the endoscopic insertion apparatus shown in fig1 to 5 essentially comprises a holding device 1 , a screwing - in tool 2 , a socket wrench 3 and a clamp screw key 4 . fig1 shows a possible use for the holding device 1 in conjunction with the screwing - in tool 2 . to connect bone parts , for example two vertebrae , a bone anchoring element , for example a hollow screw 5 , is screwed into the vertebra 6 , which is shown purely schematically in dashed lines . the hollow screw 5 is essentially formed by three support pins 7 of equal length which run parallel to one another . the support pins 7 are arranged in cross - section at the corners of an equilateral triangle and are surrounded by a screw thread 8 over their whole length and are connected to the screw thread 8 . one end of the essentially cylindrical hollow screw 5 is provided with a cylindrical termination plate 9 which bears a ball head 10 extending in the axial direction . the ball head 10 contains an internal hexagon 11 in the axial direction , said internal hexagon 11 ending in the manner of a blind hole in the direction of the screw thread 8 . the ball head 10 is essentially rotationally symmetrically surrounded by a vertebra plate 12 which has a socket - like ball head mount 13 , in which the ball head 10 is mounted . this allows the vertebra plate 12 to turn around the ball head 10 and to be inclined away sideways from the common axis of symmetry . the outer edge of the vertebra plate 12 has spikes 14 pointing in the direction of the hollow screw 5 . in addition , the vertebra plate 12 has a sleeve section 15 which extends in the axial direction as an extension of the ball head mount 13 . sleeve section 15 is provided with a clamp screw thread 16 on the outside and with a holding thread 17 on the inside . to screw in the hollow screw 5 , the vertebra plate 12 is connected to the two - part holding device 1 . the holding device 1 comprises two parts , a guide sleeve 18 and a sleeve - like centering piece 19 . one end of the centering piece 19 of the holding device 1 has a screwing - in holding thread 20 which can be screwed into the holding thread 17 of the vertebra plate 12 . the screwing - in holding thread 20 has a somewhat smaller external diameter than the centering piece 19 , which forms a stop shoulder 21 . the screwing - in holding thread 20 then extends over a length of the centering piece 19 in such a manner that the ball head 10 is still free to move inside the ball head mount 13 when the stop shoulder 21 encounters an end edge 22 of the sleeve section 15 . the internal diameter of the centering piece 19 broadens out after approximately one quarter of its length , starting from the end provided with the screwing - in holding thread 20 , such that the wall thickness of the centering piece is reduced to approximately two thirds . the outer surface of the centering piece 19 is completely smooth , starting from the stop shoulder 21 in the axial direction to approximately three quarters of the length of the centering piece 19 . this is adjoined by a coupling outer hexagon 23 produced in the outer peripheral wall , the largest external diameter of said coupling outer hexagon 23 being somewhat smaller than the largest external diameter of the centering piece 19 . the coupling outer hexagon 23 is adjoined by a further smooth centering sleeve section 24 , whose external diameter is reduced somewhat towards the other end of the centering piece 19 . the centering piece 19 also has a centering end 26 which is surrounded by an annular bead 25 projecting outwards radially . this annular bead 25 has a latching edge 27 pointing in the direction of the hollow screw 5 . the guide sleeve 18 is connected to the centering piece 19 so as not to rotate and so as to be immovable in the axial direction . the end of the longitudinal guide sleeve 18 which faces the centering piece 19 is provided with a coupling inner hexagon 28 which surrounds the coupling outer hexagon 23 of the centering piece 19 in a positively locking manner . the end of the guide sleeve 18 seated on the centering piece 19 then encounters a coupling stop 29 of the centering piece , which is formed by the transition between the longest smooth section of the centering piece 19 and the coupling outer hexagon 23 . extending in the axial direction of the guide sleeve 18 are two spring windows 30 which are arranged so as to be staggered by 180 ° and whose longitudinal edges run parallel to the longitudinal axis of the guide sleeve 18 . the spring windows 30 are almost completely filled by a leaf spring 31 which supplements the sleeve wall and is connected to the guide sleeve 18 at one window edge 32 which extends in the circumferential direction of the guide sleeve 18 . the free end of the leaf spring 31 has a semi - annular spring bead 33 which extends radially inwards and forms a latching lug 34 being arranged away from the centering piece 19 . the thickness of the springs in the radial direction increases in steps , starting from the latching lug 34 , which forms an unlocking surface 35 . after a maximum wall thickness , this thickness in turn decreases continually and thus forms a locking surface 36 . adjacent to the locking surface 36 , the wall thickness of the leaf spring 31 remains essentially constant up to the window edge 32 . the guide sleeve 18 extends over approximately two thirds of its length with a constant internal and external diameter . in the end region of the guide sleeve 18 , the outer diameter tapers a little at a taper edge 37 . further towards the end an annular groove 38 is formed in the guide sleeve 18 . directly adjacent to the sleeve end 39 , the guide sleeve 18 is provided with a removal hexagon 54 which has the same external diameter as the annular groove 38 . this forms an annular coupling projection 40 . the holding device 1 is formed from the centering piece 19 and the guide sleeve 18 as a unit which is connected together so as to be non - rotating . in the connected state , the coupling inner hexagon 28 of the guide sleeve 18 surrounds the coupling outer hexagon 23 of the centering piece 19 . the arrangement of the annular bead 25 on the centering piece 19 is provided such that the latching lug 34 on the leaf spring 31 of the guide sleeve 18 engages behind the latching edge 27 when the guide sleeve 18 encounters the coupling stop 29 of the centering piece 19 . in this manner , the centering piece 19 and the guide sleeve 18 are connected to one another with virtually no play . the vertebra plate 12 , and hence also the hollow screw 5 which is connected to it , can be held , guided and positioned by the holding device 1 . to screw the hollow screw 5 into the vertebra 6 , the screwing - in tool 2 is required . the screwing - in tool 2 comprises a grip unit 41 and a tool insert 42 . the tool insert 42 essentially comprises a cylindrical rod having an external diameter chosen such that the tool insert 42 can be inserted into the guide sleeve 18 and is free to move in it . that end of the tool insert 42 which is remote from the grip unit is shaped as a hexagon 43 which can be inserted in a positively locking manner into the inner hexagon 11 of the ball head 10 of the hollow screw 5 . starting from the hexagon 43 , the tool insert 42 merges into the cylindrical rod , which has the smallest diameter over this section . this diameter broadens out continuously to the maximum diameter of the tool insert 42 . in this way , a slide surface 44 in the form of a truncated cone is formed . this is adjoined by a tool section 45 having the maximum diameter of the tool insert 42 . further along the tool insert 42 , the diameter is reduced over a rod section 46 , specifically such that oblique slide surfaces are formed in the transitional regions 47 and 48 . the other end of the tool insert 42 is connected to the grip unit 41 via a coupling device 50 shown schematically by the annular projection 49 . the grip unit 41 is essentially rotationally symmetrical and comprises a mounting unit 51 , which can be connected to the tool insert 42 so as not to rotate , and a t - shaped handle 52 . the handle 52 is arranged on the mounting unit 51 via a ratchet mechanism which is known to the person skilled in the art . the mounting unit 51 has a rotationally symmetrical cylindrical recess 53 into which the tool insert 42 can be inserted . the recess 53 is additionally prepared to receive that end of the guide sleeve 18 which is provided with the annular groove 38 , so that the coupling projection 40 can slide in the recess 53 in the axial direction . the external diameter of that end of the grip unit 41 which faces the guide sleeve 18 broadens out towards the end . starting from the maximum diameter , this diameter is reduced in a single step , which forms a slide bearing surface 55 running transversely with respect to the longitudinal axis of the grip unit 41 . in this region of the grip unit 41 , there is a spring - actuated locking unit 56 , as shown in cross - section in fig2 . in the region of the single - step reduction in the diameter of the grip unit 41 , part of the sleeve - like region of the grip unit 41 is removed , so that a c - shaped mounting guide 57 remains on the grip unit 41 . transversely to the longitudinal axis , a blocking slide 58 is inserted directly adjacent to the slide bearing surface 55 . the bottom end of the c - shaped mounting guide 57 is provided with a securing thread 59 . a securing nut 60 is screwed onto this securing thread and forms the termination of the grip unit 41 . the blocking slide 58 thus slides between the slide bearing surface 55 and the securing nut 60 . the c - shaped region of the mounting guide has a hole 61 formed radially opposite the open section , and a spring 62 is supported in this hole 61 so as to project radially outwards . the other end of the spring 62 is supported in a spring hole 63 provided for it in the blocking slide 58 , the axes of symmetry of the hole 61 and the spring hole 63 coinciding . the blocking slide 58 is perforated parallel to the longitudinal axis of the grip unit 41 . in the spring - loaded state , the blocking slide 58 locks the guide sleeve 18 located in the recess 53 . the blocking slide 58 then encounters one side of the annular groove 38 in the guide sleeve 18 with a semicircular inner edge 66 of the perforation 64 . in this position , a semicircular outer edge 67 of the blocking slide 58 is matched to the diameter of the grip unit 41 . two further side edges 65 of the blocking slide 58 run parallel to the axis of symmetry of the spring 62 . the pressure edge 68 opposite the outer edge 67 has a significantly larger radius of curvature and serves to actuate the blocking slide 58 by pressing onto the pressure edge 68 . a further component of the endoscopic insertion apparatus which is provided is the socket wrench 3 , as shown in fig4 . this essentially comprises an elongated socket sleeve 69 . one end of the socket sleeve 69 has a key grip 70 which runs transversely with respect to the longitudinal axis and is formed by two radially projecting grip rods 71 . at the opposite end , the socket sleeve 69 is extended by a rotationally symmetrical nut mount 72 whose inside is shaped such that it can surround a clamp nut 73 in a positively locking manner . the clamp nut 73 is therefore situated in a rotationally symmetrical arrangement with respect to the longitudinal axis of the socket sleeve 69 . a further instrument of the insertion apparatus which is provided is the clamp screw key 4 . this essentially resembles the screwing - in tool 2 and accordingly comprises a handle 74 and a screwing tool 75 . the screwing tool 75 and the handle 74 are connected to one another detachably . this connection can be designed in a similar manner to the connection between the tool insert 42 and the grip unit 41 of the screwing - in tool 2 . similarly , the handle 74 can be designed as a ratchet grip . that end of the screwing tool 75 which is remote from the handle 74 has a taper 76 which merges into a cylindrical end section 77 . the end of the end section 77 bears a shaping tool 78 ( not shown in further detail ). this is shaped , for example as an outer hexagon , such that it can engage in a complementary recess in a clamp screw 79 having a clamp thread 80 on the outside which can be screwed into the holding thread 17 of the sleeve section 15 of the vertebra plate 12 of the hollow screw 5 . the use of the endoscopic insertion apparatus will now be described below with the aid of fig1 to 5 for the case of relative fixing of two vertebrae 6 . for this , the holding device 1 and the screwing - in tool 2 must first be prepared . in a first step , the hollow screw 5 is screwed to the centering piece 19 using the holding thread 17 provided for this . the screwing - in holding thread 20 of the centering piece is screwed into the holding thread 17 until the centering piece 19 encounters the end edge 22 of the sleeve section 15 with the stop shoulder 21 . next , the guide sleeve 18 is connected to the centering piece 19 . for this purpose , that end of the guide sleeve 18 which has the leaf spring 31 is guided in the axial direction over that end of the centering piece 19 which has the annular bead 25 . the configuration of the ends of the centering piece 19 and of the guide sleeve 18 with a coupling outer hexagon 23 and a coupling inner hexagon 28 produces six angle dependent coupling positions . accordingly , the guide sleeve 18 needs to be turned relative to the centering piece 19 such that the coupling inner hexagon 28 engages completely around the coupling outer hexagon 23 . in the course of this axial movement of the guide sleeve 18 towards the centering piece 19 , the spring bead 33 of the leaf spring 31 slides on the annular bead 25 , which causes the leaf spring 31 to open outwards in the radial direction . as soon as the end of the guide sleeve 18 encounters the coupling stop 29 of the centering piece 19 , the leaf spring 31 relaxes because the latching lug 34 slides back behind the latching edge 27 and is latched there . the holding device 1 is thus completely assembled , and the guide sleeve 18 is connected to the centering piece 19 so as not to rotate and so as to be fixed in the axial direction . the screwing - in tool 2 can now be inserted into the holding device 1 . this holding device was previously assembled from the grip unit 41 and the tool insert 42 using the coupling device 50 . the screwing - in tool 2 is now pushed into the holding device 1 until the blocking slide 58 encounters the sleeve end 39 . the exertion of pressure onto the pressure edge 68 of the blocking slide 58 moves the blocking slide 58 transversely with respect to the longitudinal axis of the screwing - in tool , and this means that the screwing - in tool 2 can now be pushed further forward into the holding device 1 . if an axial position as shown in fig1 is reached , the pressure on the blocking slide 58 is reduced and the inner edge 66 of the blocking slide 58 slides forward into the annular groove 38 . in this way , the grip unit 41 is connected to one end of the guide sleeve 18 and is fixed in the axial direction . while the screwing - in tool 2 was being inserted into the holding device 1 , which already has the hollow screw 5 screwed onto it , the hexagon 43 slid into the inner hexagon 11 of the ball head 10 of the hollow screw 5 . the preparations described above have now produced a unit comprising the holding device 1 , the screwing - in tool 2 and the hollow screw 5 . the hollow screw 5 can now be attached to a vertebra 6 and can be screwed into the vertebra 6 by turning the hand grip 52 of the screwing - in tool 2 . for this , the hand grip 52 has to be turned clockwise out of sight of the surgeon , as indicated in fig1 . the hollow screw 5 is now screwed into the vertebra 6 to an extent such that the spikes 14 have not yet penetrated the vertebra 6 . in a subsequent step , the guide sleeve 18 is separated from the centering piece 19 , specifically by withdrawing the screwing - in tool 2 from the holding device 1 . to detach the screwing - in tool 2 from the guide sleeve 18 , the blocking slide 58 must first be released from its locked position . this is done , in turn , by exerting pressure onto the pressure edge 68 . the screwing - in tool 2 can now be withdrawn from the guide sleeve 18 in the axial direction . during this movement , the transitional region 48 slides on the unlocking surface 35 of the tool insert 42 , which stretches the leaf spring 31 radially outwards . this causes the latching lug 34 to move out from its latching position behind the latching edge 27 and release the latter , as shown in fig3 . the guide sleeve 18 and the centering piece 19 are now unlocked and can be separated from one another in the axial direction . the centering piece 19 remains on the hollow screw 5 . a further centering piece 19 is once again assembled using the withdrawn unit comprising the screwing - in tool 2 and the guide sleeve 18 in the manner described , after it has been connected to a further hollow screw 5 . using the procedure which is already known , the further hollow screw 5 is screwed into an adjacent vertebra 6 . the guide sleeve 18 is then separated from the centering piece 19 , in the manner which is already known , by withdrawing the screwing - in tool 2 . the two centering pieces can now be used to thread a connection plate 81 and thus place it into the connection plate mounts 82 so as to connect the two hollow screws 5 . instead of a connection plate 81 , two connection rods 83 can also be provided . to fix the connection plate 81 or the connection rods 83 to the vertebra plates 12 of the hollow screws 5 , a clamp nut 73 is placed into the nut mount 72 of the socket wrench 3 . the socket wrench 3 is now guided , together with the clamp nut 73 , over the centering piece 19 , and the internal thread of the clamp nut 73 is screwed onto the clamp screw thread 16 and firmly tightened . the socket wrench 3 is then withdrawn and fitted with another clamp nut 73 . the socket wrench 3 is inserted over the further centering piece 19 in a similar way and the clamp screw 73 is first screwed loosely to the vertebra plate 12 . if appropriate , a traction apparatus ( not shown ) can be used at this stage to set the distance between the two vertebrae 6 as desired . as soon as the desired distance has been achieved , the socket wrench 3 is used to screw the other clamp nut 73 firmly to the second vertebra plate 12 as well . the two vertebrae 6 are now firmly connected to one another via the connection plate 81 . to bring the hollow screws 5 into their final position , the centering piece 19 must first be removed . for this , the guide sleeve 18 is fitted over the centering piece 19 and latched to it , as described further above . the guide sleeve 18 and the centering piece 19 are thus connected to one another so as not to rotate . an open - ended wrench ( not shown ) can be used to remove the holding device 1 from the hollow screw 5 by means of the removal hexagon 54 by turning the holding device 1 anticlockwise . if the two centering pieces 19 are removed from the hollow screws 5 in this way , the screwing - in tool 2 can be engaged in the inner hexagon 11 of the ball head 10 of the hollow screw 5 again . the hollow screw 5 is now screwed into the vertebra 6 until the spikes 14 penetrate the vertebra 6 and the vertebra plate 12 bears against the vertebra 6 . to prevent further rotation of the vertebra plate 12 relative to the ball head 10 , a clamp screw 79 is placed onto the shaping tool 78 of the clamp screw key 4 and 15 screwed to the vertebra plate 12 . a clamp thread 80 of the clamp screw 79 then engages in the holding thread 17 of the sleeve section 15 of the vertebra plate 12 . the two vertebrae 6 are finally fixed when the two hollow screws 5 are provided with a clamp screw 79 which is tightened so firmly that relative movement of the vertebra plate 12 and the ball head 10 becomes impossible . the clamp screw key 4 can then be removed from the patient &# 39 ; s body again .
an endoscopic insertion apparatus for a spinal column implant system is provided having a screwing - in tool and an elongated holding device for holding a bone plate . the implant system essentially comprises at least one anchoring element , a bone plate connected to the anchoring element and at least one connection element for connecting at least two bone plates . the holding device comprises an insertion sleeve and a centering element . the centering element and the insertion sleeve can be connected to one another in a screwing - in position by a coupling mechanism in the direction of a longitudinal axis of the holding device , and the centering element and insertion sleeve can be separated from one another in a centering position . the invention reduces the number of parts used as compared to prior art insertion apparatus and simplifies handling , particularly of the centering element , since the centering element is provided as part of the holding device .