In an exemplary procedure, a surgeon pulls or otherwise manipulates a tissue structure in close proximity to porous surface 106 and then tightens fasteners 103 , 105 , into body 82 to clamp lateral ingrowth pads 102 , 104 , against the tissue structure. Using this exemplary procedure, the tissue structure may become mechanically fixed to proximal femoral implant 80 . Also, over time, the tissue structure may grow into porous surface 109 of lateral ingrowth pad 102 , porous surface 107 of lateral ingrowth pad 104 , and/or porous surface 106 of body 82 .

Although not illustrated in FIGS. 13-17 , proximal femoral implant 80 may also use at least one rotatable fixation structure similar to washers 50 , 50 ′, described above with respect to FIGS. 6-8 , to mechanically fix a tissue structure to proximal femoral implant 80 and to facilitate grasping and pulling a tissue structure into contact with proximal femoral implant 80 .

Referring now to FIG. 22 , another embodiment proximal femoral implant 80 A is shown and may be substantially identical to proximal femoral implant 80 , described above with reference to FIGS. 13-17 , except as described below. Proximal femoral implant 80 A includes body 82 , neck 84 , adjustment tabs (not shown), medial protrusion 86 , lateral protrusion 94 , distal end 90 , and proximal end 92 . The medial side of proximal femoral implant 80 A includes porous surface 96 and a plurality of apertures 98 defining corresponding throughbores in body 82 . The lateral side of proximal femoral implant 80 A includes lateral ingrowth pads 102 A, 104 A, and a plurality of lateral apertures 108 defining corresponding throughbores in body 82 . Lateral ingrowth pads 102 A, 104 A, may be substantially identical to lateral ingrowth pads 102 , 104 , described above with reference to FIGS. 13-17 , except as described below.

As shown in FIG. 22 , lateral ingrowth pads 102 A, 104 A, are constructed entirely of a porous material, such that porous surfaces 109 , 107 , substantially cover lateral ingrowth pads 102 A, 104 A, respectively. Lateral ingrowth pads 102 A, 104 A, may be modular components that are attached to body 82 via one or more fasteners (not shown) inserted through lateral ingrowth pads 102 A, 104 A, and into body 82 . The fastener may include a screw, bolt, anchor mechanism, a mechanism which expands once inserted into body 82 , or any other suitable fastening mechanism. Lateral ingrowth pads 102 A, 104 A, may be inset into body 82 , such as received within a recess of body 82 . When lateral ingrowth pads 102 A, 104 A, are attached to body 82 , porous surfaces 109 , 107 , of lateral ingrowth pads 102 A, 104 A, may be substantially flush with the remainder of the proximal femoral implant 80 A.

In operation, a surgeon may attach tissue structures to proximal femoral implant 80 A. To attach a tissue structure to the medial side of proximal femoral implant 80 A, the surgeon may follow the same process described above with respect to proximal femoral implant 80 of FIGS. 13-17 . For example, the surgeon may place the tissue structure in contact with porous surface 96 on medial protrusion 86 of proximal femoral implant 80 A and secure the tissue structure in place by threading sutures through apertures 98 and the corresponding throughbores. To attach a tissue structure to the lateral side of proximal femoral implant 80 A, the surgeon positions the tissue structure in contact with one or more of porous surfaces 109 , 107 . In one embodiment, the attachment to porous surfaces 109 , 107 , may be maintained by threading at least one suture or other surgical fastener through at least one aperture 108 and its associated throughbore. In another embodiment, the attachment to porous surfaces 109 , 107 , may be maintained by placing the tissue structure between lateral ingrowth pads 102 A, 104 A, and body 82 . Tightening lateral ingrowth pads 102 A, 104 A, against body 82 of proximal femoral implant 80 A clamps and holds the tissue structure between lateral ingrowth pads 102 A, 104 A, and body 82 . As shown in FIG. 22 , lateral ingrowth pads 102 A, 104 A, may be constructed of a material that allows tissue and blood vessels to grow through the plate. In another embodiment, a tissue structure may be held against lateral ingrowth pads 102 A, 104 A, using sutures or a muscle, for example.

Referring now to FIGS. 35-43 , yet another embodiment proximal femoral implant 80 B is shown and may be substantially identical to proximal femoral implant 80 , described above with reference to FIGS. 13-17 , or proximal femoral implant 80 A, described above with reference to FIG. 22 , except as described below. Proximal femoral implant 80 B includes body 82 , adjustment tabs 88 , medial protrusion 86 , lateral protrusion 94 , distal end 90 , and proximal end 92 . Body 82 receives modular neck 84 B that is configured to mate with a corresponding femoral head component (not shown) of a prosthetic hip joint. The medial side of proximal femoral implant 80 B includes porous surface 96 and a plurality of apertures 98 defining throughbores in body 82 . The lateral side of proximal femoral implant 80 B includes porous surfaces 106 , 106 ′, and a plurality of lateral apertures 108 defining throughbores in body 82 .

Additionally, proximal femoral implant 80 B includes proximal fixation structure 300 and distal fixation structure 302 . Proximal femoral implant 80 B includes proximal bore 304 that is sized to receive proximal fixation structure 300 and distal bore 306 that is sized to receive distal fixation structure 302 . Walls 314 , 316 , that define bores 304 , 306 , respectively, may include various features to cooperate with fixation structures 300 , 302 , respectively. For example, walls 314 , 316 , may define a polygonal, or non-circular, bore 304 , 306 , such as the octagonal bores 304 , 306 , shown in FIG. 35 . As another example, walls 314 , 316 , may include internal threads 310 , annular indentation 312 , and/or shoulder 348 , as shown in FIG. 43 .

Proximal fixation structure 300 is illustrated in FIGS. 38-40 and includes washer 320 , fastener 322 , and snap ring 324 . Washer 320 is an essentially L-shaped structure that includes body portion 326 and tissue engagement arm 328 that extends substantially perpendicular to body portion 326 . A plurality of teeth 330 extend from washer 320 , and specifically from tissue engagement arm 328 of washer 320 . Teeth 330 may be arranged in various patterns. For example, teeth 330 may be aligned in columns and rows, teeth 330 may be aligned diagonally, or teeth 330 may be distributed randomly across the surface of washer 320 . Adjacent teeth 330 may be separated by approximately 1 mm, 2 mm, 3 mm, or more, for example. According to an exemplary embodiment of the present disclosure, each tooth 330 includes at least one face, referred to herein as blocking face 332 , that extends substantially normal to engagement arm 328 of washer 320 and/or body 82 of proximal femoral implant 80 B, as discussed in more detail below. Blocking faces 332 of teeth 330 may face the same or different directions. Washer 320 includes bore 340 configured to receive fastener 322 . Fastener 322 may include any suitable fastening mechanism, including an anchor or a mechanism that expands once inserted into body 82 of proximal femoral implant 80 B. For example, fastener 322 may be a screw or bolt having external thread 344 and head 346 , as shown in FIG. 40 .

Distal fixation structure 302 is illustrated in FIGS. 41-42 and may be substantially identical to proximal fixation structure 300 , described above with reference to FIGS. 38-40 , except as described below. Distal fixation structure 302 includes washer 320 ′, fastener 322 ′, and snap ring 324 ′. Washer 320 ′ is an essentially T-shaped structure that includes body portion 326 ′ and tissue engagement arms 328 ′ that extend substantially perpendicular to body portion 326 and in opposite directions from one another. A plurality of teeth 330 ′ extend from washer 320 ′, and specifically from tissue engagement arms 328 ′ of washer 320 ′. In the illustrated embodiment of FIG. 37 , blocking faces 332 ′ of teeth 330 ′ on the top tissue engagement arm 328 ′ and blocking faces 332 ′ of teeth 330 ′ on the bottom tissue engagement arm 328 ′ face in opposite directions, but it is within the scope of the present invention that blocking faces 332 ′ of teeth 330 ′ may face in substantially the same direction.

In operation, a surgeon may attach tissue structures to proximal femoral implant 80 B. To attach a tissue structure to the medial side of proximal femoral implant 80 B, the surgeon may follow the same processes described above with respect to proximal femoral implant 80 of FIGS. 13-17 and proximal femoral implant 80 A of FIG. 22 . For example, the surgeon may place the tissue structure in contact with porous surface 96 on medial protrusion 86 of proximal femoral implant 80 B and secure the tissue structure in place by threading sutures through apertures 98 and the corresponding throughbores. To attach a tissue structure to the lateral side of proximal femoral implant 80 B, the surgeon first positions the tissue structure in contact with one or more of porous surfaces 106 , 106 ′. Next, the surgeon may clamp the tissue structure against porous surfaces 106 , 106 ′, using fixation structures 300 , 302 . An exemplary method of clamping the tissue structure with fixation structures 300 , 302 , is set forth in the following paragraphs.

First, the surgeon selects desired fixation structures 300 , 302 , from a set provided. The set may include, for example, washers 320 , 320 ′, of various sizes and washers 320 , 320 ′, having various arrangements and sizes of teeth 330 , 330 ′. According to an exemplary embodiment of the present disclosure, body portions 326 , 326 ′, of washers 320 , 320 ′, and/or fasteners 322 , 322 ′, may be provided in various lengths to alter the final distance between engagement arms 328 , 328 ′, of washers 320 , 320 ′, and body 82 of proximal femoral implant 80 B. This distance may impact the clamping force applied by washers 320 , 320 ′, to the tissue structure and the space available for the tissue structure. Therefore, depending on the desired clamping force, the amount of tissue to be attached, and other considerations, the distance between engagement arms 328 , 328 ′, of washers 320 , 320 ′, and body 82 of proximal femoral implant 80 B may vary. For example, the distance between engagement arms 328 , 328 ′, of washers 320 , 320 ′, and body 82 of proximal femoral implant 80 B may vary between approximately 1 mm, 2 mm, 3 mm, 4 mm, 5 mm, 6 mm, 7 mm, 8 mm, or more. As shown in FIG. 43 , the surgeon may select washer 320 ′ having engagement arm 328 ′ that is separated from body 82 by distance D 1 . If more space is desired between engagement arm 328 ′ and body 82 , the surgeon may select washer 320 ′ having engagement arm 328 ′ that is separated from body 82 by distance D 2 which is greater than distance D 1 , as shown in FIG. 43A . As the distance between engagement arms 328 , 328 ′, of washers 320 , 320 ′, and body 82 increases, teeth 330 , 330 ′, may also increase in length. For example, teeth 330 , 330 ′, may be available in lengths of approximately 1 mm, 2 mm, 3 mm, 4 mm, 5 mm, 6 mm, 7 mm, 8 mm, or more.

Next, the surgeon aligns the selected washers 320 , 320 ′, relative to body 82 and inserts washers 320 , 320 ′, into bores 304 , 306 , of proximal femoral implant 80 B. The surgeon may rotate washers 320 , 320 ′, at an angle relative to body 82 , as shown in FIG. 36A , especially if a significant amount of tissue remains. Alternatively, the surgeon may align washers 320 , 320 ′, in a straight configuration proximally-distally relative to body 82 , as shown in FIG. 36 . According to an exemplary embodiment of the present disclosure, the surgeon may align washers 320 , 320 ′, to substantially cover the tissue structure with engagement arms 328 , 328 ′, of washers 320 , 320 ′. In other words, the surgeon may align washers 320 , 320 ′, to maximize contact between engagement arms 328 , 328 ′, of washers 320 , 320 ′, and the tissue structure. For example, as shown in FIG. 36A , washers 320 , 320 ′, may be rotated side to side to follow the path of the tissue structure. According to another exemplary embodiment of the present disclosure, the surgeon may rotate washers 320 , 320 ′, to resist movement or retraction of the tissue structure with teeth 330 , 330 ′, and specifically blocking faces 332 , 332 ′, of teeth 330 , 330 ′. Referring to FIG. 37 , blocking faces 332 of teeth 330 on proximal fixation structure 300 are aligned to resist proximal movement of a tissue structure away from proximal femoral implant 80 B, while blocking faces 332 ′ of teeth 330 ′ on distal fixation structure 302 are aligned to resist both proximal and distal movement of a tissue structure away from proximal femoral implant 80 B. According to an exemplary embodiment of the present invention, blocking faces 332 of teeth 330 on proximal fixation structure 300 are aligned to resist proximal movement the gluteus medius and the gluteus minimus muscles, while blocking faces 332 ′ of teeth 330 ′ on distal fixation structure 302 are aligned to resist proximal movement of the gluteus maximus muscle and distal movement of a quadriceps muscle. In the illustrated embodiment of FIG. 36 , each washer 320 , 320 ′, may be rotated to eight different positions due to the octagonal shape of bores 304 , 306 , and the corresponding octagonal shape of body portion 326 , 326 ′, of washers 320 , 320 ′. The number of available positions may be increased or decreased by varying the shape of bores 304 , 306 , and washers 320 , 320 ′.

After aligning washers 320 , 320 ′, with proximal femoral implant 80 B, the surgeon secures washers 320 , 320 ′, to proximal femoral implant 80 B using fasteners 322 , 322 ′, and optionally snap rings 324 , 324 ′. Referring to the illustrated embodiment of FIG. 43 , fastener 322 ′ and snap ring 324 ′ attached thereto are first inserted through bore 340 of washer 320 ′ and into bore 306 in body 82 of proximal femoral implant 80 B. Eventually, external thread 344 ′ of fastener 322 ′ engages internal thread 310 of bore 306 , and snap ring 324 ′ expands into annular indentation 312 . In this arrangement, head 346 ′ of fastener 322 ′ prevents washer 320 ′ from withdrawing from bore 306 and shoulder 348 of wall 316 prevents washer 320 ′ from retracting into bore 306 . Therefore, washer 320 ′ is able to maintain a fixed axial spacing from body 82 . Also, the keyed engagement between octagonal body portion 326 ′ of washer 320 ′ and octagonal wall 316 prevents washer 320 ′ from spinning freely in bore 306 .

Other suitable mechanisms for maintaining the desired alignment of fixation structures 300 C, 302 C, relative to body 82 are illustrated in FIGS. 44-47 with respect to another proximal femoral implant 80 C. Like the keyed mechanism described above with respect to washers 320 , 320 ′, of FIGS. 35-37 , the mechanisms of FIGS. 44-47 may prevent washers 320 C, 320 C′, from spinning freely relative to body 82 once the desired alignment of washers 320 C, 320 C′, is selected. For example, the mechanisms of FIGS. 44-47 may be used to secure washers 320 C, 320 C′, in a straight configuration proximally-distally relative to body 82 or in an angled configuration relative to body 82 . As shown in FIG. 44 , body 82 may include any number of protrusions 360 configured to abut washer 320 C and/or washer 320 C′. As shown in FIG. 45 , washers 320 C, 320 C′, may be secured together in a desired alignment to form a unitary structure. For example, washer 320 C could be secured at an angle relative to washer 320 C′, or washers 320 C, 320 C′, may be attached together in parallel. As shown in FIG. 46 , washers 320 C, 320 C′, may include protrusions 362 , 362 ′, configured to be received within corresponding grooves 364 , 364 ′, of body 82 . As shown in FIG. 47 , each washer 320 C, 320 C′, may include more than one fastener, including fastener 322 , 322 ′, described above and an additional fastener 322 C, 322 C′, both configured to engage body 82 .

According to an exemplary embodiment of the present disclosure, the tissue structure should be held tightly in contact with porous surfaces 106 , 106 ′, of proximal femoral implant 80 B, beneath washers 320 , 320 ′. More particularly, the tissue structure should be held tightly in contact with porous surfaces 106 , 106 ′, of proximal femoral implant 80 B, beneath engagement arms 328 , 328 ′, of washers 320 , 320 ′. Thus, the bottom surfaces of engagement arms 328 , 328 ′, of washers 320 , 320 ′, act as clamping surfaces. According to another exemplary embodiment of the present disclosure, washers 320 , 320 ′, should permit adequate circulation and fluid flow through the tissue structure. For example, teeth 330 , 330 ′, on washers 320 , 320 ′, may be oriented to resist movement of the tissue structure, but adjacent teeth 330 , 330 ′, may be separated to permit blood and fluid to flow between adjacent teeth 330 , 330 ′. Optionally, if washers 320 , 320 ′, provide too much or too little clamping pressure against the tissue structure, fixation structures 300 , 302 , may be removed and replaced with fixation structures 300 , 302 , of a different size. For example, if washers 320 , 320 ′, provide too much clamping pressure against the tissue structure, fixation structures 300 , 302 , may be removed and replaced with fixation structures 300 , 302 , having longer body portions 326 , 326 ′, and/or longer fasteners 322 , 322 ′. Also, the attachment between the tissue structures and porous surfaces 106 , 106 ′, may be enhanced with sutures threaded through at least one aperture 108 and its associated throughbore.

Referring next to FIGS. 48-50 , yet another embodiment proximal femoral implant 80 D is shown and may be substantially identical to proximal femoral implant 80 , described above with reference to FIGS. 13-17 , proximal femoral implant 80 A, described above with reference to FIG. 22 , proximal femoral implant 80 B, described above with reference to FIGS. 35-43 , or proximal femoral implant 80 C, described above with reference to FIGS. 44-47 , except as described below. Proximal femoral implant 80 D includes body 82 , neck 84 , adjustment tabs 88 , medial protrusion 86 , lateral protrusion 94 , distal end 90 , and proximal end 92 . The medial side of proximal femoral implant 80 D includes porous surface 96 and a plurality of apertures 98 defining throughbores in body 82 . The lateral side of proximal femoral implant 80 D includes porous surfaces 106 , 106 ′, and a plurality of lateral apertures 108 defining throughbores in body 82 . Porous surfaces 96 , 106 , 106 ′, may include porous material that is substantially identical to porous surface 45 described above. As shown in FIG. 48 , porous surfaces 96 , 106 , 106 ′, are inlayed and attached to body 82 , such as via diffusion bonding. Body 82 of proximal femoral implant 80 D also includes cross apertures 112 , 114 , which are described further below.

Referring still to FIGS. 48-50 , proximal femoral implant 80 D further includes proximal fixation structure 300 D and distal fixation structure 302 D. Fixation structures 300 D, 302 D, may be substantially identical to fixation structures 300 , 302 , described above with reference to FIGS. 35-43 , and fixation structures 300 C, 302 C, described above with reference to FIGS. 35-37 , except as described below. Proximal fixation structure 300 D includes washer 320 D, fastener 322 D, and set screw 350 D, and distal fixation structure 302 D includes washer 320 D′, fastener 322 D′, and set screw 350 D′.

Both washers 320 D, 320 D′, are essentially T-shaped structures. Unlike proximal washer 320 of FIGS. 38-40 , proximal washer 320 D of FIGS. 48-49 widens at its proximal end. More particularly, tissue engagement arm 328 D of proximal washer 320 D widens near proximal end 92 of proximal femoral implant 80 D. In this embodiment, proximal washer 320 D may be configured to wrap around proximal end 92 of proximal femoral implant 80 D, proximally, anteriorly, and/or posteriorly, for improved tissue attachment. Like washers 320 , 320 ′ of FIGS. 38-40 , washers 320 D, 320 D′ of FIGS. 48-49 may be configured to rotate relative to body 82 . Alternatively, washers 320 D, 320 D′, may be attached in fixed angular alignment relative to body 82 . Each fastener 322 D, 322 D′, is provided with a sharp tip 370 D, 370 D′.

In operation, as fasteners 322 D, 322 D′, are inserted into body 82 , tips 370 D, 370 D′, may puncture the tissue structure that has been pulled across the lateral side of body 82 . In this embodiment, the surgeon is able to pull the tissue structure to a desired tension and simultaneously insert fasteners 322 D, 322 D′, and washers 320 D, 320 D′. The surgeon avoids having to cut the tissue structure with a blade and then insert fasteners 322 D, 322 D′, and washers 320 D, 320 D′, all while trying to maintain the desired tension of the tissue structure. Also, as shown in FIG. 48 , set screws 350 D, 350 D′, may be inserted anteriorly and/or posteriorly into cross apertures 112 , 114 , of body 82 to contact and secure medially extending fasteners 322 D, 322 D′, in body 82 .

Referring next to FIGS. 51-54 , yet another embodiment proximal femoral implant 80 E is shown and may be substantially identical to proximal femoral implant 80 , described above with reference to FIGS. 13-17 , proximal femoral implant 80 A, described above with reference to FIG. 22 , proximal femoral implant 80 B, described above with reference to FIGS. 35-43 , proximal femoral implant 80 C, described above with reference to FIGS. 44-47 , or proximal femoral implant 80 D, described above with reference to FIGS. 48-50 , except as described below. Proximal femoral implant 80 E includes body 82 , neck 84 , adjustment tabs 88 , medial protrusion 86 , lateral protrusion 94 , distal end 90 , and proximal end 92 . As shown in FIG. 51 , neck 84 includes flats 85 to aid in gripping proximal femoral implant 80 E during implantation. Also, proximal end 92 of body 82 includes recess 89 that is sized to receive an impaction tool during implantation. The medial side of proximal femoral implant 80 E includes porous surface 96 and a plurality of apertures 98 defining throughbores in body 82 . The lateral side of proximal femoral implant 80 E includes porous surfaces 106 , 106 ′, and a plurality of lateral apertures 108 defining throughbores in body 82 . Porous surfaces 96 , 106 , 106 ′, may include porous material that is substantially identical to porous surface 45 described above. As shown in FIG. 51 , porous surfaces 96 , 106 , 106 ′, are inlayed and attached to body 82 , such as via diffusion bonding. Body 82 of proximal femoral implant 80 E also includes cross apertures 112 , 114 , which are described further below.

Referring to FIG. 54 , proximal femoral implant 80 E further includes proximal fixation structure 300 E and a distal fixation structure (not shown), which may be substantially identical to fixation structures 300 , 302 , described above with reference to FIGS. 35-43 , fixation structures 300 C, 302 C, described above with reference to FIGS. 35-37 , or fixation structures 300 D, 302 D, described above with reference to FIGS. 48-50 , except as described below. Proximal fixation structure 300 E includes washer 320 E, fastener 322 E, set screw 350 E, and spike 380 E. As shown in FIG. 54 , both fastener 322 E and spike 380 E have sharp, pointed tips. Specifically, fastener 322 E includes sharp tip 370 E and spike 380 E includes sharp tip 382 E.

As shown by comparing FIGS. 54 and 54A , fastener 322 E may be provided in various lengths to alter the final distance between engagement arms 328 E of washer 320 E and body 82 of proximal femoral implant 80 E. This distance may impact the clamping force applied by washer 320 E to the tissue structure and the space available for the tissue structure. Therefore, depending on the desired clamping force, the amount of tissue to be attached, and other considerations, the distance between engagement arms 328 E of washer 320 E and body 82 of proximal femoral implant 80 B may vary. For example, the distance between engagement arms 328 E of washer 320 E and body 82 of proximal femoral implant 80 B may vary between approximately 1 mm, 2 mm, 3 mm, 4 mm, 5 mm, 6 mm, 7 mm, 8 mm, or more. As shown in FIG. 54 , the surgeon may select washer 320 E having engagement arm 328 E that is separated from body 82 by distance D 1 . If more space is desired between engagement arm 328 E and body 82 , the surgeon may select an alternative washer 320 E′ having engagement arms 328 E′ that are separated from body 82 by distance D 2 which is greater than distance D 1 , as shown in FIG. 54A . As the distance between engagement arms 328 E of washer 320 E and body 82 increases, teeth 330 E may also increase in length. For example, teeth 330 E of FIG. 54 may have a length of approximately 4 mm or 5 mm, while teeth 330 E′ of FIG. 54A may have a length of approximately 7 mm or 8 mm. According to an exemplary embodiment of the present invention, a set of washers may be provided including washer 320 E of FIG. 54 , washer 320 E′ of FIG. 54A , and washers having teeth of other lengths.

Referring to FIGS. 53 and 54 , proximal femoral implant 80 E includes proximal bore 304 that is sized to receive proximal fixation structure 300 E and distal bore 306 that is sized to receive the distal fixation structure (not shown). For example, as shown in FIG. 54 , bore 304 may be sized and shaped to receive both fastener 322 E and spike 380 E of proximal fixation structure 300 E. It is also within the scope of the present invention that proximal femoral implant 80 E may include distinct, spaced apart bores for receiving fastener 322 E and spike 380 E. Walls 314 , 316 , that define bores 304 , 306 , respectively, may include various features to facilitate insertion of the fixation structures. For example, as shown in FIG. 53 , wall 316 that defines distal bore 306 includes chamfered portion 390 . Chamfered portion 390 of wall 316 may define a conically or spherically shaped entry into distal bore 306 to guide insertion of the distal fixation structure (not shown).

In operation, as proximal fixation structure 300 E and the distal fixation structure (not shown), are inserted into body 82 , tip 370 E of fastener 322 E and tip 382 E of spike 380 E may puncture the tissue structure that has been pulled across the lateral side of body 82 . In this embodiment, the surgeon is able to pull the tissue structure to a desired tension and simultaneously insert fastener 322 E and spike 380 E. The surgeon avoids having to cut the tissue structure with a blade and then insert fastener 322 E and spike 380 E, all while trying to maintain the desired tension of the tissue structure. Then, as shown in FIG. 54 , the surgeon inserts set screw 350 E anteriorly and/or posteriorly into cross aperture 112 of body 82 to contact and secure the medially extending fastener 322 E. With both fastener 322 E and spike 380 E located within bore 304 of body 82 , proximal fixation structure 300 E is prevented from spinning relative to body 82 .

Although the methods and apparatuses described in this disclosure describe attachment of natural tissue structures to the orthopaedic implants, the methods and apparatuses may also be used to secure artificial tissue structures to the orthopaedic implants in substantially similar manners.

While this disclosure has been described as having exemplary designs, the present disclosure can be further modified within the spirit and scope of this disclosure. This application is therefore intended to cover any variations, uses, or adaptations of the disclosure using its general principles. Further, this application is intended to cover such departures from the present disclosure as come within known or customary practice in the art to which this disclosure pertains and which fall within the limits of the appended claims.