The present invention relates generally to a system for installing knotless suture fasteners onto sutures used, for example, to secure medical implants without requiring suture knots.
Heart valve disease is a widespread condition in which one or more of the valves of the heart fails to function properly. Various surgical techniques may be used to repair a diseased or damaged valve, including securing a cardiac implant to the diseased annulus. Cardiac implants include a prosthetic heart valves and annuloplasty rings. In a valve replacement operation, the damaged leaflets are excised and the annulus sculpted to receive a replacement valve. About one-half of patients receive a mechanical heart valve, which are composed of rigid, synthetic materials, and the remaining patients received bioprosthetic heart valve replacements, which utilize biologically derived tissues for flexible fluid occluding leaflets. Another less drastic method for treating defective valves is through repair or reconstruction, which is typically used on minimally calcified valves. One repair technique that has been shown to be effective in treating incompetence is annuloplasty, in which the deformed valve annulus is reshaped by attaching a prosthetic annuloplasty repair segment or ring to the valve annulus.
In a typical cardiac implant procedure, the aorta is incised and, in a valve replacement operation, the defective valve is removed leaving the desired placement site that may include a fibrous tissue layer or annular tissue. Known cardiac implant techniques include individually pre-installing sutures through the fibrous tissue or desired placement site within the valve annulus to form an array of sutures. Free ends of the sutures are draped out of the thoracic cavity and are spaced apart, sometimes being distributed around a suture organizer. The free ends of the sutures are then individually threaded through a suture-permeable sewing edge of the annuloplasty ring or prosthetic heart valve. Once all sutures have been run through the sewing edge (typically 12 to 18 sutures), all the sutures are pulled up taught and the prosthesis is slid or “parachuted” down until it sits against the target annulus. The cardiac implant is then secured in place by traditional knot tying of the anchoring sutures on the proximal side of the sewing edge. There are often 7-10 knots on each suture advanced by pushing the knot one at a time to the desired location by using a knot pusher device. This procedure is obviously time-consuming.
During open-heart procedures, the patient is on heart-lung bypass which reduces the patient's oxygen level and creates non-physiologic blood flow dynamics. The longer a patient is on heart-lung bypass, the greater the risk for complications including permanent health damage. Existing techniques for suturing cardiac implants extend the duration of bypass and increase the health risks due to heart-lung bypass. Furthermore, the securing force created by suturing varies significantly because the pre-tensioning of the suture just prior to knot tying is difficult to consistently maintain, even for an experienced medical professional.
There exists a need for devices and methods that reduce the time required to secure a medical implant in place. Additionally, there exists a need to make it easier to secure a cardiac implant, in particular, in place. Currently, a clinician must work in the limited space near the heart to tie knots in sutures. This is a cumbersome process even for a clinician of great dexterity and patience.
The present application discloses an installation system for securing an annuloplasty ring or a prosthetic heart valve to a heart valve annulus using knotless suture fasteners. The knotless suture fasteners are desirably spring-biased so as to self-actuate and grip onto annulus anchoring sutures passed therethrough. The system includes a fastener deployment tool with a proximal handle and a distal shaft to which a fastener cartridge attaches. A plurality of disposable cartridges are sequentially attached to the end of the deployment tool and used to secure the medical implant one fastener at a time. The deployment tool may also cut the sutures being fastened.
A preferred embodiment of the present application includes a system for securing a suture without knots, comprising a reusable deployment tool having a distal shaft terminating in a distal tip, the tool including an ejector movable within the distal shaft, and a plurality of pre-assembled, disposable fastener cartridge and suture snare subassemblies. Each subassembly has a cartridge having a lumen that receives a single suture fastener within a distal end thereof, a proximal end of the cartridge lumen being sized to engage the distal tip of the deployment tool shaft. The suture fastener includes clamping structure that can be flexed to an open condition through which a suture can pass and is biased toward a closed position which clamps onto a suture passed therethrough. The cartridge has at least one stop that maintains the suture fastener in its open condition. The subassembly further includes a suture snare having an elongated flexible snare portion size to pass radially inward through aligned ports in the engaged cartridge and tool shaft and distally through the suture fastener in its open condition. The snare portion is adapted to capture and pull a suture proximally through the suture fastener and out of the aligned ports in the cartridge and tool shaft. When the cartridge is engaged with the deployment tool, movement of the ejector contacts and converts the suture fastener from its open condition to its closed condition to clamp onto a suture passed therethrough.
Another system for securing a suture without knots disclosed herein includes a deployment tool with a distal shaft terminating in a distal tip having locking structure thereon, the tool including an ejector movable within the tool shaft, and the tool shaft having a side port adjacent the distal tip. The system includes a suture fastener having clamping structure that can be flexed to an open condition through which a suture can pass and which is biased toward a closed position which clamps onto a suture passed therethrough. A fastener cartridge as a lumen that receives the suture fastener at a distal end and has at least one stop that maintains the suture fastener in its open condition. A proximal end of the cartridge having mating structure for engaging the locking structure of the distal tip of the deployment tool shaft, and the cartridge also has an access port that aligns with the side port of the tool shaft when the two are engaged. Finally, a suture snare includes an elongated flexible snare portion size to pass through the access port of the cartridge, through the side port of the tool shaft, and distally through the suture fastener in its open condition. Movement of the ejector contacts and converts the suture fastener from its open condition to its closed condition to clamp onto a suture passed therethrough.
In either of the systems described above, the deployment tool preferably has a proximal handle with a trigger, and the ejector is longitudinally movable within the tool shaft upon actuation of the trigger. The ejector may further include a sharp edge such that movement thereof also severs a suture extending through the suture fastener and out of the aligned ports in the cartridge and tool shaft.
Preferably, the suture fastener comprises a disk-shaped main body, and the clamping structure comprises at least one tab separated from the main body with slits and being spring-biased toward the closed condition where the tab is aligned with the main body, and the cartridge includes at least one stop that maintains the suture fastener in its open condition flexes the tab away from alignment with the main body.
Desirably, the suture snare comprises a proximal handle connected to the elongated flexible snare portion in the form of a flexible loop, and a grip/key having a peripheral groove for receiving and holding open the flexible loop, and wherein the grip/key is demountably attached to a distal end of the cartridge.
In a preferred embodiment, the cartridge is generally tubular and the proximal end includes an L-shaped slot terminating in a circular lockout that receives a locking pin extending outward from the deployment tool shaft, the cartridge engaging the distal tip of the deployment tool shaft by axially advancing and then rotating thereover to position the locking pin in the circular lockout. The distal tip of the deployment tool shaft may have an L-shaped slot with an axially-extending portion and a circumferential portion, and wherein the axially-extending portion aligns with a first of the aligned ports located on the cartridge to avoid binding on the snare portion when engaging the cartridge to the tool shaft, and the circumferential portion terminates in a second of the aligned ports located on the tool shaft, the first and second aligned ports only being aligned when the cartridge and tool shaft are fully engaged.
In accordance with one aspect, a method for securing an implant without knots initially includes the step of pre-installing a plurality of sutures at an anatomical location and passing the sutures through a suture-permeable portion of an implant. A fastener cartridge and suture snare subassembly is attached to a distal tip of a shaft of a deployment tool. The cartridge has a lumen that receives a single suture fastener within a distal end thereof and at least one stop that maintains clamping structure of the suture fastener in an open condition spring-biased toward a closed condition. The suture snare includes an elongated flexible snare portion sized to pass radially inward through aligned ports in the attached cartridge and tool shaft and distally through the suture fastener in its open condition. The method includes snaring one of the pre-installed sutures with the snare portion, advancing the cartridge along the suture to the implant with the deployment tool until the suture fastener is adjacent to the suture-permeable portion, actuating an ejector within the tool shaft to contact and convert the suture fastener from its open condition to its closed condition in which the clamping structure clamps onto the suture, and severing the suture.
The aforementioned methods may further include one or more of the steps of:
The implant is desirably selected from the group consisting of an annuloplasty ring and a heart valve. The suture fasteners preferably each comprise a disk-shaped main body, and the clamping structure comprises at least one tab separated from the main body with slits and being spring-biased toward the closed condition where the tab is aligned with the main body, and the at least one stop that maintains the suture fastener in its open condition flexes the tab away from alignment with the main body. Furthermore, the deployment tool may have a proximal handle with a trigger for actuating the ejector, and the ejector further includes a sharp edge such that movement thereof also severs the suture extending through the suture fastener and out of the aligned ports in the cartridge and tool shaft.
A further understanding of the nature and advantages of the present invention are set forth in the following description and claims, particularly when considered in conjunction with the accompanying drawings in which like parts bear like reference numerals.
The disclosed technology will now be explained and other advantages and features will appear with reference to the accompanying schematic drawings wherein:
The present application provides improved systems for securing a cardiac implant to a heart valve annulus using knotless suture fasteners. Proximal and distal refer to the opposite directions toward and away, respectively, a surgeon performing the implant. The term cardiac implant as used herein primarily refers to prosthetic heart valves and annuloplasty rings or segments. However, the suture fastening systems described herein can be used to attach other prostheses such as stents, grafts, stent-grafts, fluid delivery reservoirs, electro-stimulators, or the like. Furthermore, the cardiac implants are desirably secured at a target heart valve annulus, but the suture fastening systems may also be used to attach implants to other anatomical structures such as vessels, organs (e.g., intestine, heart, skin, liver, kidney, stomach) or other locations where sutures are typically used to attach the implant. Indeed, the present suture fastening systems can be used to secure tissue structures together, such as for closure of vascular punctures or other wound closure.
Several exemplary embodiments of knotless suture fasteners are disclosed herein and shown in the attached figures. These embodiments should not be construed as limiting in any way. Instead, the present disclosure is directed toward all novel and nonobvious features and aspects of the suture fastening systems described herein, alone and in various combinations and sub-combinations with one another, and regardless of what type of suture fastener is used. The suture fasteners can secure a single suture or to two or more sutures at the same time.
The disclosed suture fasteners all engage a suture by first threading a free end of the suture through an opening in the fastener. For example, the embodiment shown in
Once a knotless suture fastener is positioned on a suture and released, the fastener can prevent the suture from sliding axially through the device in one or both longitudinal directions of the suture. In some embodiments, the device can be biased to allow the suture to slide through the device in one longitudinal direction, but prevent the suture from sliding in the opposite direction, forming a one-way suture lock, or ratchet mechanism. In other embodiments, the device can prevent the suture from sliding in both longitudinal directions, forming a more restrictive two-way suture lock.
By using the disclosed knotless suture fasteners rather than tying knots in the sutures, the sutures can be secured in less time and with less difficulty (especially in hard-to-reach locations). In addition, some knotless suture fasteners can allow the amount of slack left in the sutures to be more precisely controlled, the devices can be less likely to come loose than knots, and some embodiments of the devices can be easily removed or adjusted after they are initially deployed. Furthermore, the knotless suture fasteners can be small, durable, biocompatible, and inexpensive.
While
To help retain sutures in the midsection of the slit 42′, the slit includes serpentine sections 47 on either side. The tabs 34′, 36′ are identical, or mirror images of each other, though one may be larger than the other. Small circular enlargements 48 on the terminal end of each curved slot 38′, 40′ facilitate bending of the tabs 34′, 36′ and act as stress relievers to reduce the chance of fracture at those points. Two semi-circular cutouts 49 are provided on opposite sides of the outer edge 32′ perpendicular to the straight section of the slit 42′. The cutouts 48 provide orientation features for the suture fastener 46 that cooperate with features on a tool (not shown) which can hold and deploy multiple suture fasteners in series.
Some suture fasteners can be relatively thin, disk-shaped members but have a generally curved rather than a planar shape. The embodiments shown in
In some embodiments, such curved suture fasteners are formed from a sidewall of a tube. The outer radius of the tube can define the curvature of the convex major surface of the suture fastener while the inner radius of the tube can define the curvature of the concave major surface of the device. The uniform thickness of a curved suture fastener is equal to the wall thickness of the tube that the device is cut from. In other embodiments, the suture fasteners are formed from a sidewall of a non-cylindrical tube, or from a wall of other three-dimensional objects having a curved wall, such as a hollow sphere, spheroid, ellipsoid, etc., or from other three-dimensional objects having a curvature.
The suture fasteners disclosed herein may be formed from suitable biocompatible material, including, for example, Nickel-Titanium or other shape-memory alloys, stainless steel, titanium, other metals, various plastics, and other biologically-compatible materials. The illustrated suture fasteners are mostly flat or curved disc-shaped bodies which are relatively thin axially, and may be up to about 1-2 mm in height. The diameter of the suture fasteners may be between 2-4 mm, but only needs to be sufficiently large to be incapable of penetrating a suture-permeable sewing edge of a cardiac implant, such as a sewing ring of a prosthetic heart valve or an annuloplasty ring. That is, the suture fasteners are wide enough to avoid being pulled through a sewing edge of a cardiac implant when the sutures captured therein are placed under tension.
Braided sutures are used to attach prosthetic heart valves to annuluses as opposed to monofilament polypropylene sutures (e.g., Prolene) which are used in other surgical environments. In the United States, suture diameter is represented on a scale descending from 10 to 1, and then descending again from 1-0 to 12-0. A number 9 suture is 0.0012 in (0.03 mm) in diameter, while the smallest, number 12-0, is smaller in diameter than a human hair. Although suture size depends on surgeon preference, typically 1-0 or 2-0 braided sutures are used. In one embodiment, if larger sutures are used the diameter of the suture fastener is up to 4 mm, while if smaller sutures, such as 2-0, are used the diameter may be as small as 2 mm.
The knotless suture fasteners described herein include self-actuating or spring-loaded devices that clamp onto sutures. Passing one or more sutures through the suture fastener and then converting it from an open to a closed state causes features to collapse inward and clamp onto the suture(s). The conversion desirably occurs upon removal of an impediment to inward motion of clamping elements, though other spring-loaded configurations are possible. Such self-actuating suture fasteners are preferred over plastically-deformable fasteners which must be crimped over the sutures using forceps or other such compression tools. On the other hand, for added security a supplemental portion (not shown) of the suture fasteners disclosed herein may be deformable so that a user may crimp it onto the sutures—a hybrid fastener. For the purpose of defining terms, the term “self-actuating” suture fastener refers to a spring-biased type of device which does not require crimping, but which, on the other hand, does not exclude a crimpable portion. A “self-actuating” suture fastener is not entirely autonomous, in that there is a trigger prior to the deployment, such as removal of an element or change in temperature, but the term excludes devices that require mechanical crimping using a supplemental tool such as a hammer and anvil system.
Alternative self-actuating fasteners may be made of a temperature-activated memory material that biases the fastener to its closed configuration when exposed to a selected temperature range, though the control and timing of such devices add complexity. With the temperature-activated memory material in its austenite state, the fastener tabs extend into the inner lumen to their greatest extent, so that the fastener is in a “closed” configuration wherein the tabs block movement of any lengths of suture passing through the inner lumen. The austenite state can be set to occur when the suture fastener is generally unstressed and at human body temperature, so that when deployed in the patient's body it will be remain biased toward its closed configuration.
Fastener Deployment Tools
A subassembly 210 including a disposable fastener cartridge 212 and suture snare 214 is configured to mate with a distal tip 216 of the deployment tool shaft 204, and as such is shown slightly removed therefrom in
An alternative embodiment of a suture snare 224 shown in
With reference to
As seen in
With reference to the sectional views of
The fastener 250 may be any of the fasteners described above, such as those shown in
The cartridge body 252 also includes an access port 270 typically located opposite the lockout 260. As seen in
The surgeon pre-attaches the anchoring sutures S at evenly spaced locations around the aortic annulus. The anchoring sutures S are typically looped twice through the annulus from the outflow or ascending aorta side to the inflow or ventricular side. Of course, other suturing methods or pledgets may be used depending on surgeon preference. Once each anchoring suture S is secured to the annulus, it extends proximally in pairs of free lengths out of the operating site. The heart valve HV is typically mounted on a valve holder and delivery handle (not shown), and the surgeon threads the pairs of anchoring sutures S through evenly spaced locations around the sewing ring SR corresponding to their locations around the annulus. The surgeon then advances the valve HV into position within the aortic annulus along the array of anchoring sutures S. Some of the anchoring sutures S are not shown around the front of the heart valve HV in
Subsequently, the surgeon installs a suture fastener 250 on each pair of anchoring sutures S on the proximal or outflow side of the sewing ring SR. This is accomplished using the fastener deployment tool 200 in conjunction with the suture snare 214. First, the surgeon captures two free lengths of a pair of anchoring sutures S with the snare end 220 of the snare 214 using forceps, for example. Subsequently, the surgeon pulls the suture snare 214 proximally through and out of engagement with the deployment tool 200, as indicated by the arrows in
The surgeon then maintains tension on the anchoring sutures S through the side port 244, and advances the shaft 204 of the deployment tool 200 distally until it contacts the valve sewing ring SR. The suture fastener 250 is then deployed using the trigger actuator 206 (
After pulling the sutures S in a proximal direction through the fastener 250, cartridge 212 and deployment tool 200, the surgeon triggers the actuator 206 which displaces the push rod 234 distally. As seen in
Now with reference to
The heart valve HV is representative of numerous types of heart valves, including those with flexible leaflets as shown and also mechanical valves with rigid metallic leaflets, in addition to other surgical implants as mentioned above. Further, the flexible leaflet heart valve HV is shown with the suture fasteners 250 deployed from an outflow side of the valve, which typically indicates that the valve is for implant at the aortic annulus where the outflow is also the proximal side relative to conventional heart valve delivery. However, it should be understood that the suture fasteners 250 could be reversed within the heart valve HV so that they are deployed from the inflow side, such as in a mitral valve replacement procedure.
In this embodiment, a marker line 302 is provided on the same side of the tool shaft 204 as the locking pin 242 and extends a short distance from the distal tip 216 in a proximal direction. This marker line 302 facilitates alignment of the axial slot 256 on the cartridge 212 with the locking pin 242.
The snare 300 comprises the key 304, wire 306, and a proximal handle 308 in the form of a bulb. The flexible wire 306 extends from the proximal handle 308 and loops around the placement grip/key 304, preferably being held within an outer groove 309 therein. The loop formed by the wire 306 is routed around the groove 309 in the placement grip/key 304 for shipping, storage and handling purposes and to prevent twisting or tangling of the loop.
Subsequently, the user pulls the placement grip/key 304 axially away from the fastener cartridge 212 to create some separation therebetween, as seen in
As seen in
Finally, as seen in
As explained above, the suture snare 300 comprises the placement grip/key 304 connected via the flexible wire 306 to the proximal handle 308. The placement grip/key 304 and proximal handle 308 are desirably made of a relatively soft polymer such as an elastomer. A proximal end of the key 304 includes an enlarged annular sleeve 320 having an inner diameter that is sized approximately the same as the outer diameter of the fastener cartridge 212. The annular sleeve 320 can thus be pushed over the distal tip of the cartridge 212 and it will be held thereon by a close interference fit. The flexible wire 306 passes inward through the aligned ports 270, 244, as explained above, out through the suture fastener 250 at the distal end of the cartridge 212, backward between the sleeve 320 and the cartridge, and then into the peripheral groove 309 around the key. In a preferred embodiment, the flexible wire 306 is formed of an annealed stainless steel having a diameter of approximately 0.007 inches, and has sufficient flexibility to withstand kinking when routed in this manner.
While the disclosed technology has been described in its preferred embodiments, it is to be understood that the words which have been used are words of description and not of limitation. Therefore, changes may be made within the appended claims without departing from the true scope of the invention(s).
This application is a continuation of U.S. patent application Ser. No. 14/329,797, filed Jul. 11, 2014, which claims the benefit of U.S. Provisional Application No. 61/845,359, filed Jul. 11, 2013, both of which are incorporated by reference herein in their entireties.
Number | Name | Date | Kind |
---|---|---|---|
2264679 | Ravel | Dec 1941 | A |
2516710 | Mascolo | Jul 1950 | A |
2715486 | Marcoff-Moghadam et al. | Aug 1955 | A |
2890519 | Storz, Jr. | Jun 1959 | A |
3143742 | Cromie | Aug 1964 | A |
3249104 | Hohnstein | May 1966 | A |
3274658 | Pile | Sep 1966 | A |
3452742 | Muller | Jul 1969 | A |
3506012 | Brown | Apr 1970 | A |
3509882 | Blake | May 1970 | A |
3541591 | Hoegerman | Nov 1970 | A |
3547103 | Cook | Dec 1970 | A |
3570497 | Lemole | Mar 1971 | A |
3608095 | Barry | Sep 1971 | A |
3638654 | Akuba | Feb 1972 | A |
RE27391 | Merser | Jun 1972 | E |
3753438 | Wood et al. | Aug 1973 | A |
3859668 | Anderson | Jan 1975 | A |
3875648 | Bone | Apr 1975 | A |
3898999 | Haller | Aug 1975 | A |
3910281 | Kletschka et al. | Oct 1975 | A |
3954109 | Patel | May 1976 | A |
3958576 | Komiya | May 1976 | A |
3976079 | Samuels et al. | Aug 1976 | A |
3988810 | Emery | Nov 1976 | A |
3996623 | Kaster | Dec 1976 | A |
4038725 | Keefe | Aug 1977 | A |
4103690 | Harris | Aug 1978 | A |
4140125 | Smith | Feb 1979 | A |
4170990 | Baumgart et al. | Oct 1979 | A |
4192315 | Hilzinger et al. | Mar 1980 | A |
4217902 | March | Aug 1980 | A |
4324248 | Perlin | Apr 1982 | A |
4345601 | Fukuda | Aug 1982 | A |
4416266 | Baucom | Nov 1983 | A |
4456017 | Miles | Jun 1984 | A |
4485816 | Krumme | Dec 1984 | A |
4522207 | Klieman et al. | Jun 1985 | A |
4535764 | Ebert | Aug 1985 | A |
4548202 | Duncan | Oct 1985 | A |
4549545 | Levy | Oct 1985 | A |
4586502 | Bedi et al. | May 1986 | A |
4586503 | Kirsch et al. | May 1986 | A |
4595007 | Mericle | Jun 1986 | A |
4612932 | Caspar et al. | Sep 1986 | A |
4637380 | Orejola | Jan 1987 | A |
4665906 | Jervis | May 1987 | A |
4683895 | Pohndorf | Aug 1987 | A |
4705040 | Mueller et al. | Nov 1987 | A |
4719924 | Crittenden et al. | Jan 1988 | A |
4730615 | Sutherland et al. | Mar 1988 | A |
4741330 | Hayhurst | May 1988 | A |
4743253 | Magladry | May 1988 | A |
4750492 | Jacobs | Jun 1988 | A |
4809695 | Gwathmey et al. | Mar 1989 | A |
4823794 | Pierce | Apr 1989 | A |
4863460 | Magladry | Sep 1989 | A |
4873975 | Walsh et al. | Oct 1989 | A |
4896668 | Popoff et al. | Jan 1990 | A |
4899744 | Fujitsuka et al. | Feb 1990 | A |
4901721 | Hakki | Feb 1990 | A |
4924866 | Yoon | May 1990 | A |
4926860 | Stice et al. | May 1990 | A |
4929240 | Kirsch et al. | May 1990 | A |
4932955 | Merz et al. | Jun 1990 | A |
4950283 | Dzubow et al. | Aug 1990 | A |
4950285 | Wilk | Aug 1990 | A |
4955913 | Robinson | Sep 1990 | A |
4976715 | Bays et al. | Dec 1990 | A |
4983176 | Cushman et al. | Jan 1991 | A |
4990152 | Yoon | Feb 1991 | A |
4997439 | Chen | Mar 1991 | A |
5002550 | Li | Mar 1991 | A |
5002562 | Oberlander | Mar 1991 | A |
5002563 | Pyka et al. | Mar 1991 | A |
5026379 | Yoon | Jun 1991 | A |
5047047 | Yoon | Sep 1991 | A |
5053047 | Yoon | Oct 1991 | A |
5070805 | Plante | Dec 1991 | A |
5071431 | Sauter et al. | Dec 1991 | A |
5074874 | Yoon et al. | Dec 1991 | A |
5078731 | Hayhurst | Jan 1992 | A |
5100418 | Yoon et al. | Mar 1992 | A |
5116840 | Ganguly et al. | May 1992 | A |
5123913 | Wilk et al. | Jun 1992 | A |
RE34021 | Mueller et al. | Aug 1992 | E |
5152769 | Baber | Oct 1992 | A |
5154189 | Oberlander | Oct 1992 | A |
5158566 | Pianetti | Oct 1992 | A |
5163954 | Curcio et al. | Nov 1992 | A |
5171250 | Yoon | Dec 1992 | A |
5171251 | Bregen et al. | Dec 1992 | A |
5171252 | Friedland | Dec 1992 | A |
5174087 | Bruno | Dec 1992 | A |
5196022 | Bilweis | Mar 1993 | A |
5219358 | Bendel et al. | Jun 1993 | A |
5222976 | Yoon | Jun 1993 | A |
5234449 | Bruker et al. | Aug 1993 | A |
5236440 | Hlavacek | Aug 1993 | A |
5242456 | Nash et al. | Sep 1993 | A |
5246443 | Mai | Sep 1993 | A |
5258011 | Drews | Nov 1993 | A |
5258015 | Li et al. | Nov 1993 | A |
5269783 | Sander | Dec 1993 | A |
5269809 | Hayhurst et al. | Dec 1993 | A |
5282832 | Toso et al. | Feb 1994 | A |
5290289 | Sanders et al. | Mar 1994 | A |
5304204 | Bregen | Apr 1994 | A |
5306290 | Martins et al. | Apr 1994 | A |
5306296 | Wright et al. | Apr 1994 | A |
5312436 | Coffey et al. | May 1994 | A |
5330503 | Yoon | Jul 1994 | A |
5336239 | Gimpelson | Aug 1994 | A |
5356424 | Buzerak et al. | Oct 1994 | A |
5374268 | Sander | Dec 1994 | A |
5383904 | Totakura et al. | Jan 1995 | A |
5383905 | Golds et al. | Jan 1995 | A |
5391173 | Wilk | Feb 1995 | A |
5403346 | Loeser | Apr 1995 | A |
5409499 | Yi | Apr 1995 | A |
5437680 | Yoon | Aug 1995 | A |
5437685 | Blasnik | Aug 1995 | A |
5439479 | Shichman et al. | Aug 1995 | A |
5445167 | Yoon et al. | Aug 1995 | A |
5450860 | O'Connor | Sep 1995 | A |
5452733 | Sterman et al. | Sep 1995 | A |
5456246 | Schmieding et al. | Oct 1995 | A |
5462558 | Kolesa et al. | Oct 1995 | A |
5462561 | Voda | Oct 1995 | A |
5474557 | Mai | Dec 1995 | A |
5474572 | Hayhurst | Dec 1995 | A |
5480405 | Yoon | Jan 1996 | A |
5486197 | Le et al. | Jan 1996 | A |
5496336 | Cosgrove et al. | Mar 1996 | A |
5499990 | Schulken et al. | Mar 1996 | A |
5500000 | Feagin et al. | Mar 1996 | A |
5520691 | Branch | May 1996 | A |
5520702 | Sauer et al. | May 1996 | A |
5527342 | Pietrzak et al. | Jun 1996 | A |
5531763 | Mastri et al. | Jul 1996 | A |
5545178 | Kensey et al. | Aug 1996 | A |
5549619 | Peters et al. | Aug 1996 | A |
5562685 | Mollenauer et al. | Oct 1996 | A |
5569274 | Rapacki et al. | Oct 1996 | A |
5569301 | Granger et al. | Oct 1996 | A |
5582616 | Bolduc et al. | Dec 1996 | A |
5582619 | Ken | Dec 1996 | A |
5586983 | Sanders et al. | Dec 1996 | A |
5591179 | Edelstein | Jan 1997 | A |
5593414 | Shipp et al. | Jan 1997 | A |
5593424 | Northrup, III | Jan 1997 | A |
5609608 | Benett et al. | Mar 1997 | A |
5626590 | Wilk | May 1997 | A |
5630824 | Hart | May 1997 | A |
5632752 | Buelna | May 1997 | A |
5632753 | Loeser | May 1997 | A |
5643289 | Sauer et al. | Jul 1997 | A |
5643295 | Yoon | Jul 1997 | A |
5645553 | Kolesa et al. | Jul 1997 | A |
5645568 | Chervitz et al. | Jul 1997 | A |
5665109 | Yoon | Sep 1997 | A |
5669917 | Sauer et al. | Sep 1997 | A |
5669935 | Rosenman et al. | Sep 1997 | A |
5681351 | Jamiolkowski et al. | Oct 1997 | A |
5683417 | Cooper | Nov 1997 | A |
5695505 | Yoon | Dec 1997 | A |
5697943 | Sauer et al. | Dec 1997 | A |
5700270 | Peyser et al. | Dec 1997 | A |
5700271 | Whitfield et al. | Dec 1997 | A |
5707380 | Hinchliffe et al. | Jan 1998 | A |
5709693 | Taylor | Jan 1998 | A |
5709695 | Northrup, III | Jan 1998 | A |
5725539 | Matern | Mar 1998 | A |
5725542 | Yoon | Mar 1998 | A |
5725556 | Moser et al. | Mar 1998 | A |
5728135 | Bregen et al. | Mar 1998 | A |
5735290 | Sterman et al. | Apr 1998 | A |
5735877 | Pagedas | Apr 1998 | A |
5766183 | Sauer | Jun 1998 | A |
5776188 | Shepherd et al. | Jul 1998 | A |
5799661 | Boyd | Sep 1998 | A |
5810851 | Yoon | Sep 1998 | A |
5810882 | Bolduc et al. | Sep 1998 | A |
5820631 | Nobles | Oct 1998 | A |
5824008 | Bolduc et al. | Oct 1998 | A |
5830221 | Stein et al. | Nov 1998 | A |
5833696 | Whitfield et al. | Nov 1998 | A |
5845645 | Bonutti | Dec 1998 | A |
5849019 | Yoon | Dec 1998 | A |
5861004 | Kensey et al. | Jan 1999 | A |
5879371 | Gardiner et al. | Mar 1999 | A |
5891130 | Palermo et al. | Apr 1999 | A |
5891160 | Williamson, IV et al. | Apr 1999 | A |
5895393 | Pagedas | Apr 1999 | A |
5895394 | Kienzle et al. | Apr 1999 | A |
5919207 | Taheri | Jul 1999 | A |
5948001 | Larsen | Sep 1999 | A |
5961481 | Sterman et al. | Oct 1999 | A |
5961539 | Northrup, III et al. | Oct 1999 | A |
5964772 | Bolduc et al. | Oct 1999 | A |
5972024 | Northrup, III et al. | Oct 1999 | A |
5976159 | Bolduc et al. | Nov 1999 | A |
5984917 | Fleischman et al. | Nov 1999 | A |
5989242 | Saadat et al. | Nov 1999 | A |
5989268 | Pugsley, Jr. et al. | Nov 1999 | A |
5997556 | Tanner | Dec 1999 | A |
6001110 | Adams | Dec 1999 | A |
6013084 | Ken et al. | Jan 2000 | A |
6015428 | Pagedas | Jan 2000 | A |
6039176 | Wright | Mar 2000 | A |
6066160 | Colvin et al. | May 2000 | A |
6074409 | Goldfarb | Jun 2000 | A |
6120524 | Taheri | Sep 2000 | A |
6132438 | Fleischman et al. | Oct 2000 | A |
6139540 | Rost et al. | Oct 2000 | A |
6143004 | Davis et al. | Nov 2000 | A |
6176413 | Heck et al. | Jan 2001 | B1 |
6190373 | Palermo et al. | Feb 2001 | B1 |
6193733 | Adams | Feb 2001 | B1 |
6193734 | Bolduc et al. | Feb 2001 | B1 |
6231592 | Bonutti et al. | May 2001 | B1 |
6241765 | Griffin et al. | Jun 2001 | B1 |
6254615 | Bolduc et al. | Jul 2001 | B1 |
6306141 | Jervis | Oct 2001 | B1 |
6346112 | Adams | Feb 2002 | B2 |
6368334 | Sauer | Apr 2002 | B1 |
6432123 | Schwartz et al. | Aug 2002 | B2 |
6475230 | Bonutti et al. | Nov 2002 | B1 |
6514265 | Ho et al. | Feb 2003 | B2 |
6533796 | Sauer et al. | Mar 2003 | B1 |
6537290 | Adams et al. | Mar 2003 | B2 |
6551332 | Nguyen et al. | Apr 2003 | B1 |
6589279 | Anderson et al. | Jul 2003 | B1 |
6607541 | Gardiner et al. | Aug 2003 | B1 |
6613059 | Schaller et al. | Sep 2003 | B2 |
6626930 | Allen et al. | Sep 2003 | B1 |
6641592 | Sauer et al. | Nov 2003 | B1 |
6641593 | Schaller et al. | Nov 2003 | B1 |
6682540 | Sancoff et al. | Jan 2004 | B1 |
6719767 | Kimblad | Apr 2004 | B1 |
6746457 | Dana et al. | Jun 2004 | B2 |
6749622 | McGuckin, Jr. et al. | Jun 2004 | B2 |
6776784 | Ginn | Aug 2004 | B2 |
6860890 | Bachman et al. | Mar 2005 | B2 |
6896686 | Weber | May 2005 | B2 |
6913607 | Ainsworth et al. | Jul 2005 | B2 |
6918917 | Nguyen et al. | Jul 2005 | B1 |
6921407 | Nguyen et al. | Jul 2005 | B2 |
6926730 | Nguyen et al. | Aug 2005 | B1 |
6945980 | Nguyen et al. | Sep 2005 | B2 |
6960221 | Ho et al. | Nov 2005 | B2 |
7011669 | Kimblad | Mar 2006 | B2 |
7083628 | Bachman | Aug 2006 | B2 |
7094244 | Schreck | Aug 2006 | B2 |
7112207 | Allen et al. | Sep 2006 | B2 |
7220266 | Gambale | May 2007 | B2 |
7235086 | Sauer et al. | Jun 2007 | B2 |
7264625 | Buncke | Sep 2007 | B1 |
7381210 | Zarbatany et al. | Jun 2008 | B2 |
7628797 | Tieu et al. | Dec 2009 | B2 |
7731727 | Sauer | Jun 2010 | B2 |
7833237 | Sauer | Nov 2010 | B2 |
7842051 | Dana et al. | Nov 2010 | B2 |
7862584 | Lyons et al. | Jan 2011 | B2 |
7875056 | Jervis et al. | Jan 2011 | B2 |
7959674 | Shu et al. | Jun 2011 | B2 |
7981139 | Martin et al. | Jul 2011 | B2 |
8021421 | Fogarty et al. | Sep 2011 | B2 |
8100923 | Paraschao et al. | Jan 2012 | B2 |
8105355 | Page et al. | Jan 2012 | B2 |
8252005 | Findlay, III et al. | Aug 2012 | B2 |
8398657 | Sauer | Mar 2013 | B2 |
8398680 | Sauer et al. | Mar 2013 | B2 |
8425555 | Page et al. | Apr 2013 | B2 |
8480686 | Bakos et al. | Jul 2013 | B2 |
8753373 | Chau et al. | Jun 2014 | B2 |
9017347 | Oba et al. | Apr 2015 | B2 |
20030109922 | Peterson et al. | Jun 2003 | A1 |
20030195563 | Foerster | Oct 2003 | A1 |
20030233105 | Gayton | Dec 2003 | A1 |
20040181238 | Zarbatany et al. | Sep 2004 | A1 |
20040204724 | Kissel et al. | Oct 2004 | A1 |
20040249414 | Kissel et al. | Dec 2004 | A1 |
20050251209 | Saadat et al. | Nov 2005 | A1 |
20060047314 | Green | Mar 2006 | A1 |
20060079913 | Whitfield et al. | Apr 2006 | A1 |
20060089571 | Gertner | Apr 2006 | A1 |
20060184203 | Martin et al. | Aug 2006 | A1 |
20060265010 | Paraschac et al. | Nov 2006 | A1 |
20060276871 | Lamson et al. | Dec 2006 | A1 |
20060282119 | Perchik | Dec 2006 | A1 |
20070005079 | Zarbatany et al. | Jan 2007 | A1 |
20070005081 | Findlay et al. | Jan 2007 | A1 |
20070049952 | Weiss | Mar 2007 | A1 |
20070049970 | Belef | Mar 2007 | A1 |
20070088391 | McAlexander et al. | Apr 2007 | A1 |
20070179530 | Tieu et al. | Aug 2007 | A1 |
20070270907 | Stokes et al. | Nov 2007 | A1 |
20080154286 | Abbott et al. | Jun 2008 | A1 |
20080255591 | Harada et al. | Oct 2008 | A1 |
20080281356 | Chau et al. | Nov 2008 | A1 |
20090143821 | Stupak | Jun 2009 | A1 |
20090281377 | Newell et al. | Nov 2009 | A1 |
20100001038 | Levin et al. | Jan 2010 | A1 |
20100076462 | Bakos et al. | Mar 2010 | A1 |
20100324597 | Shikhman | Dec 2010 | A1 |
20110087241 | Nguyen | Apr 2011 | A1 |
20110087242 | Pribanic et al. | Apr 2011 | A1 |
20110224714 | Gertner | Sep 2011 | A1 |
20110283514 | Fogarty et al. | Nov 2011 | A1 |
20120089182 | Page et al. | Apr 2012 | A1 |
20120102526 | Lejeune | Apr 2012 | A1 |
20130053884 | Roorda | Feb 2013 | A1 |
20130110164 | Milazzo et al. | May 2013 | A1 |
20130158600 | Conklin et al. | Jun 2013 | A1 |
20130165953 | Oba et al. | Jun 2013 | A1 |
20130282028 | Conklin et al. | Oct 2013 | A1 |
20140031864 | Jafari et al. | Jan 2014 | A1 |
Number | Date | Country |
---|---|---|
2141911 | Aug 1995 | CA |
2141913 | Aug 1995 | CA |
2558335 | Jul 2003 | CN |
69512446 | May 2000 | DE |
69612447 | Jul 2001 | DE |
0669101 | Aug 1995 | EP |
0669103 | Aug 1995 | EP |
1484023 | Dec 2004 | EP |
01049207 | Jul 2001 | WO |
0166001 | Sep 2001 | WO |
2004024006 | Mar 2004 | WO |
Entry |
---|
International Search Report for PCT/US2014/046423, dated Oct. 20, 2014. |
European Search Report issued for Application No. 12858766.4, dated Sep. 16, 2015. |
EP Supplementary Search Report for EP12858766, completed Sep. 7, 2015. |
CN Office Action for App No. 2012800690769, dated Mar. 23, 2015. |
European Supplementary Search Report dated Feb. 9, 2016 for EP13817447. |
Office Action for CN 2013800370375, dated Mar. 28, 2016. |
Int'l. Search Report for PCT/US2016/022495, dated Jun. 1, 2016. |
Int'l. Search Report for PCT/US15/65033, dated Feb. 18, 2016. |
EP Supplementary European Search Report issued for EP14823055, dated Jan. 10, 2017. |
Number | Date | Country | |
---|---|---|---|
20170156720 A1 | Jun 2017 | US |
Number | Date | Country | |
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61845359 | Jul 2013 | US |
Number | Date | Country | |
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Parent | 14329797 | Jul 2014 | US |
Child | 15438404 | US |