Method and apparatus for reducing femoral fractures

• US 20030220641A1
• Filed: 05/23/2002
• Published: 11/27/2003
• Est. Priority Date: 03/07/2000
• Status: Active Grant

• Current Assignee: Zimmer Technology Incorporated (Zimmer Biomet Holdings, Inc.)
• Original Assignee: Zimmer Technology Incorporated (Zimmer Biomet Holdings, Inc.)
• Inventors: Lozier, Antony J., Miller, Rick, Dietzel, Steven E., Sisk, Billy N., Thelen, Sarah L.
• Granted Patent: US 7,258,692 B2
• Time in Patent Office: Days
• US Class Current: 606/60
• CPC Class Codes: A61B 17/1615 Drill bits, i.e. rotating tools extending from a handpiece to contact the worked material
• CPC Class Codes: A61B 17/1631 Special drive shafts, e.g. flexible shafts A61B17/1642, A61B17/164 take precedence
• CPC Class Codes: A61B 17/164 intramedullary
• CPC Class Codes: A61B 17/1642 for producing a curved bore
• CPC Class Codes: A61B 17/1668 for the upper femur A61B17/164 takes precedence
• CPC Class Codes: A61B 17/1735 for rasps or chisels
• CPC Class Codes: A61B 17/175 for preparing the femur for hip prosthesis insertion
• CPC Class Codes: A61B 17/7097 Stabilisers comprising fluid filler in an implant, e.g. balloon; devices for inserting or filling such implants disc prostheses made of inflatable chambers or pockets filled with fluid A61F2/441; replacing the nucleus pulposus A61F2002/444
• CPC Class Codes: A61B 17/742 having one or more longitudinal elements oriented along or parallel to the axis of the neck
• CPC Class Codes: A61B 17/8805 for introducing fluid filler into bone or extracting it A61B17/7097, A61B17/8833 take precedence
• CPC Class Codes: A61B 17/8863 Apparatus for shaping or cutting osteosynthesis equipment by medical personnel
• CPC Class Codes: A61B 17/8875 Screwdrivers, spanners or wrenches
• CPC Class Codes: A61B 2017/00238 Type of minimally invasive operation A61B2017/00805 takes precedence
• CPC Class Codes: A61B 2017/00287 Bags for minimally invasive surgery
• CPC Class Codes: A61B 2017/00557 inflatable A61B2017/22051 takes precedence
• CPC Class Codes: A61B 2017/1602 Mills
• CPC Class Codes: A61F 2002/2825 Femur
• CPC Class Codes: A61F 2002/30583 filled with hardenable fluid, e.g. curable in-situ
• CPC Class Codes: A61F 2210/0085 hardenable in situ, e.g. epoxy resins

Abstract

An improved method and apparatus for reducing a hip fracture utilizing a minimally invasive procedure which does not require incision of the quadriceps. A femoral implant in accordance with the present invention achieves intramedullary fixation as well as fixation into the femoral head to allow for the compression needed for a femoral fracture to heal. To position the femoral implant of the present invention, an incision is made along the greater trochanter. Because the greater trochanter is not circumferentially covered with muscles, the incision can be made and the wound developed through the skin and fascia to expose the greater trochanter, without incising muscle, including, e.g., the quadriceps. After exposing the greater trochanter, novel instruments of the present invention are utilized to prepare a cavity in the femur extending from the greater trochanter into the femoral head and further extending from the greater trochanter into the intramedullary canal of the femur. After preparation of the femoral cavity, a femoral implant in accordance with the present invention is inserted into the aforementioned cavity in the femur. The femoral implant is thereafter secured in the femur, with portions of the implant extending into and being secured within the femoral head and portions of the implant extending into and being secured within the femoral shaft.

Claims

1. A method of reducing a femoral fracture, comprising:

making an incision generally aligned with a patient'"'"'s greater trochanter;

developing a wound from said incision to the greater trochanter;

through said wound, creating a cavity in a femur, said cavity extending from a greater trochanter into a femoral head, said cavity further extending from the greater trochanter into an intramedullary canal of the femur; and

positioning a femoral implant in said cavity.

2. The method of claim 1, wherein said incision measures about 2-3 cm.

3. The method of claim 1, wherein said step of creating a cavity in the femur comprises:

straight reaming into the femur through the greater trochanter to form a femoral access therethrough;

inserting a swivel reamer into said access;

swivel reaming to expand the cavity toward the femoral head and the femoral shaft, without enlarging said access;

inserting a curved reamer into said access;

advancing said curved reamer into the femoral head;

removing said curved reamer from the femoral head; and

advancing said curved reamer into the femoral shaft.

4. The method of claim 1, wherein said step of positioning a femoral implant into said cavity comprises:

inserting said femoral implant into an access formed in the greater trochanter, said access intersecting said cavity, said femoral implant comprising;

a bag;

a lag screw tube; and

a lag screw;

advancing said lag screw through said lag screw tube and into the femoral head; and

filling said bag with a substance to expand said bag to substantially fill said cavity.

5. The method of claim 4, wherein said substance comprises bone cement.

6. The method of claim 4, wherein said bag comprises an acrylic bag.

7. The method of claim 1, further comprising:

affixing a guide plate to the greater trochanter;

affixing a retractor to said guide plate, said retractor extending from the greater trochanter through said incision; and

wherein said step of creating a cavity in the femur comprises creating a cavity in the femur through the retractor.

8. The method of claim 7, wherein said step of creating a cavity in the femur through the retractor comprises:

providing a straight reamer having a straight reamer guide tube, said straight reamer guide tube having an exterior geometry, said retractor having a hollow interior, said hollow interior of said retractor and said exterior geometry of said straight reamer guide tube cooperating to allow insertion of said straight reamer guide tube into said retractor, whereby said straight reamer guide tube is substantially prohibited from rotating about an axis perpendicular to a longitudinal axis thereof when said straight reamer guide tube is inserted in said retractor;

inserting said straight reamer guide tube into said retractor;

straight reaming with the straight reamer into the femur through the greater trochanter to form a femoral access therethrough;

providing a swivel reamer having a swivel reamer guide tube and a swivel reamer head, said swivel reamer guide tube having an exterior geometry cooperating with said hollow interior of said retractor to allow insertion of said swivel reamer guide tube into said retractor, whereby said swivel reamer guide tube is substantially prohibited from rotating about an axis perpendicular to a longitudinal axis thereof when said swivel reamer guide tube is inserted in said retractor;

inserting said swivel reamer guide tube into said retractor, and thereby inserting said swivel reamer head through said access;

swivel reaming to expand the cavity toward the femoral head and the femoral shaft, without expanding said access;

providing a curved reamer having a curved reamer guide tube and a curved reamer head, said curved reamer guide tube having an exterior geometry cooperating with said hollow interior of said retractor to allow insertion of said curved reamer guide tube into said retractor, whereby said curved reamer guide tube is substantially prohibited from rotating about an axis perpendicular to a longitudinal axis thereof when said curved reamer guide tube is inserted in said retractor;

inserting said curved reamer guide tube into said retractor, and thereby inserting said curved reamer head through said access;

advancing said curved reamer head into the femoral head;

removing said curved reamer head from the femoral head; and

advancing said curved reamer head into the femoral shaft.

9. The method of claim 7, further comprising:

choosing one of a straight retractor and an angled retractor prior to said step of attaching a retractor to said guide plate, and wherein said retractor attached to said guide plate comprises the retractor chosen in said choosing step.

10. The method of claim 9, wherein said step of choosing one of a straight retractor and an angled retractor comprises:

a) attaching one of said straight retractor and said angled retractor to said guide plate;

b) providing an alignment device having an extension with an exterior geometry cooperating with a hollow interior of said retractor to allow insertion of said extension into said retractor, whereby said extension is substantially prohibited from rotating about an axis perpendicular to a longitudinal axis thereof when said extension is inserted in said retractor, said alignment device further including an alignment arm having a distal end curved to follow a path from the central portion of the greater trochanter, along the central axis of the femoral neck to the central portion of the femoral head;

c) inserting said extension into said retractor;

d) comparing said alignment arm to said path on the femur; and

e) repeating steps a)-d) above until said alignment arm generally coincides with said path from the central portion of the greater trochanter, along the central axis of the femoral neck to the central portion of the femoral head.

11. The method of claim 9, wherein said angled retractor includes a distal end for attachment to said guide plate and a retractor body, and wherein a longitudinal axis of said distal end forms an angle of about 10 degrees with a longitudinal axis of said retractor body.

12. The method of claim 10, wherein said comparing step comprises:

positioning said alignment arm adjacent to the patient; and

observing the path of the distal end of the alignment arm relative to a femoral path from the central portion of the greater trochanter, along the central axis of the femoral neck to the central portion of the femoral head using a fluoroscope.

13. The method of claim 7, wherein said step of affixing a guide plate to the greater trochanter comprises the steps of:

selectively attaching said guide plate to a distal end of an insertion member;

inserting said guide plate and said distal end of said insertion member into said wound;

using tactile feedback, placing said guide plate atop the greater trochanter;

using a fluoroscope, observing the placement of said guide plate atop the greater trochanter; and

repositioning said guide plate until the guide plate is positioned atop the greater trochanter.

14. The method of claim 13, wherein said step of affixing a guide plate to the greater trochanter further comprises:

inserting a stabilization nail into an elongate aperture formed in said insertion member;

impacting a proximal impact surface of said stabilization nail to drive said stabilization nail into the greater trochanter;

driving a plurality of screws through a plurality of screw apertures formed in said guide plate and into the greater trochanter, whereby said screws retain the position of said guide plate atop the greater trochanter; and

removing said stabililzation nail from engagement with the greater trochanter; and

removing said insertion member from said guide plate.

15. The method of claim 8, wherein said straight reamer has a reamer shaft with a flange formed thereon, said flange cooperating with said straight reamer guide tube to limit a reaming depth of said straight reamer, and wherein said straight reaming step comprises straight reaming with the straight reamer into the femur through the greater trochanter until said flange contacts said proximal end of said straight reamer guide.

16. The method of claim 8, wherein said swivel reamer includes a swivel reamer head connected to a swivel reamer shaft, said swivel reamer shaft operatively connected to a pivot, whereby said swivel reamer shaft is pivotable along an axis perpendicular to a longitudinal axis of said swivel reamer shaft, and wherein said step of swivel reaming to expand the cavity toward the femoral head and the femoral shaft without expanding said access comprises the steps of:

actuating said swivel reamer head; and

pivoting said swivel reamer shaft about said pivot to expand the cavity toward the femoral head and femoral shaft.

17. The method of claim 8, wherein said curved reamer guide tube includes a curved guide channel, and wherein said curved reamer further includes a curved reamer shaft positioned in said curved guide channel, and wherein said step advancing said curved femoral reamer into the femoral head comprises the step of inserting said curved reamer shaft through said curved guide channel and into the femoral head, and wherein said step of advancing said curved reamer into the femoral shaft comprises advancing said curved reamer shaft through said curved guide channel into the femoral shaft.

18. The method of claim 7, wherein said step of creating a cavity in the femur through the retractor comprises:

providing a combination reamer having a combination reamer guide tube and a combination reamer head, said combination reamer guide tube having an exterior geometry, said retractor having a hollow interior, said hollow interior of said retractor and said exterior geometry of said combination reamer guide tube cooperating to allow insertion of said combination reamer guide tube into said retractor, whereby said combination reamer guide tube is substantially prohibited from rotating about an axis perpendicular to a longitudinal axis thereof when said combination reamer guide tube is inserted in said retractor;

inserting said combination reamer guide tube into said retractor;

straight reaming with the combination reamer into the femur through the greater trochanter to form a femoral access therethrough;

adjusting said combination reamer to accommodate swivel reaming;

swivel reaming to expand the cavity toward the femoral head and the femoral shaft, without expanding said access;

providing a curved reamer having a curved reamer guide tube and a curved reamer head, said curved reamer guide tube having an exterior geometry cooperating with said hollow interior of said retractor to allow insertion of said curved reamer guide tube into said retractor, whereby said curved reamer guide tube is substantially prohibited from rotating about an axis perpendicular to a longitudinal axis thereof when said curved reamer guide tube is inserted into said retractor;

inserting said curved reamer guide tube into said retractor, and thereby inserting said curved reamer head through said access;

advancing said curved reamer head into the femoral head;

removing said curved reamer head from the femoral head;

removing said curved reamer guide tube from said retractor;

reinserting said curved reamer guide tube into said retractor, and thereby inserting said curved reamer head through said access; and

advancing said curved reamer head into the intramedullary canal.

19. The method of claim 1, wherein said step of creating a cavity in the femur comprises:

positioning a plunge reamer through the incision and atop the greater trochanter;

actuating the plunge reamer;

reaming with the plunge reamer through the greater trochanter into the femur to form a portion of said cavity in the femur;

removing the plunge reamer through the incision;

inserting a guide plate through said incision;

placing said guide plate atop the greater trochanter, a central aperture of said guide plate aligned with said portion of said cavity;

securing said guide plate to the greater trochanter utilizing a cannulated fixation screw allowing access to said portion of said cavity; and

creating said cavity in the femur through said guide plate.

20. The method of claim 19, wherein said step of securing said guide plate to the greater trochanter comprises the steps of:

inserting said cannulated fixation screw through said incision, through said central aperture, and into said portion of said cavity; and

threading said fixation screw into said portion of said cavity until a head of said fixation screw abuts a shoulder of said guide plate and said guide plate is secured intermediate the femur and said fixation screw.

21. The method of claim 19, wherein said step of creating said cavity in the femur through said guide plate further comprises the steps of:

affixing a retractor to said guide plate, said retractor extending from the greater trochanter through said incision; and

creating said cavity in the femur through both said guide plate and said retractor.

22. The method of claim 1, wherein said step of creating a cavity in the femur comprises:

positioning a plunge reamer through the incision and atop the greater trochanter;

actuating the plunge reamer;

reaming with the plunge reamer through the greater trochanter into the femur to form a portion of said cavity in the femur;

removing the plunge reamer through the incision;

inserting a retractor through said incision;

placing said retractor atop the greater trochanter, a central aperture of said retractor aligned with said portion of said cavity, said retractor extending from the greater trochanter through said incision;

securing said retractor to the greater trochanter utilizing a cannulated fixation screw allowing access to said portion of said cavity; and

creating said cavity in the femur through said retractor.

23. The method of claim 22, wherein said step of securing said retractor to the greater trochanter comprises the steps of:

inserting said cannulated fixation screw through said incision, through said central aperture, and into said portion of said cavity; and

threading said fixation screw into said portion of said cavity until a head of said fixation screw abuts a shoulder of said retractor and said retractor is secured intermediate the femur and said fixation screw.

24. The method of claim 7, wherein said step of creating a cavity in the femur through the retractor comprises:

inserting a guide wire through the greater trochanter into the femoral head;

providing a flexible reamer having a flexible reamer guide tube, said flexible reamer guide tube having an exterior geometry, said retractor having a hollow interior, said hollow interior of said retractor and said exterior geometry of said flexible reamer guide tube cooperating to allow insertion of said flexible reamer guide tube into said retractor, whereby said flexible reamer guide tube is substantially prohibited from rotating about an axis perpendicular to a longitudinal axis thereof when said flexible reamer guide tube is inserted in said retractor;

inserting said flexible reamer guide tube into said retractor while inserting said guide wire into a canula of said flexible reamer;

reaming with said flexible reamer into the femur through the greater trochanter to the femoral head with the flexible reamer, with the flexible reamer being guided by said guide wire;

removing said guide wire and said flexible reamer from said retractor;

inserting a guide wire through the greater trochanter into the intramedullary canal of the femur;

inserting said flexible reamer guide tub into said retractor while inserting said guide wire into said canula of said flexible reamer; and

reaming from the greater trochanter into the intramedullary canal with the flexible reamer being guided by said guide wire.

25. The method of claim 24, wherein said step of inserting a guide wire through the greater trochanter into the femoral head comprises the step of inserting a guide wire shaped to follow a path from the greater trochanter to a central portion of the femoral head, and wherein said step of inserting a guide wire through the greater trochanter into the intramedullary canal of the femur comprises the step of inserting a guide wire shaped to follow a path from the greater trochanter into the intramedulary canal of the femur.

26. The method of claim24, wherein said step of inserting a guide wire through the greater trochanter into the femoral head comprises the step of in vivo bending a guide wire to follow a path from the greater trochanter to a central portion of the femoral head while concurrently inserting said guide wire through the greater trochanter and into the femoral head, and wherein said step of inserting a guide wire through the greater trochanter into the intramedullary canal of the femur comprises the step of in vivo bending a guide wire to follow a path from the greater trochanter to the intramedulary canal of the femur while concurrently inserting said guide wire through the greater trochanter and into the intramedulary canal.

27. A prosthetic implant, comprising:

a bag;

a fill access providing access to an interior of said bag; and

a tube, said bag secured to an exterior of said tube.

28. The prosthetic implant of claim 27, further comprising:

a lag screw, comprising;

a shaft, said shaft having an exterior geometry cooperating with an interior geometry of said tube to allow relative axial displacement of said lag screw and said tube; and

a screw head, said screw head rotabably connected to said shaft.

29. The prosthetic implant of claim 28, wherein said lag screw shaft includes an interior elongate aperture, and wherein said screw head includes a drive connector for selective engagement with a rotatable drive instrument, said interior elongate aperture of said lag screw shaft providing access to said drive connector.

30. The prosthetic implant of claim 28, wherein said lag screw shaft is curved from a proximal end thereof to a distal end thereof, and wherein said tube is curved from a proximal end thereof to a distal end thereof, said tube and said lag screw shaft having a similar curvature, whereby said lag screw shaft is slidable relative to said tube when said lag screw shaft is placed within said tube.

31. The prosthetic implant of claim 27, further comprising a fill tube, said fill tube providing said access.

32. The prosthetic implant of Claim 31, wherein said fill tube has a length, said length sized to allow retrograde filling of said bag.

33. The prosthetic implant of claim 27, further comprising:

a substantially V-shaped expansion bar positioned within said bag.

34. A guide plate for guiding a plurality of instruments utilized to reduce a bone fracture, comprising:

a guide plate body having a central aperture through which said instruments can pass, said guide plate including means for selectively locking an instrument guide thereto; and

a means for affixing said guide plate to the bone.

35. The guide plate of claim 34, wherein said means for affixing said guide plate to the bone comprises a plurality of screws cooperating with a plurality of screw apertures in said guide plate.

36. The guide plate of claim 34, wherein said means for affixing said guide plate to the bone comprises a cannulated fixation screw including a fixation screw head with a plurality of resilient fingers depending therefrom, said resilient fingers having threads thereon, said fixation screw abutting a shoulder of said guide plate when said resilient fingers are positioned through said central aperture.

37. A straight reamer, comprising:

a straight reamer guide tube having an elongate aperture formed therein; and

a straight reamer shaft located in said elongate aperture of said straight reamer guide tube, said reamer shaft including a straight reamer head on a distal end thereof, said straight reamer shaft further including a flange, said straight reamer guide tube positioned intermediate said flange and said straight reamer head.

38. A swivel reamer, comprising:

a swivel reamer guide tube having a pivot pivotally connected thereto, said pivot having a longitudinal aperture;

a swivel reamer shaft located in said longitudinal aperture of said pivot, said swivel reamer shaft having a pair of flanges abutting opposing ends of said pivot; and

a swivel reamer head formed on a distal end of said swivel reamer shaft, said swivel reamer head protruding from said swivel reamer guide tube;

said swivel reamer guide tube including a cutout, whereby said swivel reamer shaft traverses said cutout when said pivot pivots relative to said swivel reamer guide tube.

39. A curved reamer, comprising:

a curved reamer guide tube including a curved guide channel; and

a curved reamer shaft positioned in said curved guide channel, whereby said curved reamer shaft can be advanced through said curved reamer guide channel, said curved reamer shaft including a reamer head on a distal end thereof.

40. An angled guide tube/retractor, comprising:

a tubular distal end including a means for selectively affixing the guide tube/retractor to a guide plate; and

a tubular retractor body, said distal end having a distal end longitudinal axis, said retractor body having a retractor body longitudinal axis, said distal end longitudinal axis forming an acute angle with said retractor body longitudinal axis.

41. The angled guide tube/retractor of claim 40, wherein said acute angle measures 10 degrees.

42. An alignment device for choosing a guide tube/retractor through which a medical procedure will be performed, comprising:

an insertion member having an exterior geometry cooperating with a hollow interior of the guide tube/retractor to allow insertion of said insertion member into the guide tube/retractor, whereby said insertion member is substantially prohibited from rotating about an axis perpendicular to a longitudinal axis thereof when said insertion member is inserted in the guide tube/retractor;

a transverse bar connected to said insertion member; and

an alignment arm slidably attached to said transverse bar, said alignment arm having a distal end, said distal end having a shape substantially matching a biological landmark, said distal end aligning with said biological landmark when the appropriate guide tube/retractor is utilized.

43. A combination reamer, comprising:

a combination reamer guide tube having a pivot pivotally connected thereto, said pivot having a longitudinal aperture;

a combination reamer shaft located in said longitudinal aperture of said pivot;

a combination reamer head formed on a distal end of said combination reamer shaft, said combination reamer head protruding from said combination reamer guide tube;

said combination reamer guide tube including a cutout, whereby said combination reamer shaft traverses said cutout when said pivot pivots relative to said swivel reamer guide tube;

a reamer shaft tube slidably connected about said combination reamer shaft, said pivot positioned on said combination reamer shaft intermediate a distal flange of said combination reamer shaft and a distal end of said reamer shaft tube;

a lock mechanism for selectively locking said reamer shaft tube to said combination reamer shaft; and

a swivel/plunge reaming selector rotatably connected to said combination reamer guide tube, said swivel/plunge reaming selector having a selector cutout, said swivel/plunge reaming selector being rotatable relative to said combination reamer guide tube to a first position in which said selector cutout is aligned with said combination reamer guide tube cutout to allow for rotation of said pivot to effect swivel reaming, said swivel/plunge reaming selector being further rotatable relative to said combination reamer guide tube to a second position in which said selector cutout is not aligned with said combination reamer guide tube cutout to prevent rotation of said pivot and thereby prevent swivel reaming.

44. A flexible reamer guide, comprising:

a flexible reamer guide tube including a substantially straight elongate guide wire aperture; and

a guide wire positioned in said guide wire aperture, said guide wire including a distal end having a curvature, said guide wire formed from a shape memory substance, whereby said guide wire will retain said curvature after being deflected, whereby said guide wire is deflected when the distal end is positioned in said guide wire aperture.

45. The flexible reamer guide of claim 44, wherein said flexible reamer guide tube further includes an elongate guide channel, said flexible reamer guide further comprising:

a guide position in said guide channel, said guide wire secured to said guide, whereby said guide controls the position of said guide wire in said guide wire aperture, and whereby relative axial displacement of said guide relative to said flexible reamer guide tube causes relative axial displacement of said guide wire relative to said flexible reamer guide tube.

46. The flexible reamer guide of claim 45, wherein said flexible reamer guide tube further includes an elongate advance/retract screw aperture, said flexible reamer guide further comprising:

an advance/retract screw positioned in said advance/retract screw aperture, said advance/retract screw including an advance/retract screw flange, said guide including a proximal flange, said advance/retract screw threadably connected to said flexible reamer guide tube, whereby rotation of said advance/retract screw in a first direction causes said advance/retract screw to be axially displaced relative to said flexible reamer guide tube and further causes engagement of said advance/retract screw flange with said proximal flange of said guide to thereby effect axial displacement of said guide and said guide wire relative to said flexible reamer guide tube.

47. A flexible reamer guide wire bender, comprising:

a flexible reamer guide wire bender guide tube including an elongate guide wire aperture;

a guide wire positioned in said guide wire aperture;

a means for shaping said guide wire connected to a distal end of said flexible reamer guide wire bender guide tube; and

a means for advancing said guide wire through said means for shaping to thereby shape said guide wire.

48. The flexible reamer guide wire bender of claim 47, wherein said means for shaping said guide wire comprises:

a wire shaping head pivotally connected to said flexible reamer guide wire bender guide tube;

a pair of rollers rotatably connected to said wire shaping head; and

an adjustment screw threadably engaged with said flexible reamer guide wire bender guide tube, said adjustment screw having a distal end for contacting said wire shaping head and rotating said wire shaping head relative to said flexible reamer guide wire bender guide tube, whereby said guide wire contacts said rollers and is thereby shaped as said means for advancing advances said guide wire therethrough.

49. A flexible reamer guide wire bender, comprising:

a flexible reamer guide wire bender guide tube including an elongate guide wire aperture;

a guide wire positioned in said guide wire aperture;

a wire shaping head pivotally connected to a distal end of said flexible reamer guide wire bender guide tube;

a pair of rollers rotatably connected to said wire shaping head; and

an adjustment screw threadably engaged with said flexible reamer guide wire bender guide tube, said adjustment screw having a distal end for contacting said wire shaping head and rotating said wire shaping head relative to said flexible reamer guide wire bender guide tube, said guide wire contacting said rollers as said guide wire exits said distal end of said flexible reamer guide wire bender guide tube.

50. The flexible reamer guide wire bender of claim 49, further comprising:

a means for advancing said guide wire through said wire shaping head.