hereinafter , a method for arthroscopic ankle arthrodesis using an ultrasonic treatment tool according to an embodiment of the present invention will be described with reference to the drawings . fig1 shows a configuration example of an operation system including an ultrasonic treatment tool to perform a method for arthroscopic ankle arthrodesis according to the present embodiment . fig2 is a diagram showing a state in which an arthroscope and an ultrasonic treatment tool are inserted into an anterolateral inserting point and an anteromedial inserting point . in the present embodiment described below , a site to be treated 100 will be described by taking an ankle as an example , but the present embodiment is not limited to the ankle and other joints can similarly be operated on easily using the ultrasonic treatment tool . an operation system 1 according to the present embodiment includes an ultrasonic treatment tool 2 and an endoscopic system 3 including an arthroscope 21 . the ultrasonic treatment tool 2 includes an the ultrasonic wave generating section 11 that generates an ultrasonic vibration using an ultrasonic vibration element ( for example , a piezoelectric element ), a probe 12 that performs the ultrasonic treatment procedure of the site to be treated by transmitting the ultrasonic vibration , and an operation section 13 that performs an on / off operation of the generation of an ultrasonic vibration by exercising drive control of the ultrasonic wave generating section 11 . the endoscopic system 3 includes the arthroscope 21 rigid endoscope , a visible light source 22 that radiates an illumination light of visible light as a light source of illumination light , a controller 23 that controls the endoscopic system 3 as a whole , an input section 24 such as a keyboard or a touch panel , a display section 25 that displays surgery information including imaged surgery conditions , and a water - supply / water - discharge section 26 that supplies physiological saline to the ankle lateral ligament of a site to be treated 100 and surroundings thereof or drains or perfuses physiological saline . in the present embodiment , the water - supply / water - discharge section 26 is configured to supply physiological saline to the site to be treated through the arthroscope 21 or drain physiological saline , but a perfusion containing physiological saline or the like may be supplied or drained from the ultrasonic treatment tool 2 . as illustrated in fig2 , the probe 12 used in the present embodiment is an elongated rod - like member of about 2 mm to 4 mm in diameter extending linearly in a longitudinal direction and has a tip portion and a base end . the base end is linked to the ultrasonic wave generating section 11 and the tip portion is provided with a treatment section 14 that excises the cartilage . the treatment section 14 of the probe 12 of the ultrasonic treatment tool 2 will be described . the treatment section 14 provided at the tip of the probe 12 illustrated in fig3 a has a shape in which an inverted isosceles trapezoid expands upward from below and an upper base of the trapezoid on the lower side is an opening 14 c in a rectangular shape that cuts by being brought into contact with a site to be treated and a lower base of the trapezoid on the upper side is an opening to be an outlet of filing . edges 14 d are provided at respective ends of the opening 14 c where inclined planes ( legs ) 14 a , 14 b inclined opposite to each other like expanding are in contact . these edges 14 d function like a planer blade and can cut the site to be treated . thus , the treatment section 14 of the probe 12 is structured to perform not only ultrasonic treatment s 1 by a pull operation , but also an ultrasonic treatment s 2 by a push operation by providing cutting edges forward and backward in a traveling direction of an opening that ablates the cartilage . an edge is provided only on a tip side of an opening in a conventional curette and thus , after pulling nearer for the ultrasonic treatment , an operation to return to the original cutting start position is needed . to cut a surface 101 , for example , a cutting operation of 5 - time reciprocation is needed . in contrast , the treatment section 14 according to the present embodiment can cut both ways and thus , when a surface 102 having the same area as the surface 101 , a cutting operation of 2 - and - half - time reciprocation is needed . that is , the ultrasonic treatment procedure of 5 - time reciprocation is reduced to the ultrasonic treatment procedure of 2 - and - half - time reciprocation for the same area and thus , the treatment section 14 according to the present embodiment has substantially 2 - time cutting capacities when compared with the conventional curette and can make the dissection treatment more efficient . fig3 b shows a configuration example in which the structure of the treatment section 14 in fig3 a is applied to an ultrasonic vibration curette 15 by providing the structure at the tip of the probe 12 . if the curette 15 is produced with a thin blade of about 2 to 3 mm in thickness or by being bent , the cartilage and bone on a tibia surface and talus surface curved inside a joint fissure expanded to about 4 to 5 mm can be cut by being in traction in a state of ultrasonic vibration . the curette 15 may have elastically deforming characteristics to suitably adjust a pressing force . fig3 c shows a treatment section 17 having a plurality of steps of edges 16 formed by a plurality of parallel grooves so as to rotate in a direction intersecting a longitudinal axis as a vibration direction of the probe 12 . by providing edges on both sides of edges in the treatment section 17 , the cartilage and bone are cut in both push and pull directions . the probe 12 illustrated in fig3 d is provided with a treatment section 19 that opens a bone hole at the tip thereof and has protrusions 19 c in a rectangular shape arranged checkerwise on the side face extending about halfway around the probe 12 . the treatment section 19 has an apical protrusion 19 a longer than other protrusions to align with a guide hole formed in advance arranged in the center of the tip surface and a plurality of protrusions 19 b arranged therearound . the treatment section 19 can carry out a cutting procedure of bones ( cortical bones and cancellous bones ) the cartilage and subchondral bone and all sites of living body tissues . that is , the cartilage can be shaved off by dissolution the cartilage using frictional heat generated between the treatment section 19 and the cartilage when the protrusions 19 c made of edges formed on the side face of the probe 12 are put thereon . in addition , the bone is cut by being hammered by the protrusions 19 b of the treatment section 19 provided at the tip of the probe 12 like ultrasonic vibration and extremely finely smashed and then shaved off . therefore , by fitting the treatment section 19 at the tip of the probe to a shape matching an object to be cut , not only the type of the site to be cut , but also the amount of cutting and the shape thereof can appropriately be selected . incidentally , though the amount of cutting is smaller than that of the protrusions 19 b , the protrusions 19 c provided on the side face of the probe 12 can knock and cut the bone . a conventional drill used to form a bone hole opens a hole by rotation and thus , the basic shape of the hole is circular and even if the drill is moved in the left and right direction , the result is only an increased diameter in an indefinite shape and a desired shape cannot be formed . in contrast , the probe 12 of the ultrasonic treatment tool 2 does not rotate and moves infinitesimally in a forward and backward direction and thus , if the probe tip is hit against a bone and knocked vertically with respect to the bone surface , the bone hole is not limited to a circular shape and a bone hole in a shape matching the external shape of the treatment section ( or a sectional shape of the probe ) can be formed . by moving the location where the treatment section 19 is hit , a bone hole in any shape can be formed . if the shape of a bone hole to be formed is determined , for example , as illustrated in fig3 e , a bone hole in any shape can be formed by external appearance of a treatment section 20 provided with an apical protrusion 20 a and a plurality of protrusions 20 b at the tip of the probe 12 in an elliptic shape . in this example , grooves 20 c are arranged so as to be arrayed in two rows in the longitudinal direction on the side face of the probe 12 to constitute edges for cutting . similarly , a treatment section 20 d in a long hole shape ( track shape ) illustrated in fig3 f or a treatment section 20 e in a rectangular shape illustrated in fig3 g can form a bone hole in a shape matching the shape of the treatment section . further , the bone hole is not limited to a linear shape and a bone hole having a curved portion can also be formed . when , for example , a problem of being unable to fix a tendon or the like arises because only a short length ( depth ) of a bone hole can be taken depending on the shape of the bone if the bone hole is linear , fixing may be enabled by forming a curved bone hole . a bone hole having a curved portion can be implemented by using a probe having a curve in a tip portion . regarding the diameter or width of a bone hole , not only holes of the same diameter or the same width , but also holes in a tapering shape of the diameter or width from the inlet can be formed . in this case , the tapering shape can be formed with steps or without steps . if the probe tip having edges is pressed horizontally against the surface of a bone , vibrations occur like knocking while sliding on the treatment surface of a site to be treated and thus , the site can be excised by knocking and shaving off using edges . if the site to be treated has elasticity like the cartilage or fat , the site can be excised by shaving off using edges and fusing by frictional heat . next , the procedure of a method for arthroscopic ankle arthrodesis will be described with reference to fig2 to 10 . fig4 is a diagram showing an example of positions where an anterolateral inserting point and an anteromedial inserting point are created , fig5 is a diagram showing a state in which holes are formed in a subchondral bone plate by an ultrasonic treatment tool whose tip has a needle shape , fig6 is a diagram showing a fixed state of the tibia and the talus by a method for ankle arthrodesis according to the present embodiment , fig7 is a diagram showing a conventional fixed state for comparison with fig6 , fig8 is a diagram showing the fixed state of the tibia and the talus fixed by the method for ankle arthrodesis according to the present embodiment , and fig9 is a diagram showing a conventional fixed state for comparison with fig8 . fig1 is a flow chart illustrating surgical steps of the method for ankle arthrodesis . the method for ankle arthrodesis according to the present embodiment is a method for ankle arthrodesis that forms a fusion surface of bone by successively removing a damaged cartilage and bone on the tibia surface and talus surface in an ankle using an ultrasonic treatment tool and fixing and fusing the tibia and the talus . before surgery is started , a leg is first placed on an operating table and a bandage is applied such that , as shown in fig2 , the instep falls to expand the joint fissure to be a space for treatment and the bandage is in traction by a tractor ( not illustrated ). for the traction , for example , a traction force of about 6 kg is applied for traction ( step s 1 ). then , an anteromedial inserting point 41 and an anterolateral inserting point 42 ( portal ) to insert the arthroscope 21 and the ultrasonic treatment tool 2 are formed ( step s 2 ). when determining positions thereof , as illustrated in fig4 , a large number of blood vessels / nerves , muscle - tendons and the like are arranged along a tibia 32 , a peroneal bone 33 , and a talus 34 . here , an anteromedial inserting point that is relatively safe is first created . the anteromedial inserting point 41 is formed in a position between a lower portion 32 a of the tibia on the inner side and the talus 34 and the anterolateral inserting point 42 is formed in a position between the lower portion 32 a of the tibia on the outer side , a lower portion of the peroneal bone 33 , and the talus 34 by avoiding these vascular nerves , muscle - tendons and the like . next , as illustrated in fig2 , the ultrasonic treatment tool 2 is inserted from the anteromedial inserting point 41 and the arthroscope 21 is inserted from the anterolateral inserting point 42 ( step s 3 ). incidentally , insertion locations may be interchanged in accordance with the location of the site to be treated . after the insertion , a perfusion made of physiological saline and the like is allowed to flow into the joint from the arthroscope 21 and the perfusion is circulated at a fixed flow rate by using a perfusion apparatus ( not illustrated ) ( step s 4 ). a cartilage tissue 44 attached to a tibia surface 32 b and a cartilage tissue 45 attached to a talus surface 34 a illustrated in fig6 are all excised by causing an ultrasonic vibration of the treatment section 14 of the probe 12 of the ultrasonic treatment tool 2 ( step s 5 ). if any osteophyte is found during cutting , the osteophyte is also excised . if any of the cartilage tissues 44 , 45 and osteophyte remains between joint surfaces of the tibia surface and the talus surface while the joint is fixed by fusion , such a remnant could be an inhibition factor of fusion of the tibia and the talus . subsequently , curved surfaces are adjusted by the treatment section 14 provided at the tip of the probe so that curved shapes of the talus and the tibia are in close contact without any gap when the talus and the tibia are matched . that is , each bone is shaved off and shaped such that a concave curved surface of the tibia surface 32 b and a convex curved surface of the talus surface 34 a match by eliminating unevenness of each curved surface using the treatment section 14 vibrated ultrasonically to have curved surfaces of similar curves ( step s 6 ). next , the ultrasonic treatment tool 2 having the probe 12 including a treatment section 18 with an apical portion having a sharp tip as illustrated in fig5 and bent halfway through the portion is used . holes of a minimized area are made in 50 to 60 locations using the ultrasonic treatment tool 2 including the treatment section 18 . the treatment section 18 has , as illustrated in fig5 , a bent tip and thus , instead of moving the ultrasonic treatment tool by applying a force in the longitudinal direction of the main body thereof , the ultrasonic treatment tool is moved in a direction perpendicular to the longitudinal direction and therefore , even if the joint fissure is narrow , drilling can easily be performed if only the tip portion of the treatment section 18 is inserted into the joint fissure . a bone hole is formed in the tibia surface 32 b and / or the talus surface 34 a using the treatment section 18 . the bone hole may be formed in , for example , a dimple shape of a golf ball . the bone hole is made so as to pierce through the subchondral bone plate and the bottom thereof reaches the cancellous bone to allow blood a to bleed onto the bone surface from inside ( step s 7 ). incidentally , the bone hole is not limited to the dimple shape and any shape in which a small amount of blood remains on the surface may be adopted . this is because immobilization is promoted by bone marrow stimulation contained in the bone marrow . the tibia 32 and the talus 34 are matched so that the tibia surface 32 b and the talus surface 34 a are brought into close contact as similar curved surfaces a . further , as illustrated in fig6 and 8 , for example , a plurality of screws are used for screwing to retain a state in which the tibia 32 and the talus 34 are matched ( step s 8 ). after the aforementioned traction is removed , as illustrated in fig6 , a plurality of screws is screwed into the ankle under radiographic conditions if necessary . if , as a portion thereof , two or three screws are screwed in obliquely downward so as to intersect , for example , from outside the tibia , the fixing force until bones are fused is improved . as a concrete procedure , first a guide wire is inserted from the outer surface of the tibia 32 toward the talus 34 in a direction to correct deformation . secondly , after the insertion of the guide wire into a body of talus is verified under radiographic conditions , a first screw 43 a is screwed in by over - drilling . thirdly , a second screw 43 b is screwed in from inside the tibia 32 into the body of talus . here , care needs to be taken so that an intersection 51 of two screws is not placed in a high position of the talocrural articulation on both front and rear surfaces and side faces . fourthly , if sufficient space is available , a third screw 43 c is screwed in . then , a wound closure procedure is performed . this is done by suturing only the epidermis using a nylon yarn . at this point , care needs to be taken so that rami of superficial peroneal nerves running hypodermically are not sutured . the method for ankle arthrodesis as described above is applied to cases in which activities of daily living ( called adl ) are hindered due to pain derived from joints observed in degenerative ankle disease and articular rheumatism or deformation ( irreversible ). in the method for ankle arthrodesis , with an increasing range of motion of neighboring joint groups , the motion of the fixed ankle is compensated for . here , as a reference example for comparison with the present embodiment , a conventional representative method for ankle arthrodesis will be described . as illustrated in fig7 , a lower portion 32 c of tibia in a concave shape of the tibia 32 and a lower portion 34 b of talus in a convex shape of the talus 34 are cut along a plane b and these planes are matched and then , as described above , screwed using a plurality of screws 43 . the conventional method for ankle arthrodesis as described above is easier to perform surgically than the method in the present embodiment , but the tibia 32 and the talus 34 are partially cut relatively deeply and thus , when only one leg is operated on , the leg becomes shorter than the other leg that is not operated on , which makes it difficult for the patient to walk and poses a problem that the patient &# 39 ; s upper body is tilted when walking . also in the present embodiment , cartilage tissues are excised and bones are formed by using an ultrasonic treatment tool . in contrast , when a conventional treatment tool is used to perform , like the present embodiment , the method for ankle arthrodesis that cuts cartilage tissues and adjusts curved shapes of bone , the procedure therefor is as described below : first , all cartilage tissues are ablated using a curette or a rasp . then , the bone is shaved using an ablator and further shaved beyond the subchondral bone plate in , for example , a dimple shape of a golf ball for bleeding . next , the tibia 32 and the talus 34 are fixed by screwing using a plurality of screws . if a conventional treatment tool is used for this surgery step , the following problems arise : if a cartilage the ultrasonic treatment procedure is performed using a curette or a rasp , the treatment surface has a coarse finish . the tibia surface 32 b and the talus surface 34 a have a concave curve surface and a convex curved surface respectively and thus , a joint fissure expanded by traction is narrow and a treatment tool such as a curette and a rasp does not reach the rear side of the talar joint and a sufficient amount of the cartilage cannot be excised . tissues of the remaining cartilage and the like could become , as described above , an inhibition factor of bone fusion . further , in a rotating treatment tool such as an ablator and a drill , other tissues ( anterior blood vessel / nerves ) could be caught and the closest attention needs to be paid . when a hole is made using a drill , heat necrosis may arise in bone due to frictional heat . in contrast , if an ultrasonic treatment tool is used , heat necrosis is minimized and bleeding to promote immobilization can be expected . further , when a bone hole for bleeding is formed using a drill , power is transmitted linearly and thus , no work can be done on the back side of the joint . the present embodiment described above performs a cartilage the ultrasonic treatment procedure using an ultrasonic treatment tool and therefore , compared with the past , the following operation / working effects are achieved : due to micro - vibrations , the ultrasonic treatment tool can finely adjust the amount shaved off at a time by a pressing force of the treatment tool and also due to micro - vibrations , the treatment surface becomes smooth and an effect of promoting immobilization can be expected . also , by producing the tip portion of the ultrasonic treatment tool thinly or in a thin blade shape , a region unreachable by conventional surgical instruments can be reached from the front portal . the tip portion of the ultrasonic treatment tool does not rotate and therefore , tissues are not caught during treatment . as illustrated in fig6 , the cartilage is excised using an ultrasonic treatment tool and bone boring is performed on , for example , the subchondral bone . compared with the conventional procedure , drilling using a drill may delay bone fusion due to heat necrosis in surrounding tissues . in contrast , if an ultrasonic treatment tool is used , heat necrosis and the bone architecture breakdown are minimized so that promotion of bone fusion at an early stage can be expected . in the conventional procedure using an ablator , a driving force acts in the rotation direction due to rotation and therefore , it is difficult to create a smooth surface and the tip needs a certain thickness because of the need of a cover for the prevention of being caught . in the present embodiment , by contrast , a desired shape can be produced because the procedure proceeds in a direction in which a force is applied by devising a curved shape for the tip portion of the ultrasonic treatment tool . when a conventional ablator is used , shaving scum of bone is large and it is difficult to suck , which could also lead to inflammation . in contrast , the ultrasonic treatment tool can finely shave only a surface in contact and therefore , shaving scum can be reduced and it is easy to suck . the treatment sections of probes of the ultrasonic treatment tools illustrated in fig3 a and 3b have a structure that ablates the cartilage also during a push operation , in addition to a pull operation , by providing edges ( blades ) for treatment forward and backward in a traveling direction of an opening that ablates the cartilage . with this structure , the ultrasonic treatment procedure of 5 - time reciprocation is reduced to the ultrasonic treatment procedure of 2 - and - half - time reciprocation for the same area . a conventional current remove only when pulled and also a ultrasonic treatment tool in a conventional structure performs the ultrasonic treatment procedure only in any one direction , but the structure in the present embodiment performs the ultrasonic treatment procedure in both directions of the forward direction and the backward direction so that efficiency can further be improved . in the past , if only the dimple shape is adopted for holes , the diameter increases when the depth is needed and therefore , an adhesive area of the talus and the tibia decreases and the extension of a bone fixing period is assumed . in addition , holes are normally formed in 50 to 60 locations and a lot of time is needed for boring . in the present embodiment , by contrast , as illustrated in fig5 , an ultrasonic treatment tool whose tip has a needle shape is used for treatment and holes of a small area reaching the subchondral bone plate can be formed . in the past , a treatment tool for treating the cartilage and a treatment tool for boring a hole are separate and a lot of work is needed , but an ultrasonic treatment tool in the present embodiment can treat both . the ultrasonic treatment tool can be made as thin as possible and so , with its excellent accessibility , can easily treat a site unreachable by an existing treatment tool . ultrasonic vibrations of infinitesimal amplitude are used for shaving and therefore , the cut surface can be made smooth . therefore , postoperative conditions are good . further , ultrasonic vibrations are used for shaving and therefore , cutting is reliable , thermal damage to the site to be treated can be reduced , postoperative conditions are good , and minimal invasiveness is superior . the ultrasonic treatment tool can treat both of soft tissues and hard tissues such as the cartilage and bone and therefore , replacement work of treatment tools can be reduced and burdens on engineers can be reduced . cutting is achieved by applying the treatment section vibrating ultrasonically and therefore , compared with a treatment section using a drill bit , almost no damage is done even if the treatment tool comes into contact with other sites that are not to be treated . additional advantages and modifications will readily occur to those skilled in the art . therefore , the invention in its broader aspects is not limited to the specific details and representative embodiments shown and described herein . accordingly , various modifications may be made without departing from the spirit or scope of the general inventive concept as defined by the appended claims and their equivalents .
an ankle arthrodesis of this embodiment performs a cartilage the ultrasonic treatment procedure using an ultrasonic treatment tool . as one condition , when wear of cartilage has attained to the whole of an ankle , it carries out . a method for ankle arthrodesis is disposal which excises the cracked organization which exists in an ankle using the ultrasonic treatment tool , and fixes a tibia and a talus under it with a screw .