CROSS-REFERENCE TO RELATED APPLICATION

[0001] This application claims the benefit of U.S. Application Serial No. 62/220,771 entitled "INTERAMEDULLARY FIXATED SUBACROMIAL SPACERS" and filed on September 18, 2015, which is hereby incorporated by reference in its entirety.

TECHNICAL FIELD

[0002] The present invention, in some embodiments thereof, relates to shoulder implants, and in particular to prostheses for spacing acromion and humeral head in a shoulder.

BACKGROUND

[0003] The human shoulder has many degrees of freedom and a unique mechanism for stabilization at rest. FIG. 1 schematically illustrates a portion of a human shoulder anatomy. The shoulder girdle consists of the scapula and the clavicle, and along with the humerus (upper arm bone), they form the framework of the shoulder. The upper end or head of the humerus (the humeral head) is hemisphere-like and is adjacent to two bony prominences, the greater and lesser tuberosities (tubercles). The clavicle extends from the base of the neck to the shoulder and is connected laterally to the acromion of the scapula, at the

acromioclavicular (AC) joint.

[0004] Rotation of the humerus is accomplished by a group of four muscles, subscapularis, supraspinatus, infraspinatus, and teres minor, collectively called the rotator cuff. These muscles originate on different parts of the scapula, and insert like a cuff around the perimeter of the humeral head, where their tendons blend with the joint capsule. In addition to externally and internally rotating the humerus, the rotator cuff helps stabilize the joint during abduction by pulling the humeral head into the glenoid fossa. The rotator cuff stabilizes the humeral head by contrasting the action exerted by the deltoid muscle. In case of a severe damage of the rotator cuff (for example, a complete tear), the humeral head tends to migrate upwards, and a consequent subacromial impingement takes place in which the humeral head scrapes the acromion at motion, therefore creating limitation and/or pain associated with arm motions, such as arm abduction. [0005] There are number of bursae in the region of the shoulder, each is a fluid-filled saclike cavity situated in between tissues where friction would otherwise occur. The subacromial bursa is located between the acromion and the joint capsule and is commonly involved in pathology. Ill, nonfunctional or absent subacromial bursa may cause direct contact between bone parts (e.g., between humeral head and acromion) and/or between soft and hard tissues (e.g., between the rotator cuff and the acromion) in ways that may result in damage to soft and perhaps hard tissues, hindered and limited motion, and pain.

SUMMARY

[0006] According to an aspect of some embodiments of the present invention there is provided a prosthesis which includes a subacromial spacer. In some embodiments the subacromial spacer includes a surface contoured to maintain an acromion in chosen distance to a humeral head upon rotation. Optionally, the chosen distance is maintained particularly during and following a shoulder full range of motion. In some embodiments, the full range of motion includes abduction to a substantial transverse position followed by an adduction to a substantial medial position.

[0007] In some embodiments, the prosthesis further including fixation means to fixate the subacromial spacer to a humeral medullary cavity and/or to an intramedullary fixator implanted or configured for implantation in the humeral medullary cavity. In some embodiments, the fixating means includes an elongated member sized to snugly fit in the medullary cavity or a slightly reamed segment in the medullary cavity.

[0008] In some embodiments, the subacromial spacer includes at least two hingedly connected parts, optionally making an articulation mechanism configured to allow relative motion in at least one axis. Optionally, the articulation mechanism is a bipolar articulation.

[0009] In an aspect of some embodiments, there is provided a surgical kit, including the prosthesis and a proximal humeral nail. In some embodiments, the fixating means are connectable into a proximal opening of the proximal humeral nail.

[0010] In an aspect of some embodiments, there is provided a method including at least one of the following steps (not necessarily in same order): creating a percutaneous passage from an outer-body space to a portion of a humeral head; removing bony tissue to facilitate direct communication between the outer-body space and a humeral medullary cavity enclosed in the humeral head; providing a prosthesis including a subacromial spacer having a surface; and fixating the subacromial spacer to the humeral medullary cavity and/or to an intramedullary fixator implanted or configured for implantation in the humeral medullary cavity.

[0011] Unless otherwise defined, all technical and/or scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which the invention pertains. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of embodiments of the invention, exemplary methods and/or materials are described below. In case of conflict, the patent specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and are not intended to be necessarily limiting.

BRIEF DESCRIPTION OF THE DRAWINGS

[0012] Some embodiments of the invention are herein described, by way of example only, with reference to the accompanying drawings. With specific reference now to the drawings in detail, it is stressed that the particulars shown are by way of example and for purposes of illustrative discussion of embodiments of the invention. In this regard, the description taken with the drawings makes apparent to those skilled in the art how embodiments of the invention may be practiced.

[0013] In the drawings:

[0014] FIG. 1 schematically illustrates a portion of a human shoulder anatomy;

[0015] FIG. 2 schematically illustrates an exemplary prosthesis comprising a subacromial spacer, in accordance with some embodiments of the present invention;

[0016] FIG. 3 schematically illustrates an exemplary prosthesis adapted for fixating to a proximal humeral nail, in accordance with some embodiments of the present invention;

[0017] FIGS. 4A-C schematically illustrate an exemplary prosthesis comprising a subacromial spacer configured for greater tubercle introduction, and exemplary features thereof, in accordance with some embodiments of the present invention;

[0018] FIGS. 5A-B schematically illustrate an exemplary prosthesis comprising a subacromial spacer connectable to a short PH nail and a long PH nail, respectively, in accordance with some embodiments of the present invention; [0019] FIGS. 6A-F schematically illustrate steps in a method for implanting an exemplary prosthesis and an intramedullary fixator in a humerus, in accordance with some embodiments of the present invention;

[0020] FIG. 7 schematically illustrates an exemplary prosthesis comprising an expandable subacromial spacer, in accordance with some embodiments of the present invention;

[0021] FIGS. 8A-B schematically illustrate an exemplary subacromial spacer assembly, in accordance with some embodiments of the present invention; and

[0022] FIGS. 9A-B schematically illustrate other exemplary prostheses, in accordance with some embodiments of the present invention.

DESCRIPTION OF EMBODIMENTS OF THE INVENTION

[0023] The following preferred embodiments may be described in the context of exemplary humerus and/or subacromial space related surgical procedures for ease of description and understanding. However, the invention is not limited to the specifically described devices and methods, and may be adapted to various clinical applications without departing from the overall scope of the invention. For example, devices and related methods including concepts described herein may be used for other orthopaedic surgical procedures such as but not limited to: hip, ankle, long bones and short bones.

[0024] It is understood that the invention is not limited to the particular methodology, protocols, and reagents, etc., described herein, as these may vary as the skilled artisan will recognize. Unless defined otherwise, all technical and scientific terms used herein have the same meanings as commonly understood by one of ordinary skill in the art to which the invention pertains. The embodiments of the invention and the various features and advantageous details thereof are explained more fully with reference to the non-limiting embodiments and examples that are described and/or illustrated in the accompanying drawings and detailed in the following description. It should be noted that the features illustrated in the drawings are not necessarily drawn to scale, and features of one

embodiment may be employed with other embodiments as the skilled artisan would recognize, even if not explicitly stated herein. Descriptions of well-known components and processing techniques may be omitted so as to not unnecessarily obscure the embodiments of the invention. The examples used herein are intended merely to facilitate an understanding of ways in which the invention may be practiced and to further enable those of skill in the art to practice the embodiments of the invention. Accordingly, the examples and embodiments herein should not be construed as limiting the scope of the invention, which is defined solely by the appended claims and applicable law. Moreover, it is noted that like reference numerals reference similar parts throughout the several views of the drawings.

[0025] The present invention, in some embodiments thereof, relates to shoulder implants, and in particular to prostheses for spacing acromion and humeral head in a shoulder.

[0026] An aspect of some embodiments of the present invention relates to a prosthesis including a subacromial spacer. In some embodiments, the subacromial spacer is at least partially rigid, and optionally at least partially formed of a biocompatible material, such as a plastic, polymer, metal alloy, ceramic or others. Optionally, the subacromial spacer includes parts or portions made of stainless steel and/or titanium alloy. Optionally, alternatively or additionally, the subacromial spacer includes a resilient portion, which is, optionally, malleable, elastic or plastic, expandable, compressible and/or stretchable. In some embodiments, the resilient portion includes a contact surface with the acromion. Optionally, the resilient portion is substantially compressive only above a predetermined threshold, optionally switching between a first mode, in which a first greater distance is maintained between the humeral head and the acromion, and a second mode, in which the distance is decreased while optionally resisting compression while creating a cushioning effect.

[0027] In some embodiments, the subacromial spacer comprises at least two hingedly connected parts, optionally making an articulation mechanism configured to allow relative motion in at least one axis, optionally at least two axes. Optionally, the articulation mechanism is a bipolar or a dual articulation, optionally self-centering, optionally uses primary internal articulation to reduce secondary acetabular articulation and associated acetabular wear.

[0028] In some embodiments, the subacromial spacer comprises a surface contoured to maintain an acromion in chosen distance to a humeral head. Optionally, such a chosen distance or a chosen range of distances is maintained at rest and/or upon rotation of the humeral head, particularly but not only during and/or following a shoulder range of motion, optionally a full range of motion. Optionally, the full range of motion includes, at least, an abduction to a substantial transverse position, optionally followed by an adduction to a substantial medial position. In this disclosure, "abduction" refers to moving of a body part away from the central axis of the body; "adduction" refers to moving of a body part toward the central axis of the body; and "medial" refers to being in or directed toward the midline or medial plane of the body. A normal shoulder range of motion may include at least one of flexion (optionally 0 to 90°), extension (optionally 0 to 50°), abduction (optionally 0 to 90°), adduction (optionally 90 to 0°), lateral rotation (optionally 0 to 90°) and medial rotation (optionally 0 to 90°).

[0029] In some embodiments, the surface of the subacromial spacer described above is smooth and allowing unhindered slippery motion with the acromion. Optionally, the surface is in contact with the acromion during an entire normal or full range of motion. The surface may be contoured such to maintain cam-like mechanical interaction between the humeral head and the acromion, while keeping a chosen or a normal variable distance between the humeral head and the acromion (e.g., by filling the void created therebetween) as the superior portion of the humeral head changes position. In some embodiments, the surface includes at least two portions, wherein a first portion is in contact with the acromion when the shoulder is at abduction, and wherein a second portion is in contact with the acromion when the shoulder is at adduction.

[0030] In some embodiments, the prosthesis also includes fixation means. In some embodiments, the fixation means are configured to fixate the subacromial spacer to a humeral medullary cavity. Optionally, alternatively or additionally, the fixation means are configured to fixate the subacromial spacer to an intramedullary fixator implanted or configured for implantation in the humeral medullary cavity. In some embodiments, the intramedullary fixator includes a proximal humeral nail, either a long nail or a short nail. Optionally, additionally or alternatively, the proximal humeral nail is readily provided in a humeral medullary cavity upon or before implanting the prosthesis or subacromial spacer.

[0031] In some embodiments, the fixation means comprise a portion or a member, optionally an elongated member, sized to snugly fit in a medullary cavity of the humerus or a slightly reamed segment in the medullary cavity, or optionally change in size, selectively or predeterminately, to anchor or fixate thereinside. In some embodiments, the elongated member includes at least lateral opening configured for lateral fixation by at least one locking screw. In some embodiments, the fixation means include threading or bolting configuration and for example may be sized to thread into a proximal opening of a proximal humeral nail. Optionally, alternatively or additionally, the fixation means include an expandable member or portion, optionally an inflatable member or portion. In some embodiments, such an expandable member or portion is configured for selectively expanding to anchor and/or fasten in the humeral medullary cavity. Optionally, alternatively or additionally, the expandable member or portion is configured for selectively expanding to anchor and/or fasten to the intramedullary fixator (e.g., the proximal humeral nail).

[0032] In some embodiments, the prosthesis includes a spring element allowing relative axial motion between the subacromial spacer and the fixation means, optionally over a predetermined threshold weight. In some embodiments, the prosthesis is provided as a monoblock comprising a subacromial spacing portion and an intramedullary fixator portion. In some embodiments, the subacromial spacer is formed of a different material than of the fixation means, being at least one of: plastic, metal, ceramic or any combination thereof, such as metal-backed polyethylene. Optionally parts or members of the prosthesis are glued or adhered one to the other and/or to adjacent bony tissue, optionally by using a bone cement such as PMMA based cement.

[0033] In some embodiments, the prosthesis is provided in a surgical kit, also comprising a proximal humeral nail. In some embodiments, the fixation means of the prosthesis, which may be part of the prosthesis, and which may be provided readily connected to the prosthesis or detached therefrom, are connectable into a proximal opening of the proximal humeral nail also provided in the kit. In some embodiments, the kit also includes at least one locking screw which is adapted to travel through a corresponding lateral opening in the proximal humeral nail. In some embodiments, the surgical kit includes a nail guide configured to guide at least one locking screw in at least one orientation to a corresponding at least one lateral opening in the proximal humeral nail.

[0034] In an aspect of some embodiments, there is provided a method comprising at least one of the following steps (not necessarily in same order):

1. Creating a percutaneous passage from an outer-body space to a portion of a humeral head. The percutaneous passage may be made using an incision approach, in which the lateral deltoid is split, optionally with a 2 mm to 50 mm size incision, optionally 10 mm to 30 mm size incision, between the acromion and humeral head edges. An entry portal may be central (i.e., at the apex of the humeral head, optionally centered midway between the biceps groove anteriorly and the posterior humeral head) or lateral (i.e., medial to the tendon insertion and centered midway between the biceps groove anteriorly and the posterior humeral head). In case that the rotator cuff is normally in place, it may be divided to expose a superior portion of the humeral head, and a guide pin or trocar may be placed to provide direct passage between the entry portal and the humeral head. Guide pin or trocar positioning and alignment may be checked using imaging (e.g., fluoroscopy).

Removing bony tissue to expose a humeral medullary cavity enclosed in the humeral head and/or to facilitate direct communication between the outer-body space and the humeral medullary cavity. Bonny tissue (including but not limited to cortical bone of the superior portion of the humeral head) may be drilled, reamed, hammered and/or broached into using appropriate surgical tools.

Optionally, a wire or a rod are used to measure in the medullary cavity sizes for choosing sized or size changes in a selected prosthesis. The medullary cavity may be reamed, in full, partially or in some portions thereof prior to implantation. In some embodiments, the humeral head is further shaped by removing bony tissue to facilitate matching to a subacromial spacer.

Providing a prosthesis comprising a subacromial spacer having a surface.

Optionally, the prosthesis includes fixating means connected or connectable with the subacromial spacer. Optionally, the prosthesis is provided as part of a kit, further comprising a proximal humeral nail.

Fixating the subacromial spacer to the humeral medullary cavity and/or to an intramedullary fixator implanted or configured for implantation in the humeral medullary cavity. In case that an intramedullary fixator is used, such as an intramedullary nail (e.g., a proximal humeral nail), it is first implanted in the humeral intramedullary cavity. In some embodiments, the intramedullary nail comprises a proximal opening, so that subacromial spacer fixation may include connecting the subacromial spacer to the intramedullary nail in the proximal opening. In some embodiments, a nail guide is first attached to the prosthesis and/or to the intramedullary nail. In some such embodiments, the nail guide is configured to guide at least one locking screw in at least one orientation to a corresponding at least one lateral opening in the intramedullary nail (e.g., proximal humeral nail). In some such embodiments, fixation is accomplished by optionally traveling a locking screw through a corresponding lateral opening in the proximal humeral nail. In case that an intramedullary nail is already implanted before the method starts, and in case that the intramedullary nail is sealed at a proximal opening thereof with a sealing cap, the cap may be removed and the prosthesis may be attached instead into the proximal opening. Optionally, additionally or alternatively, fixation includes administering curable cement, optionally a PMMA type. In some embodiments, fixation includes also connection between parts of a prosthesis, for example, at least two of subacromial spacer member, an intramedullary fixator and an optional interconnecting element.

[0035] In some embodiments, before or after fixation in the medullary cavity (the latter is optional especially in case of using an intramedullary nail), the distance between the humeral head and the acromion is chosen. In some embodiments, the surface of the subacromial spacer is contoured to maintain the acromion in the chosen distance to the humeral head upon rotation, particularly during a shoulder full range of motion. In some embodiments, the subacromial spacer is selected in correlating in size according to the distance. Optionally, alternatively or additionally, a size of the prosthesis or of any part or member thereof are changed (e.g., expanded or replaced) in correlation with the distance.

[0036] Referring to the drawings, FIG. 2 schematically illustrates an exemplary prosthesis 100 shown implanted and deployed in a human shoulder. Prosthesis 100 includes a subacromial spacer 130, an intramedullary fixator 1 10 and an inner member 120. Prosthesis 100 is implanted through the apex of the humeral head and subacromial spacer 130 is located substantially beneath the acromion at rest (as shown). Subacromial spacer 130 is

substantially roundish in cross section and/or includes at least upper surface, shown in contact with the acromion, being contoured (e.g., curved) to allow unhindered motion relative to the acromion when the humerus rotates (e.g., during abduction and adduction). Upper surface of subacromial spacer 130 is elevated and contoured such to maintain a chosen distance between humeral head and acromion at different postures of the humerus relative to acromion and scapula. Optionally, the upper surface is in direct contact partly or throughout an entire shoulder normal or full range of motion. Optionally, upper surface is in direct contact with the acromion, maintaining it is a chosen (e.g., normal) distance, or range of distances, to humeral head during and/or after full abduction followed by a full adduction.

[0037] Intramedullary fixator 1 10 may be any substantially rigid or semi-rigid elongated member shaped and sized to fit in the humeral medullary cavity and fixate prosthesis 100 thereto. Intramedullary fixator 1 10 may be provided in a fixed size or be expanded or allowed to expand to a chosen size and/or shape, to either loosely or snugly fit in the medullary cavity. If not pressed to anchor or fixate in the medullary cavity, fixator 1 10 is optionally fixated thereto using auxiliary means such as laterally introduced locking screws. In some embodiments, fixator 1 10 is an intramedullary nail in the form of or resembling a proximal humeral nail, optionally a short proximal humeral nail being 200 mm or less, optionally 160 mm or less in length. In some embodiments, medullary cavity is slightly reamed, at least along a portion or length segment thereof, for better fitting with fixator 1 10.

[0038] Inner member 120 may be fixedly attached or hingedly or pivotally attached to subacromial spacer 130 at its proximal end and having a distal end connectable (either detachably or permanently) with intramedullary fixator 1 10. Optionally and alternatively, inner member 120 may be fixedly attached or hingedly or pivotally attached to

intramedullary fixator 1 10 at its proximal end and having a distal end connectable (either detachably or permanently) with subacromial spacer 130. Optionally, alternatively or additionally, inner member 120 is provided disconnected at both ends. Optionally, inner member 120 is picked out of a variety of inner members differentiated by shape and/or size, depending, for example, in chosen distance or range of distances between upper surface of subacromial spacer 130 and proximal end of fixator 1 10.

[0039] Reference is now made to FIG. 3 which schematically illustrates an exemplary prosthesis 200 adapted for fixating to a proximal humeral nail (not shown). Prosthesis 200 implantation may be performed together with proximal humeral nail implantation or to such a nail being readily implanted in a humerus (not shown). Prosthesis 200 includes a fixation member 210 provided in a bipolar articulation with a subacromial spacer member 220, allowing rotation in at least one axis therebetween. Fixation member 210 includes an elongated body sized and configured for partial insertion into a proximal opening in a proximal humeral nail (PHN), and comprising fixation threads or fins 212 in proximity to its distal end, adapted to thread with, press and/or lock onto inner wall portions of the nail. A stopper 214 sets maximal protrusion of prosthesis 100 into a PHN via its proximal opening, hence providing minimal or correct distance x between the superior portion of a humeral head (in which the PHN is implanted) and the upper surface of subacromial spacer member 220. Distance x may be any chosen value between 3 mm and 17 mm, optionally between 6 and 8 mm. An optionally frustum shaped portion 216 emerges proximally from stopper 214 and ends with a hinge 218 having a circular or other roundish cross section (optionally a cylinder or a sphere). Subacromial spacer member 220 includes a curved body 222 acting as a socket to hinge 218 allowing articulated motion around it that is limited by lateral borders 226. An optional covering portion 224 may be provided on top of body 222 and may differ from body 222 by at least one feature and/or material. In some embodiments, covering portion 224 is resilient while body 222 is substantially rigid. Optionally, alternatively or additionally, covering portion 224 has an upper surface configured for continuous contact with an acromion, allowing unhindered slippery motion with it, and comprises a coefficient of friction substantially smaller than of curved body 222.

[0040] In some embodiments, for example in scenarios where there is a need to implant a subacromial spacer adjacent to a non-torn or partially less-severely torn rotator cuff, a prosthesis including a subacromial spacer part or member may be positioned and/or shaped such to avoid harm and interference with rotator cuff integrity and/or function. FIGS. 4A-C schematically illustrate an exemplary prosthesis 300 configured for greater tubercle introduction. In FIG. 4 A prosthesis 300 is shown in a substantially medial humerus position whereas in FIG. 4B it is shown in a substantially lateral humerus position. Prosthesis 300 includes an intramedullary fixator 310 sized and/or configured for implantation in a medullary cavity of a human humerus, a subacromial spacer member 330 and an inner member 320. In some embodiments, intramedullary fixator 310 is a short or a long proximal humeral nail. Fixator 310 may be inserted through a central entry point located at the top of the humeral head or it may be inserted through a lateral entry point located inside the greater tubercle. As such, intramedullary fixator 310 may be traveled through or adjacent rotator cuff RC. Optionally and alternatively, intramedullary fixator 310 is introduced through a different entry point, optionally allowing bypass to RC.

[0041] Subacromial spacer 330 is sized and shaped to maintain direct contact with acromion and/or a chosen distance or range of distances between humeral head and acromion at most or any humerus positioning. In some embodiments, inner member 320 projects from the humerus laterally to the humeral head and in some such embodiments, subacromial spacer 330 may be contoured and/or lengthened to facilitate contact with the acromion at a full medial humerus positioning. A shown, subacromial spacer 330 includes a medial upper portion 332 and a lateral upper portion 334 configured such that at substantial medial humerus position portion 332 is in contact with the acromion, and at substantial lateral humerus position portion 334 is in direct contact with the acromion. As such, subacromial spacer 330 may be considered a cam-like member sized and shaped to convert humerus circular motion to linear motion and/or to maintain distance or range of distances relatively between humeral head and acromion. In some occasions where, for example in a substantial lateral humerus positioning (as shown in FIG. 4B), subacromial spacer 330 travels across the periphery of rotator cuff RC, it may be provided in a shaped and configured also to avoid actual contact with RC throughout its entire travel. FIG. 4C shows an upward cross section of subacromial spacer 330 and RC when humerus is at lateral position; as shown, subacromial spacer 330 has an inverted U-shaped cross section having medial upper portion 332 divided into two contact portions enclosing a void sized and shaped to accommodate RC with no direct contact with its boundaries.

[0042] Reference is now made to FIGS. 5A-B which schematically illustrate prosthesis 340 connectable to a short proximal humeral (PH) nail system 350 and a long PH nail system 360, respectively. Nail system 350 includes a short PH nail 352, a plurality of proximal lock screws 354 and a plurality of distal lock screws 356. Nail system 360 includes a long PH nail 362, a plurality of proximal lock screws 364 and a plurality of distal lock screws 366. Either nail system 350 or nail system 360 may be provided with prosthesis 340, optionally in a single kit, or may be readily implanted in the humerus before or during prosthesis 340 implantation procedure. In some embodiments, the choice between a short or a long PH nail relates to the condition of the humerus, whether it is intact, fractured and/or osteoporotic (or otherwise ill). Prosthesis 340 may be similar or identical to prosthesis 200 in the sense it includes a subacromial spacer member and a connection member for connecting with an intramedullary nail.

[0043] Reference is made to FIGS. 6A-F which schematically illustrate steps in a method for implanting an exemplary prosthesis 460 and an intramedullary fixator 440 in a humerus. A patient's arm enclosing a humerus is shown in part and in cross section. A surgical kit 400 is used comprising at least one of a guide pin 410, a drill 420, a delivery apparatus 430, intramedullary fixator 440, a guide 450 and prosthesis 460 optionally provided as separated connectable inner member 462 and subacromial spacer member 464. As shown in FIG. 6A, guide pin 410 is first used for creating a percutaneous passage from outside the arm to the humeral head, optionally through the lateral deltoid and/or the rotator cuff (not shown). An entry portal to the arm may be central or lateral. Positioning and/or alignment of guide pin 410 may be then checked using imaging (e.g., fluoroscopy).

[0044] As shown in FIG. 6B, drill 420 is introduced and directed towards a target point at humeral head boundary. In some embodiments and as shown in the figure, drill 420 includes a lumen used to pass over and along guide pin 410. Drill 420 is then used to drill through humeral head and remove bony tissue at least until reaching humeral medullary cavity, optionally exposing it for an implantation therein. Next, as shown in FIG.6C, intramedullary fixator 440 is implanted in the medullary cavity. Intramedullary fixator 440 is optionally a short PH nail which comprises an elongated body 444, optionally slightly bent as commonly known in current commercially available PH nail systems, optionally for easing lateral introductions. A proximal portion 442 in fixator 440 is hollow and ends with a proximal opening at its top. Proximal portion 442 is connected, optionally threaded, to delivery apparatus 430 when fixator 440 is introduced and deployed. Although not shown, delivery apparatus 430 may be applied while connected to guide 450. Delivery apparatus 430 includes a distal member 434 configured for delivering in patient's arm and a proximal member 432 configured for connecting with guide 450. Optionally, proximal member 432 and distal member 434 are hollow and allow introduction of parts therethrough from outside the arm and into fixator 440 and/or medullary cavity, when deployed. Optionally, distal member 434 includes connection means (e.g., thread, snap-lock, nut or bolt, etc.) to outside boundaries of proximal portion 442 of fixator 440, and/or to inner boundaries thereof. For implanting fixator 440 in the medullary cavity, a hammer or other pushing or pressing means are used to force it in place.

[0045] As shown in FIG. 6D, once in place, guide 450 is connected to delivery apparatus 430 and is used for locking fixator 440 in the medullary cavity using lateral locking screws. Guide 450 includes a leg 454 with openings and an extension 452 detachably connectable to proximal member 432 of delivery apparatus 430. When fixator 440 is correctly in place and connected with delivery apparatus 430 and guide 450, a plurality of lateral channels, including a proximal channel 456 and a distal channel 458, are introduced through the openings of leg 454 and through the arm thereby creating passages until humerus. Drills or other means are introduced (not shown) via channels 456 and 458 and utilized to create lateral openings in the humerus towards medullary cavity, until reaching corresponding lateral openings in elongated body 444 of fixator 440. As shown in FIG.6E, a plurality of locking screws, including a proximal locking screw 446 and a distal locking screw 448, are provided at least partially across the humerus and through corresponding lateral openings in fixator 440 and locking fixator 440 in the medullary cavity. After placement of the locking screws, guide 450 is removed.

[0046] Delivery apparatus 430 is optionally used then to deliver members of prosthesis 460 into the subacromial space and to connect with fixator 440. Optionally and alternatively, delivery apparatus 430 is first removed and only after prosthesis 460 and/or members thereof are delivered via the previously made percutaneous channel and at least partly occupied with delivery apparatus 430. In some embodiments, inner member 462 and subacromial spacer member 464 are delivered separately and sequentially, so at first inner member 462 is connected to fixator 440 (optionally in its proximal opening) and then subacromial spacer member 464 is delivered and connected to inner member 462. Optionally and alternatively, both members are delivered connected, optionally in lower or even lowest profile. In some embodiments, optionally in any of the two delivery options described above, subacromial spacer member 464 is delivered at lower profile, optionally having its longitudinal axis substantially coinciding with longitudinal axis of delivery apparatus 430 and/or of fixator 440. FIG. 6F shows prosthesis 460 fully deployed with intramedullary fixator 440 locked in medullary cavity with locking screws 446 and 448. [0047] Reference is now made to FIG. 7 which schematically illustrates an exemplary prosthesis 500. Prosthesis 500 is shown in a partially illustrated humerus having a humeral head and a medullary cavity. Prosthesis 500 includes an intramedullary fixator 510 provided connected or connectable with an expandable subacromial spacer 530. Subacromial spacer 530 includes an expandable spacer member 532 connected to a non-expandable inner member 534 shown connected to fixator 510. In some embodiments, expandable spacer member is inflatable, optionally by liquid (e.g., saline) or by gas (e.g., air), or optionally by other flowable materials, including but not limited to gels, hyaluronic acid, curable materials or others. In some such embodiments, subacromial spacer 530 includes an inflation port 536 connectable to an inflation system 520 comprises a pressurized or pressuring member 522, optionally filled with an inflation medium or connectable with an inflation medium reservoir (not shown), and an interconnecting line 524 allowing a pressurized inflation medium flowing therein from member 522 to inflation port 536. In some embodiments,

intramedullary fixator 510 is a rigid non-expandable type intramedullary nail as described in previous disclosures. Optionally and alternatively, fixator 510 includes at least one expandable (e.g., inflatable) portion, such as a distal expandable portion 514 and a proximal expandable portion 516, allowing it to anchor and/or press to adjacent medullary cavity wall portions. Advantages of using expandable portions instead of locking screws may include less harm to humerus and other body tissues during operation, less healing/hospitalization time and possibility to match different diameters and cross sections of medullary cavities in different humerus bones. In some embodiments, portion 514 and/or 516 is rigid enough to force shaped deformation to at least one of adjacent marrow and/or spongy bone tissues and/or cortical bone tissues. Optionally and alternatively, portion 514 and/or 516 is flexible enough to conform to local shape imposed by spongy bone tissues and/or compact bone tissues. In some embodiments, portions 514 and 516 are fluidly communicating with an inflation port, either inflation port 536 or a different one (not shown).

[0048] In some embodiments, the prosthesis or any of its members or parts (e.g., a subacromial spacer member) are delivered disassembled sequentially to a target in-body location and are assembled in-place. Advantages of such prostheses may include a smaller entry portal and delivery passage from outside the body to the humeral head and other advantages of minimally invasive procedures. FIGS. 8A-B schematically illustrate an exemplary subacromial spacer assembly 600, which includes four interconnectable members 610, 620, 630 and 640, although it may include any number of interconnectable members of different sizes and shapes according to need and design efficiency. Any of the members include a solid having an upper contact surface (surface 612 in member 610, surface 622 in member 620, surface 632 in member 630 and surface 642 in member 640) configured for providing a contact portion for maintaining a continuous direct contact with the acromion and/or a chosen distance or range of distances between humeral head and acromion, when correctly deployed to an intramedullary fixator (not shown) readily implanted in a humeral medullary cavity. Any of the members include a perpendicular extension downwardly arising from a corner of the solid (extension 614 in member 610, extension 624 in

member 620, extension 634 in member 630 and extension 644 in member 640) configured to assemble together with rest of extensions into a single leg connectable with an intramedullary fixator.

[0049] Reference is now made to FIG. 9A which schematically illustrates a monoblock type prosthesis 700 which is unitary formed and shaped such to include an intramedullary fixation portion 701 and a subacromial spacer portion 703. A neck portion 702 separates between fixation portion 701 and spacer portion 703 and is configured to be positioned adjacent outer surface of the humeral head upon implantation. Spacer portion 703 includes an upper surface 704 shaped and sized for continuous contact with an acromion when implanted in a humerus.

[0050] FIG. 9B shows another exemplary prosthesis 710 being optionally similar in overall deployment shape to monoblock prosthesis 700, having similar intramedullary fixation member 71 1 and a neck portion 712. A subacromial spacer member 713 having an upper contact surface 714 is pivotally fixated to fixation member 71 1 adjacent neck portion 712, optionally to ease maneuvering and delivery of prosthesis 710 in the body. Optionally, a spring (not shown) is provided in between subacromial spacer member 713 and fixation member 71 1 so that the shown form may be set as a normally unbiased form (i.e., when no external forces are applied to stretch such a spring).

[0051] Although the invention has been described in conjunction with specific

embodiments thereof, it is evident that many alternatives, modifications and variations will be apparent to those skilled in the art. Accordingly, it is intended to embrace all such alternatives, modifications and variations that fall within the spirit and broad scope of the appended claims.

[0052] All publications, patents and patent applications mentioned in this specification are herein incorporated in their entirety by reference into the specification, to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated herein by reference. In addition, citation or identification of any reference in this application shall not be construed as an admission that such reference is available as prior art to the present invention. To the extent that section headings are used, they should not be construed as necessarily limiting.