Patent Grant
9192372
The invention generally relates to methods and devices for the closure, sealing, repair and/or reconstruction of an intervertebral disc annulus, and accompanying delivery devices and tools, and their methods of use.
The spinal column is formed from a number of bony vertebrae, which in their normal state are separated from each other by intervertebral discs. These discs are comprised of the annulus fibrosus, and the nucleus pulposus, both of which are soft tissue. The intervertebral disc acts in the spine as a crucial stabilizer, and as a mechanism for force distribution between adjacent vertebral bodies. Without a competent disc, collapse of the intervertebral disc may occur, contributing to abnormal joint mechanics and premature development of degenerative and/or arthritic changes.
The normal intervertebral disc has an outer ligamentous ring called the annulus surrounding the nucleus pulposus. The annulus binds the adjacent vertebrae together and is constituted of collagen fibers that are attached to the vertebrae and cross each other so that half of the individual fibers will tighten as the vertebrae are rotated in either direction, thus resisting twisting or torsional motion. The nucleus pulposus is constituted of soft tissue, having about 85% water content, which moves about during bending from front to back and from side to side.
The aging process contributes to gradual changes in the intervertebral discs. Fissures in the annulus fibrosus can occur due to various causes, including disease or other pathological conditions, or the natural aging process. Occasionally fissures may form rents through the annular wall. In these instances, the nucleus pulposus is urged outwardly from the subannular space through a rent, often into the spinal column. Extruded nucleus pulposus can, and often does, mechanically press on the spinal cord or spinal nerve rootlet. This painful condition is clinically referred to as a ruptured or herniated disc.
In the event of annulus rupture, the subannular nucleus pulposus migrates along the path of least resistance forcing the fissure to open further, allowing migration of the nucleus pulposus through the wall of the disc, with resultant nerve compression and leakage of chemicals of inflammation into the space around the adjacent nerve roots supplying the extremities, bladder, bowel and genitalia. The usual effect of nerve compression and inflammation is intolerable back or neck pain, radiating into the extremities, with accompanying numbness, weakness, and in late stages, paralysis and muscle atrophy, and/or bladder and bowel incontinence. Additionally, injury, disease or other degenerative disorders may cause one or more of the intervertebral discs to shrink, collapse, deteriorate or become displaced, herniated, or otherwise damaged and compromised.
The present inventors have found, advantageously and contrary to accepted practice, that the annulus tissue may be repaired or otherwise treated and that annular healing may be facilitated by reapproximation, reinforcement, and/or support of annular tissue. Methods and devices for carrying out annular repair and/or reconstruction are a subject of the present invention.
The present invention, in one embodiment, is a system for at least partially closing an aperture in an annulus fibrosus of an intervertebral disc adjacent to a vertebral body of a patient. The system comprises a first fixation delivery apparatus, a first fixation apparatus, a second fixation delivery apparatus, and a second fixation apparatus. The first fixation delivery apparatus has a tubular shaft and a proximal handle. The first fixation apparatus is releasably coupled to the first fixation delivery apparatus and includes a bone anchor configured to be deployed at least partially into and attached to a vertebral body, and an adjustable flexible connecting element connected to the bone anchor. At least a portion of the bone anchor and a portion of the adjustable connecting element are disposed within the tubular shaft of the first fixation delivery apparatus prior to deployment of the first fixation apparatus, and the flexible connecting element can be manipulated by a user to adjust a length of thereof. The second fixation delivery apparatus includes a tubular shaft having a sharpened tissue-piercing distal tip, a proximal handle coupled to the tubular shaft, a releasable tab coupled to the handle, an ejection rod slidably disposed within the tubular shaft, and an actuator slidably coupled to the handle and operatively coupled to the ejection rod. The second fixation apparatus is releasably coupled to the second fixation delivery apparatus and includes a pair of tissue anchors and an adjustable flexible connecting element connecting the tissue anchors. The tissue anchors and a first portion of the flexible connecting element of the second fixation apparatus are disposed within the tubular shaft of the second fixation delivery apparatus, and a second portion of the flexible connecting element is coupled to the releasable tab of the second fixation delivery apparatus prior to deployment. Additionally, the bone anchor is configured to be attached to the vertebral body, the tissue anchors are configured to be attached to the annulus fibrosus with the aperture located between the bone anchor and the tissue anchors, and the flexible connecting elements of the first fixation apparatus and the second fixation apparatus are configured to be interconnected and placed in tension to at least partially close the aperture in the annulus fibrosus.
While multiple embodiments are disclosed, still other embodiments of the present invention will become apparent to those skilled in the art from the following detailed description, which shows and describes illustrative embodiments of the invention. Accordingly, the drawings and detailed description are to be regarded as illustrative in nature and not restrictive.
While the invention is amenable to various modifications and alternative forms, specific embodiments have been shown by way of example in the drawings and are described in detail below. The intention, however, is not to limit the invention to the particular embodiments described. On the contrary, the invention is intended to cover all modifications, equivalents, and alternatives falling within the scope of the invention as defined by the appended claims.
In the surgical repair of an aperture in the annulus, as shown in
Additionally, to repair a weakened or thinned wall of a disc annulus 42, a surgical incision or dissection can be made along the weakened or thinned region of the annulus 42 and one or more surgical sutures 40 can be placed at about equal distances laterally from the incision. Reapproximation or closure of the incision is accomplished by tying the sutures 40 so that the sides of the incision are drawn together. The reapproximation or closure of the incision/dissection enhances the natural healing and subsequent reconstruction by the natural tissue crossing the now surgically narrowed gap in the annulus 42. Preferably, the surgical sutures 40 are biodegradable, but permanent non-biodegradable materials may be utilized.
Where necessary or desirable, the method can be augmented by placing a patch in and across the aperture 44. The patch acts as a bridge in and across the aperture 44, providing a platform for traverse of fibroblasts or other normal cells of repair existing in and around the various layers of the disc annulus 42, prior to closure of the aperture 44.
In an illustrative embodiment, the annulus stent 10 is a solid unit, formed from one or more of the flexible resilient biocompatible or bioresorbable materials well know in the art. The selection of appropriate stent materials may be partially predicated on specific stent construction and the relative properties of the material such that, after fixed placement of the stent, the repair may act to enhance the healing process at the aperture by relatively stabilizing the tissue and reducing movement of the tissue surrounding the aperture.
For example, the annulus stent 10 may be made from:
A porous matrix or mesh of biocompatible and bioresorbable fibers acting as a scaffold to regenerate disc tissue and replace annulus fibrosus as disclosed in, for example, U.S. Pat. No. 5,108,438 (Stone) and U.S. Pat. No. 5,258,043 (Stone), a strong network of inert fibers intermingled with a bioresorbable (or bioabsorbable) material which attracts tissue ingrowth as disclosed in, for example, U.S. Pat. No. 4,904,260 (Ray et al.).
a biodegradable substrate as disclosed in, for example, U.S. Pat. No. 5,964,807 (Gan at al.); or
an expandable polytetrafluoroethylene (ePTFE), as used for conventional vascular grafts, such as those sold by W.L. Gore and Associates, Inc. under the trademarks GORE-TEX and PRECLUDE, or by Impra, Inc. under the trademark IMPRA.
Furthermore, the annulus, stent 10, may contain hygroscopic material for a controlled limited expansion of the annulus stent 10 to fill the evacuated disc space cavity.
Additionally, the annulus stent 10 may comprise materials to facilitate regeneration of disc tissue, such as bioactive silica-based materials that assist in regeneration of disc tissue as disclosed in U.S. Pat. No. 5,849,331 (Ducheyne, et al.), or other tissue growth factors well known in the art.
Many of the materials disclosed and described above represent embodiments where the device actively promotes the healing process. It is also possible that the selection of alternative materials or treatments may modulate the role in the healing process, and thus promote or prevent healing as may be required. It is also contemplated that these modulating factors could be applied to material substrates of the device as a coating, or similar covering, to evoke a different tissue response than the substrate without the coating.
Materials of the patch could include a metallic material (e.g., NiTi alloy, Stainless steel, Titanium), or a polymeric material (e.g., polypropylene, polyethylene, polyurethane, polycarbonate urethane, Polyetheretherketone (PEEK), polyester, PET, poly olefin copolymer, polypropylene, polyethylene), or a biodegradable or bioresorbable material (e.g., collagen, cellulose, polysaccharide, polyglycolic acid (PGA), a polylevolactic acid (PPLA), a polydioxanone (PDA) or for example a racemic polylactic acid (PDLLA), or a combination of these materials.
In an alternative method of securing the annulus stent 10 in the aperture 44, as shown in
Another fixation means includes the passing of “anchoring bands” into the wall of the annulus, vertebral bodies (superior, inferior, or both), of the Sharpey's Fibers (collagenous fibers between the junction of the annular fibers and vertebral bodies). In the following example of anchors, the barbs or bands are affixed to the annulus/vertebral bodies/Sharpey's fibers. Another element, for example a suture, cinch line, or a staple is utilized to attach the anchor bands to the patch, and thus hold the patch in proximity to the inner wall of the annulus. In addition, these bands may re-approximate the tissues at the aperture.
Revisiting one example of using barbs to anchor the device is shown in
Patches can be folded and expanded in a single plane or in three dimensions. Collapsing the patch can be accomplished laterally, whether the device is a single material or composite. Others can collapse in three dimensions, such as those shown in
It is understood that there can be a variety of device designs of patches/stents/meshes/devices/treatment devices to accomplish the expansion of a device from a first configuration, to a second configuration to occupy at least a portion of the sub-annular space and reduce re-extrusion of the nucleus, or otherwise facilitate maintaining other intradiscal materials within the disc space. These devices can be constructed of single components or multiple components, with a variety of different materials, whether synthetic, naturally occurring, recombinated (genetically engineered) to achieve various objectives in the delivery, deployment and fixation of a device to repair or reconstruct the annulus. The following device concepts are further discussed for additional embodiments of a device and/or system for the repair of an intervertebral disc annulus. The following descriptions will illustratively depict and describe methods, devices, and tools to deliver a treatment to an intervertebral disc after a, lumbar discectomy procedure; although, it is anticipated that these methods, devices, and tools may be similarly used in a variety of applications. As an example, the embodiments described herein may also advantageously maintain materials within the disc space other than natural disc tissue (nucleus, annulus, cartilage, etc.), such as implants and materials that may be used to replace and/or augment the nucleus pulposus or other parts of disc's tissues. These procedures may be performed to treat, for example, degenerative disc disease. Whether these materials are intended to replace the natural functioning of the nucleus pulposus (i.e., implantable prosthetics or injectable, in-situ curable polymer protein, or the like) or provide a fusion between vertebral bodies (i.e., implantable bony or synthetic prosthetics with materials to facilitate fusion, such as growth factors like bone morphogenic proteins) one skilled in the art would realize that variations to the embodiments described herein may be employed to better address characteristic differences in the various materials and/or implants that could be placed within the subannular space, and that these variations would be within the scope of the invention.
Furthermore, it should be noted that surgeons differ in their techniques and methods in performing an intervention on a spinal disc, and the inventive descriptions and depictions of methods, devices and delivery tools to repair annular tissue could be employed with a variety of surgical techniques; such as, but not limited to: open surgical, microsurgical discectomy (using a magnifying scope or loupes), minimally invasive surgical (through, for example, a METRx™ system available from Medtronic, Inc.), and percutaneous access. Surgeons may also employ a variety of techniques for intra-operative assessment and/or visualization of the procedure, which may include: intra-operative probing, radiography (e.g., C-arm, flat plate), and endoscopy. It is contemplated that the inventive embodiments described are not limited by the various techniques that may be employed by the surgeon.
In addition, the surgical approach to the intervertebral disc throughout the figures and descriptions depict a common approach, with related structures, to a lumbar discectomy; although, it is possible that surgeons may prefer alternative approaches to the intervertebral disc for various applications (for example, different intervertebral disc levels such as the cervical or thoracic region, or for nucleus augmentation), which may include, but is not limited to: posterior-lateral, anterior, anterior-lateral, transforaminal, extra-foraminal, extra-pedicular, axial (i.e., through the vertebral bodies), retroperitoneal, trans psoas (through the Psoas muscle), contralateral. The approach to the intervertebral disc space should not be interpreted to limit the use of the invention for the repair or reconstruction of the an aperture, weakened or thin portion of the annulus, as described herein.
It is also important to note that the boundary in the intervertebral disc space between the annulus fibrosus and the nucleus pulposus as depicted herein may be demarked or otherwise highlighted; however, it is important to recognize that these tissues are not as precisely demarked in human tissues, and may be even less so as the patient ages or evinces degeneration of the intervertebral disc. This demarcation may be especially difficult to discern during an operative procedure, using for example; available surgical tools (i.e., probes), fluoroscopic guidance (x-ray), or visual (endoscope) guidance. However, in general, the layers of the annulus have more structural integrity (and strength) than the nucleus, and this integrity varies from the outer most layers of the annulus being of higher structural integrity than the inner most layers of the annulus.
Moreover, the drawings and descriptions herein are necessarily simplified to depict the operation of the devices and illustrate various steps in the method. In use, the tissues may be manipulated by, and are frequently in contact with, the various tools and devices; however, for clarity of construction and operation, the figures may not show intimate contact between the tissues the tools and the devices.
As depicted in
The are a variety of ways to affix a device to the sub-annular wall of the annulus. The following exemplary embodiments are introduced here to provide inventive illustrations of the types of techniques that can be employed to reduce the time and skill required to affix the patch to the annulus, versus suturing and tying a knot. Sutures, staples and other fixation devices can be used to affix the patch to the annulus. In a simple example, a patch/stent could be compressed, passed through a guide tube and expanded within the sub-annular space.
Another fixation means includes the passing of “tissue anchoring elements” into the wall of the annulus, vertebral bodies (superior, inferior, or both), or the Sharpey's Fibers (collagenous fibers between the junction of the annular fibers and vertebral bodies). In the following example of anchoring elements, the barbs or bands may be affixed to the annulus/vertebral bodies/Sharpey's fibers. Another element, for example a suture, band, filament, cinch line, or a staple may be utilized to attach the anchor elements to the patch, and thus hold the patch in proximity to the inner wall of the annulus. In addition, these bands may also re-approximate the tissues of an aperture, weakened, delaminated, or thinned portion of the disc.
Another example of fixating the device to inner wall of the annulus is further illustrated by
The barbs and the connection band between the barbs could be constructed of the same material or of different materials. For example, the barbed part of the anchor band could be a biodegradable/bioabsorbable material (such as, for example, collagen, cellulose, polysaccharides, carbohydrates, polyglycolic acid, polylevolactic acid, polydioxanone, racemic polylactic acid) or could be constructed of a metallic or polymeric biocompatible material (e.g., titanium, NiTi alloy, stainless steel, platinum, gold, polyurethane, polycarbonate urethane, polyimide, polyamide, polypropylene, polyethylene, polypropylene, polyester, PET, PEEK). The anchors could also be constructed of a combination of these materials. In addition, the band that connects these barbs can be constructed of materials that are similar to the barbs, or different materials. For example, the connection band could be a biodegradable/bioabsorbable suture, such as Vicryl, or a biocompatible material such as polypropylene, polyethylene, silk, stainless steel, PET. In addition, it is possible that these elements are constructed from multiple materials to accomplish the objective of anchoring into the annulus and providing for a fixation site to draw the tissues together.
The cinching of the anchor bands and the patch also allows for taking-up the slack that allows for the accommodation of varying sizes. For example, the thickness of the annular wall surrounding the aperture can vary from 1 mm up to 10 mm. Therefore, if the anchor bands have a set length, this design with a cinch line accommodates different dimensions of the thickness of the wall of the annulus by drawing the “slack” of the bands together within the aperture.
Although it has been described here as patch placement that involves two lateral anchor bands or anchoring elements with a fixation element to draw the patch, bands and tissues together, one or two or more bands could be used and two bands is only an example. Furthermore, the anchor bands were placed with the barbs in a superior-inferior fashion. One skilled in the art would recognize that these could be placed at different locations surrounding the aperture. Moreover, although it was described that the anchoring elements are placed into the annulus, these anchoring elements could also be placed in the vertebral bodies as shown in
Although the patch depicted in the example above does not have barbs attached to the patch, it is also possible to provide barbs on or attached to the patch to further promote the fixation of the patch to the inner wall of the annulus.
Finally, although the drawings depict an aperture that lends itself to re-approximating the tissues, it is conceivable that some apertures, whether natural or surgically made, may be relatively large and therefore might require the placement of additional material within the aperture to act as a scaffold for tissue in growth, between the patch on the inner wall of the annulus and the anchor bands located on the outer wall. An example of material to fill the aperture might include autograft para-spinal fascial tissue, xenograft, allograft, or other natural collagenous materials. The filler material could also be of a biocompatible material such as a Dacron (polyester, or PET), polypropylene, polyethylene material.
As an alternative embodiment of the present invention, the anchor bands 709 as described previously (anchor bands into annulus) could be sufficiently long enough to pass through the annulus and then through the patch. The barbs or anchoring elements in this embodiment have an engaging involvement with the patch. This concept was previously discussed hereinabove in connection with
In addition, although the bands shown in
It is also foreseen within the scope of the invention that there may be patch designs which will accommodate the placement and securement of the anchor to the fabric that covers the frame of the patch. For example, a frame for a patch that is made out of metal such as Nitinol can provide for “windows”. The device, covered with a mesh fabric, for example silicone or Dacron, would therefore allow the anchoring barbs to be passed through the “windows” in the frame of the patch. In this case, the barb can be secured to the patch in the fabric covering the frame.
Alternatively, the patch can be secured by passing barbs that engage the lattice of the patch frame. These embodiments of the invention illustrate designs in which the barbs engage with the vertical, horizontal or criss-crossed structures/members of the frame. In this case, the barbs would pass through the mesh or lattice of the frame and they would be unable to pass back out of the structure.
Although this discussion refers to “anchor bands” that are shown to be two anchors connected by a suture, it is also contemplated that single barbs with sutures could be placed and the sutures' ends, at the outer surface of the annulus, are tied after placement through the patch. It is also possible that these “single anchors” could be retained by a suture “pledget” on the outer wall of the annulus to better hold the outer surface, or could include a suture (or band) locking device.
Alternatively, the locking mechanism can be as shown in
Although cinch lines have been described as using a knot to “lock” the length of the suture, other mechanisms could also lock the length, as shown in
Although the embodiments of
Similarly, an alternative embodiment to cause tension within the device and draw the tissues together after placement of the anchor bands might include an elastic band or band with a spring with one end attached to the anchor bands and the other end attached to the patch. Alternatively, the anchor bands, in and of themselves may be made of an elastic band between the barbs, or may contain a spring element between the barbs. Such an embodiment can be made to resemble a so-called “Bobber Spring.” Again, it is contemplated that the elastic or resilient element could be made from a wide variety of metals, polymeric, or biodegradable/bioabsorbable material.
As previously mentioned, the present invention also encompasses delivery devices or tools of the following description. The delivery devices of the present invention are configured to deliver at least one device, or a portion thereof, into (or through) the annulus or other surface or tissue, such as vertebral bodies 202, 204 or Sharpey's Fibers 802, as shown in
In addition, the following descriptions of delivery devices/tools are generally intended to be single-use and disposable; however, it is clear that these tools could as easily be constructed to be partially, or wholly, re-usable and re-sterilizable.
An illustrative delivery device, as depicted in
The delivery device 708 may also advantageously contain within it an ejection rod 715. The proximal end of the ejection rod 715 may contain an end portion 713 to function as a stopper, e.g., having a diameter larger than the remaining portion of the rod, such as is shown in
Advantageously, the ejection rod 715 and delivery device may be configured to deliver multiple fixation devices, sequentially or simultaneously. Thus, if multiple fixation devices are contained within the device, the ejection rod 715 and delivery device may be configured such that the rod 715 be pushed a first distance, sufficient to deliver a first fixation device. The device is then removed from the first insertion point and inserted into a second insertion point, where the ejection rod is then pushed a second distance for delivery of a second fixation device, and so-on as desired. For simultaneous delivery of multiple fixation devices, multiple delivery devices may be arranged in parallel (or substantially parallel). The distance between (or among) the delivery devices may be fixed or adjustable, as desired.
The distance the ejection rod 715 is pushed to define a first, second, and subsequent distances may be regulated by feel. Alternatively, the distance can be regulated by the architecture of the device. For example, the shaft and ejection rod may be fitted with a notch-and-groove configuration, respectively. In such configuration, the notch in the outer surface of the ejection rod may be aligned with a groove in the inner surface of the device. The length of the groove defines a first distance. The ejection rod 715 would be then turned or rotated within the device, aligning the notch within the device to a second groove defining a second distance, and so-on. In an alternative embodiment, the ejection rod and anchor portion of the fixation device (e.g., barb or T-anchor) may surround the shaft of the device, as a sleeve surrounds an arm. In such a configuration, the delivery tool would comprise a solid shaft and the ejection rod and fixation device would be at least partially hollow and disposed over the distal portion of the delivery device. Pushing the ejection rod in a proximal to distal direction would deploy the anchor portion of the fixation device.
Referring to
In addition, as previously described, one could use barbs having a multitude of configurations. One could also configure delivery devices to deliver one (as in
For example, although FIGS. 11 and 12A-B depict a device that places two anchors 709 banded together with one device, one could accomplish an equivalent or other desired result with a single device that delivers multiple barbs at the same time.
Although much of this description has described placement of the anchors into the annulus (or soft tissue) of the disc, one could perform anchoring into other tissues surrounding the aperture, including the bone or Sharpey fibers, it is also contemplated that, given the delivery device construction, a bone drill or similar device may facilitate the placement of the delivery device through the bony or similar tissue. Alternatively, the device delivery tool and/or the anchoring element may be of an architectural structure so as to enable the passage of the anchoring element into and/or through bony or similar tissue. For example, the device delivery tool may be of sufficient integrity so as to allow a physician to apply a force to the delivery tool with, or without, a mallet. Alternatively, the delivery tool distal end and/or anchoring elements may contain a serrated surface to facilitate placement, as an example.
The band 709′ connecting the thus implanted anchors (or barbs) advantageously contains a moveable knot 714 between the anchors. Suitable knots include, but are not limited to, the Roeder knot and its functional equivalents, and are advantageously, but not necessarily, pre-tied. After insertion of both anchors 709 (or barbs), the band 709′ is advantageously tightened by hand or by pushing on the knot with a knot-pusher or similar device. Although not shown in
The shaft of the device may be of any convenient length, typically from, e.g., 1 inch to 10 inches. Materials of which to make the delivery device include, but are not limited to: metals, such as stainless steel, nickel, titanium alloy, and titanium; plastics, such as PTFE, polypropylene, PEEK, polyethylene, and polyurethane, acrylic, polycarbonate, engineering plastics; and/or composites.
Advantageously, the shaft of the device will have a cross-sectional shape suitable to accommodate an ejection rod and at least one fixation element, or portion thereof. In one embodiment, at least a portion of the shaft of the device may be hollow, having a circular, elliptical, triangular, trapezoidal or other suitable cross-sectional area sufficient to accommodate an ejection rod.
The delivery device may also contain a handle or raised surface configured to accommodate the shape of surgeon's hands or fingers for easier handling. Such raised or configured portion may be made of the same or different material as the tube or shaft. Suitable materials known in the art include, among others, polymers, such as acrylic polymers, polyurethane, polycarbonate, engineering plastics; and metals, such as stainless steel and titanium.
Much of the previous discussion relates to the use of a patch (or stent) for annular repair and/or reconstruction. In some clinical instances, the method of the invention may be accomplished without the use of a patch, however. For example, a patch may be unnecessary to repair small apertures or apertures of certain shapes, or certain weakened or thin portion(s) of an annulus. The invention therefore also encompasses methods for repairing or reconstructing annular tissue that do not necessarily involve the use of a patch, and to fixation devices and tools useful in carrying out these methods, as exemplified in
The band and the barbs may be separate elements or comprise one continuous element. Bands and barbs may be made of the same or different materials.
The bands may be string-like, made from suture or similar material, or of any construction or dimension that is amenable to the delivery and engagement of the fixation device. For example, the band may have a width greater than, in some embodiments far greater than, its thickness. The band material may in some embodiments have a width:height ratio of 1.25:1. In some embodiments, bands may be constructed, wholly or partially, of a mesh tube. Moreover, different segments along the length of the band may have different dimensions and constructions. For example, the band may be constructed of thin material, such as nickel titanium alloy or stainless steel wire, close to the anchor barbs, while the middle portion that spans the aperture may comprise a much wider band made of optionally softer material.
The fixation devices of the invention could be delivered as a pair of barbs attached by a single band, or each barb could be delivered individually Alternatively, multiple barbs (anchors) may be pre-attached to a single or multiple bands for ease and speed of delivery. For example,
An additional exemplary depiction of fixation devices that may be used to reapproximate and hold annular tissue as previously described in
A further exemplary embodiment of the invention in the form of a braided patch 1100 such as depicted in
The “patch” 1100 is constructed from a braided tube of filaments 1102. The ends 1104 of the braided tube are heat-sealed to keep the braid from unraveling and the seals also provide structural integrity to the patch when deployed. Although the devices described herein principally utilize heat sealing for forming the ends of the device, there may be a variety of ways to fixate, secure or otherwise form the ends of the device through the addition of other materials to add structure to the filaments, to include, but not limited to, the addition of collars or sleeves, dipping the ends in a material to fixate (i.e., heated polymer, adhesive). These added materials could be metallic or polymeric.
The braided patch 1100 is woven on a braiding machine with multiple filaments 1102 to create the structure. For example, the patch can be woven with 72 polyester filaments in order to create the construct that readily deploys into the annular defect, promotes tissue or matrix ingrowth into the device, and retains an anchor after it has been placed through the wall of the annulus and through the patch. Changing the number of filaments 1102 in the patch, the material of the filaments, the dimension of the filaments (e.g., diameter), as well as the configuration of the filaments (e.g., cross-sectional area), or changing the braid pattern, can create differences in the characteristics of the patch. The braided patch can be made on a standard Steeger braider, or similar type braiding machine, that can handle braiding from anywhere from 16 filaments at a time, to up to 196 filaments. Preferably the patch is braided with between 32 to 144 filaments. In one exemplary embodiment of the present invention, the device is braided with 72 filaments of polyester filaments, with every other braid filament being approximately 0.012″ diameter, alternating with yarn (e.g., approximately 64 microfilaments, each approximately 17 microns in diameter, bundled) or alternating with a polyester braid monofilament approximately 0.004″ in diameter.
In addition, much of the description herein depicts devices that generally have a tubular form, although it is also anticipated that these devices could be woven on the braider (i.e., by changing the configuration of the braiding mandrel), or re-formed in processing (i.e., heat forming) to obtain a patch construct that deviates from a “circular” cross section, in order to obtain different characteristics of the patch pre, during or post deployment to accommodate anatomical, physical, and biological considerations of the patient or the delivery of the implant. These device configurations may include square, rectangular, oblong, symmetrical, non-symmetrical, triangular, “clover leaf”, or other cross-sectional constructions that may be partially (i.e., only in a portion of the device body, and/or only in a portion of the device ends), or completely present throughout the device.
The filaments 1102 of the patch can be made of different materials or dimensions, or all of the filaments in a patch can be of like material and dimensions. The filaments can be biocompatible metallic material, such as a stainless steel, a nickel titanium alloy, or other metallic materials. The patch 1100 can also be made from biocompatible polymeric material such as polyethyleneteraphthalate (PET), polyester, polyethylene, polycarbonate urethane, polymethylmethacrylate, or polypropylene, for example. It is also conceivable that the patch can be braided from biodegradable materials, such as polyglycolic acid (PGA), polylactic acid (PLA), collagen (or its derivatives), fibrin (or its derivatives), cellulose (or its derivatives), polysaccharides (or its derivatives) or other biocompatible material that may degrade and/or be re-absorbed by the body over time.
It is also possible to braid the patch 1100 with multiple materials and/or multiple dimensions of the filaments. For example, the patch can be braided with 32 filaments of a polymeric PET material and 32 filaments of polyester yarn material to create a patch that may be optimal for sealing an annulus. The combination of different filament materials, sizes, cross-sectional configuration, number of filaments, and braiding pattern can be used to construct a braided patch that can be delivered into the sub-annular space, while acting as a scaffold to induce healing of the aperture.
The braided patch has advantages in that it can be placed through an aperture in the wall of the annulus that is relatively small, but then expand to a dimension that is substantially greater than the aperture. For example, it is possible to construct the braided tube to be less than 5 mm in diameter, whereas in its fully deployed state it could be greater than, for example, 20 mm. This is exemplary and is not intended to be construed as limiting in the actual dimensions of the device pre and post deployment.
Referring to
Once the patch 1100 has been expanded to its fully expanded state, a cinch line 1212 that is connected to the distal and proximal ends of the patch can be tightened and a knot, such as a Roeder knot, can be used to hold the braided patch in its expanded configuration. Although, the device is shown with a cinch knot 1214, it is possible that a locking element may not be needed, depending on the means used to fixate the patch into the annulus. It is possible that no locking means is necessary. It is also possible that alternative locking means can be contemplated to keep the braided patch in its expanded form. A knot pusher 1210 can also be employed to manipulate the knot locking device 1214.
Once the device patch has been expanded into its final configuration in the aperture and subannular space, the retention member 1208 can be removed from the distal portion of the inner member by slidably pulling the proximal end of the retention member in a proximal direction. Removing the retention member relieves the stress holding the distal cuff of the patch in place and allows the patch to be slidably removed from the distal end of the delivery device, and thus deployed into the subannular space.
As depicted in
It is also conceivable that the patch could be affixed to the inner surface of the annulus through the use of adhesives, such as cyanoacrylate, fibrin glue, polymer protein, polyurethane, compounds that mimic mussel shell adhesive proteins (manufactured by Nerites Corp.), adhesive materials that may be used as adhesives for dural or dermal wound repairs/sealing, or other material used to cure, or adhesively affix the patch in the subannular space in situ. The delivery of these adhesive fixation materials could be delivered through the patch delivery tool, or through the anchor band delivery tool, or both. It is also contemplated that if an adhesive were used to affix the patch to the annulus that an additional membrane material may be added to the patch device to further help restrict fluidic extravasation of the material out of the disc during adhesive delivery, if required. Conversely, the patch construction may be altered to reduce the patch porosity in order to accomplish a similar objective. Furthermore, it is anticipated that materials maybe added to, or changed, on portions the delivery tools to reduce the possibility of the tools being adhesively bonded to the instruments during delivery. For example, a cannula or other portions of a device used for adhesive delivery may be coated with, or be constructed of, PTFE, FEP, polypropylene, polyethylene or other lubriocious materials or coatings.
The advantages of the braided design, given the right selection of filament dimension, configuration, material, braid pattern, and number of filaments is that it can be easily delivered to the annular repair site, have the flexibility to take the shape of the annular defect while maintaining the mechanical integrity needed to remain within the disc space upon loading. Another advantage, again with the appropriate selection of material, filament configuration, braiding, dimensional considerations, and multiple filament weaves, is that one can construct a patch that is conducive, in its deployed state, for incorporation of fibrosis and the fibrotic healing of the annular defect. Finally, the patch can be designed so that when it is in its delivered state, it can easily receive one or more anchor bands through the braided filaments while retaining the T-anchor or other similar type fixation device, after passing the fixation device through the patch.
As shown in
As depicted in
Additionally inventive of the anchor band device (and its delivery and deployment tools) is the unique inter-relationship of the slide body, spring, and the tension delivered to the T-anchor and tissue during deployment. For example, T-anchor assembly can be designed to pass through softer, or otherwise more pliable tissues (e.g., nucleus pulposus, softer annular layers) while resisting, under the same tension, passage through tougher tissues and/or substrates (e.g., outer annular layers, treatment device construct). In further illustrative description, tension delivered to the suture line 310 can be limited by the interface between the slide body member 318 and the suture retention block 414, through spring 316 such that tension is exerted on T-anchor body 316 which may sufficiently allow movement of T-anchor 316 through softer tissue, but alternatively requires a greater force to pull T-anchor body through other materials or substrates such as the treatment device 600 or outer layers of the annulus 232. Spring 316 can be designed to sufficiently draw tissues and/or the patch together, while not overloading suture line 310 when the fixation has been effected. Spring 316 may also be advantageously designed to allow blade assembly 420, upon reaching an appropriate loading to effect the delivery, to sever the suture line 310. As illustrative example, but not intended to be limiting, T-anchor body and suture line may be constructed to require approximately 5 pounds of force to draw the T-anchor assembly through nuclear tissue, but substantially greater load to draw T-anchor through annular tissue and/or patch device. Spring may be designed to exert approximately 5 pounds, sufficiently pulling anchor through nuclear tissue, and in proximity to treatment device, as intended. Once sufficient load has been applied to move T-anchor to engage patch, the loading on the suture line is not allowed to substantially increase. Advantageously, additional loading would cause the final compression of spring between suture retention block and blade assembly to sever suture line. Preferably, the severing and the design of the tether elements are such that the ultimate strength of the suture line is greater than the load required to draw T-anchor through soft tissue, or the like, and less than the load inflicted to cause the severing by blade assembly. The description herein is intended to be illustrative and not limiting, in that other device and delivery tools could be derived to employ the inventive embodiments.
With regards to introduction, delivery, deployment and/or fixation of fixation element 308 as described previously and in particular, with regards to
Since the surgeon's visualization of during discectomy procedures is typically limited to the epi-annular space and the aperture at the outside surface of the annulus, any tactile, visual or audible signals to assist, or otherwise enhance, the surgeon's ability to reliably deliver and deploy treatment devices and/or anchor bands may be advantageous. The anchor band delivery tool 400, may have a patch detection feature 442 on the distal end of slotted needle cannula 428 which may provide perceptible feedback (tactile and/or audible) to the surgeon that the anchor band delivery tool has accessed and penetrated the patch and it is therefore acceptable to deliver the band. As shown, detection feature 442 is composed of multiple bands or ribs although the outer surface of needle 428. The movement of the ribs of 442 against the patch structure (e.g., the filaments of treatment device 600) may produce a clicking sound and feel, and the interface of the components of the devices and tools may be optimally designed to enhance such feedback features. One, or multiple, ribs or tabs may be utilized to achieve the perceptible features. The feed back may be perceived on or with the patch and/or patch delivery tool or through the anchor band and/or anchor band delivery tool, or both.
Although much of the description of the expandable braided treatment device has illustrated the use of the braided construct as a patching-type element, the expandable braided element 1100, of for example,
As generally illustrated in
As generally illustrated throughout the
In one aspect, a fixation delivery apparatus 400 may include a single shaft 461. The shaft 461 may define a lumen 464 and/or slot 465 to serially receive two or more anchors 451. The tissue anchors 451 may be sequentially dispensed from the distal end of the shaft 461 at one or more locations within an intervertebral disc. In this embodiment, the distally positioned anchor 451 may be particularly referred to as the first anchor 452 and the proximally positioned anchor 451 may be particularly referred to as the second anchor 453. The anchors 451 are displaced from the lumen 464 and/or slot 465 of the shaft 461 by a displacement rod 463. A displacement rod 463 may communicate with an actuator 462 so that a user may advance a displacement rod 463 within the lumen 464 and/or slot 465 to dispense anchors 451 from the lumen 464 and/or slot 465 of the shaft 461. The first anchor 452 may be sized to be frictionally held within the lumen 464 and/or slot 465, may be retained in the lumen 464 and/or slot 465 by one or more detents formed within the lumen 464 and/or slot 465, may be retained in the lumen 464 and/or slot 465 by an elongated member 454 or other interconnecting members between anchors 451 and/or tethers 470, or may be otherwise temporarily secured to the lumen 464 and/or slot 465 of shaft 461. The second anchor 453 may be similarly secured to shaft 461 in a manner similar to a first anchor 452 or, alternatively, may be tethered by a tether 475 to retain a second anchor 453 secured to lumen 464 and/or slot 465 during and/or after displacement of the first anchor 452 into the intervertebral disc of a patient. In one aspect, the tether 475 may be secured to the displacement rod 463 or the actuator 462. Before, or upon, or after placement of the second anchor 453, the tether 475 may be severed, broken, cut or otherwise released from an actuator 462, displacement rod 463, and/or the delivery apparatus body 460 or shaft 461 to permit the release of the second anchor 453 from the structure to which the tether 475 is secured. In this exemplary embodiment, the first anchor 452 can be displaced from the shaft 461 by movement of the displacement rod 463 a first distance sufficient to displace the first anchor 452. This first distance may be insufficient to displace the second anchor 453. Then, the shaft 461 of the fixation delivery apparatus 400 may be moved from the first location where the first anchor 452 was dispensed and repositioned at a second location on or in the intervertebral disc to dispense the second anchor 453. The second anchor 453 may be connected to the first anchor 452 by one or more loops 466 and/or elongate members 454.
In another aspect, a fixation delivery apparatus 400 may include two or more shafts 461. In an exemplary embodiment, wherein there are two shafts, (similar to, for example,
The delivery apparatus body 460 may be generally configured to provide a user with a structure to manipulate the distal portion of the shaft 461 within a patient. The delivery apparatus body 460 may have an elongated form and define a longitudinal aspect. In one aspect the proximal portion of the shaft 461 may be secured to a distal portion of the delivery apparatus body 460. When the shaft 460 is secured to the delivery apparatus body 460, the longitudinal axis of the shaft 460 may be coaxial with the longitudinal axis of the delivery apparatus body 460. In one aspect, the delivery apparatus body 460 may include a handle 476 integral with the body, or secured to the delivery apparatus body 460. When secured to the delivery apparatus body 460, the handle 476 may be secured to the outer surface of the delivery apparatus body 460. The handle 460 is typically positioned to facilitate the manipulation of the fixation delivery apparatus 400 by a surgeon and may be particularly configured to assist the surgeon in the positioning and/or dispensing of a fixation apparatus 450 within a patient. In another aspect, the delivery apparatus body 460 may include a raised textured surface for increased friction between a user's hands and the fixation delivery apparatus 400. The delivery apparatus body 460 may further cooperate with the actuator 461 to control the movement of the displacement rod 463 within a lumen 464 and/or slot 465 of shaft 461. In another aspect, the delivery apparatus body 460 may define a body cavity 477 to movably receive the actuator 462. The delivery apparatus body 460 may also comprise a tether access portal 478 (
The delivery apparatus body 460 may be formed from a metal, polymeric material or other material that will be recognized by those skilled in the art upon review of the present disclosure. Some exemplary suitable materials recognized by those skilled in the art, include among others, polymers, such as acrylic polymers polyurethane, polycarbonate, engineered plastics; and metals, such as stainless steel and titanium.
The shaft 461 may be an elongate member that could be secured to and distally extend from the delivery apparatus body 460. Although the various embodiments described and illustrated herein typically define a delivery device 400 configuration that extends along a longitudinal axis, it is contemplated that the shaft and/or device components could extend along different projections so as to provide better visualization of the distal portions of the instruments within the surgical site. For example, it is possible that the handle and/or the proximal portion of shaft 461 define a longitudinal axis that is at a different angle than, for example, the distal portion of shaft 461. With this configuration, the handle, in use, may extend from the surgical site at a lateral position from the access incision and provide better visualization of the distal portion of shaft 461 within the surgical site. The shaft 461 may define a lumen 464 and/or slot 465 in at least a distal portion of the shaft 461. The lumen 464 and/or slot 465 may be configured to releasably secure one or more anchors 451, or portions thereof. The lumen 464 and/or slot 465 may be particularly sized and shaped to receive anchors 451 and the associated connecting loops 466 and/or elongate members 454, or portions thereof. The slots 465 may permit various components of the anchors 451 and/or elongate members 454 (including components of anchors 451, loops 466 or elongated members 454 such as retention devices and/or knots 455 or retention members, for example) to extend from the shaft 461 at a distal portion of the shaft 461. In one aspect, the lumen 464 and/or slot 465 may extend from the proximal end to the distal end of the shaft 461. In this configuration, the lumen 464 and/or slot 465 may communicate with the body cavity 477 of the delivery apparatus body 460 at a proximal portion of the shaft 461. In one aspect, the lumen 464 and/or slot 465 may be configured to slidably receive a filament 475. The lumen 464 and/or slot 465 may extend distally to about the distal portion of shaft 461 and may extend to the distal tip of the shaft 461. The lumen 464 and/or slot 465 of the shaft 461 may have a circular, elliptical, hexagonal, pentagonal square, diamond, rectangular, triangular, or other cross sectional shape and may be configured to releasably receive at least a portion of an anchor 451. In one aspect, the cross sectional shape of the lumen 464 and/or slot 465 may correspond to the cross-sectional shape of the anchor 451. In one aspect, the lumen 464 and/or slot 465 of shaft 461 may have a cross-sectional shape suitable to accommodate a displacement rod 463 and at least one anchor 451, or portion thereof. The lumen 464 and/or slot 465 may have the same or a varying configuration along their length.
The distal tip of the shaft 461 may be generally configured to permit the shaft 461 to penetrate the surface of an intervertebral disc or vertebral body using a force exerted by a surgeon on the delivery apparatus. In one aspect, the distal tip of the shaft 461 may include a sharpened tip. In another aspect, the distal tip of the shaft 461 may be chamfered to provide a point which may be sharpened to accommodate insertion through at least a portion of the annulus fibrosus of an intervertebral disc. In one embodiment, the distal tip of the shaft 461 may be cut obliquely to form a sharp leading surface or point for ease of insertion. In one embodiment, the device delivery tool and/or the anchoring element may be of an architectural structure so as to enable the passage of the anchoring element into and/or through bony tissue, such as the vertebral bodies. For example, the delivery apparatus may be of sufficient integrity so as to allow a physician to apply a force to the apparatus (e.g., with, or without, a mallet). Alternatively, the distal end of the apparatus and/or anchoring elements could contain a serrated surface.
A sheath 480 may be provided over at least a portion of the length of the shaft 461. The sheath 480 may function to reinforce the shaft 461. In alternative embodiments, the sheath 480 may provide a change in diameter longitudinally along the shaft 461 such that the penetration of the annulus fibrosus may be inhibited as the leading edge of the sheath 480 contacts the annulus. In another aspect, the shaft 461 may include a tissue stop 481 positioned relative to the distal end of the shaft 461 to inhibit the penetration of the annulus fibrosus. Typically, the tissue stop 481 may inhibit the penetration of the annulus fibrosus by providing a region of the shaft 461 with increased surface area. The tissue stop 461 may be typically sized and shaped to efficiently inhibit the penetration of the shaft 461 through the annulus fibrosus while being relatively a traumatic to the tissues which it may contact.
The distal portion of the shaft 461 may include a tactile indicator similar, as an example, to 442 of
The shaft 461 is typically from about 1 inch to 10 inches long. However, the length of the shaft 461 may vary considerably depending upon the configuration of the fixation apparatus 450 and the fixation delivery apparatus 400, and may particularly depending upon the configuration of the delivery apparatus body 460 to which the shaft 461 may be secured, as well as the technique used to access the intervertebral disc space. The shaft 461 may be made from a wide range of materials having the desired performance characteristics depending, at least in part, on the overall configuration of the fixation delivery apparatus 400 and may include: metals, such as stainless steel, nickel-titanium alloy, and titanium; plastics, such as PTFE, polypropylene, PEEK, polyethylene, and polyurethane, acrylic, polycarbonate, engineering plastics; and/or composites.
The displacement rod 463 may confer a motive force to anchors 451 to displace one or more of the anchors 451 from the lumen 464 and/or slot 465 of the shaft 461. In some embodiments, the displacement rod may also function to withdraw one or more anchors 451 into the lumen 464 and/or slot 465. A portion of the displacement rod 463 may communicate with anchors 451 which may be least partially positioned within the lumen 464 and/or slot 465 of shaft 461. In one aspect, the displacement rod 463 extends through at least a portion of lumen 464 and/or slot 465. The displacement rod 463 may be slidably received within the lumen 464 and/or slot 465. In one aspect, the displacement rod 463 may be of a size and cross-sectional shape to correspond with the size and/or internal shape of the lumen 464 and/or slot 465 in which at least a portion of the displacement rod 463 may be received. Although the characteristic of the displacement rod 463 may be typically of a unitary structure, a displacement rod 463 in accordance with the present invention may include multiple components which act in conjunction with one another to displace the anchors 451 from the shaft 461.
In one embodiment, the displacement rod 463 may define a displacement rod lumen 482. In one aspect, the displacement rod lumen 482 may extend from a proximal portion to a distal portion of the displacement rod 463. The displacement rod lumen 482 may communicate with the body cavity 477 of the delivery apparatus body 460 at a proximal portion of the displacement rod 463. In one aspect, the displacement rod lumen 482 may be configured to receive a tether line, suture, wire, filament or otherwise elongate member. Tether 475 can be formed of multiple materials and/or components to perform its function. In addition, a tether passage 483 may be defined in the wall along the proximal portion of the displacement rod 463. The tether passage 483 may permit a portion of tether 475 to exit a displacement rod lumen 482 at a proximal location or a location distal to the proximal end of the displacement rod lumen 482. The proximal portion of the displacement rod 463 may communicate with actuator 462 to actuate or regulate the movement of the displacement rod 463. In one embodiment, a proximal portion of the displacement rod 463 may be secured to actuator 462. The distal portion of the displacement rod 463 may typically communicate with at least one anchor 451. In one aspect, the distal end of the displacement rod 463 may communicate with the proximal end of anchor 451 to confer a motive force to the anchor 451.
In one exemplary embodiment, the displacement rod 463 can be advanced distally a first distance, sufficient to dispense a first anchor 452. The shaft 461 of the fixation delivery apparatus 400 may be then removed from the first insertion point in the intervertebral disc and inserted into the intervertebral disc at a second insertion point, where the displacement rod 463 may then be advanced distally a second distance to dispense a second anchor 453, and so-on as may be desired for more than two anchors 451. Alternatively, for simultaneous delivery of multiple anchors 451, multiple shafts 461, each including a displacement rod 463, may be provided on the fixation delivery apparatus 400 and may be arranged adjacent to, parallel or substantially parallel along a portion of their lengths. In such configurations, the distance between the shafts 461 may be fixed or inter-operatively adjustable, as desired. When adjustable, the fixation delivery apparatus 400 may include a mechanism, such as a ratchet or displacement mechanism (not shown), or otherwise, as will be recognized by those skilled in the art upon review of the present disclosure, to adjust the distances between the distal portions of the shafts 461. The multiple shaft embodiment may also be additionally configured for sequential displacement of anchors 451.
An actuator 462 may communicate with one or more displacement rods 463 or components thereof to assist a user in advancing the displacement rods 463 along the respective shafts 461. The actuator 462 may be configured as an enlarged body residing at the proximal portion of displacement rod 463 which may be integral with, or secured to the displacement rod 463 to assist a user in advancing displacement rod 463. In this aspect, the distance the displacement rod 463 is pushed to define a first, second, and subsequent distances may be regulated by feel. Alternatively, the distance can be regulated by the architecture of the device. In this aspect, the actuator 462 may cooperate with the delivery apparatus body 460 to control the advancing and/or retracting of the displacement rod 463 within shaft 461, for example as shown in
Exemplary cooperation of actuator 462 and body 460 is shown in
Fixation apparatus 450 as described herein may be various constructs utilized as primary reparative treatment of the soft tissues of the spine wherein re-approximation, reinforcement, stabilization, retention, reconstruction, and/or fixation as it would be otherwise achieve may be necessary for prophylactic or therapeutic repair of a defect, aperture, weakened, thinned or infirmed portion of the disc including the annulus fibrosus. In addition, fixation apparatus 450 described herein may be utilized in combination with other treatment constructs 600 such as patches, membranes, scaffolds, barriers, stents (used interchangeably) wherein fixation devices may additionally enable a treatment device 600 to be affixed to the soft tissue, including the annulus fibrosus, of the spine.
Fixation apparatus 450 may contain two or more anchors 451 and one or more elongate members 454 or may contain one or more anchors 451, one or more pledgets 309 and one or more elongate members 454. Furthermore, it is understood that multiple fixation apparatuses 450 may be used together to perform a repair or other procedure. Anchors 451 may generally be configured to maintain a position within an intervertebral disc as forces are applied to the elongate members 454. The one or more elongate members 454 may typically be connected to a first anchor 452 and a second anchor 453, or an anchor 451 and a pledget 309 and may be configured to apply a force between the first anchor 452 and the second anchor 453 or the anchor 451 and the pledget 309, while allowing the components to be drawn toward one another. One of the elongate members 454 may be elongated and may function as a cinch line 470 that is accessible to a surgeon after implantation of the anchors 451 of the fixation apparatus 450. In operation, the elongate members 454 secured between the anchors 451 may allow drawing together disc tissue, such as the annulus, between the anchors 451 when tightened. Accordingly, the fixation apparatus 450 can be placed in tension applying a force to pull together, wholly or partially, the surrounding tissue of the intervertebral disc. The forces may be applied to reapproximate, reinforce, retain, reconstruct or otherwise fix a tear, defect, incision, rent and/or delamination in the intervertebral disc of a patient.
Anchors 451 are generally configured to substantially maintain a desired position within and/or on an intervertebral disc as tension is applied to a band 454 or multiple elongate members 454 securing two or more anchors 451 together. The anchors 451 are typically configured to permit their positioning within and/or on an intervertebral disc using a fixation delivery apparatus 400 and, once positioned and secured, to resist movement within the intervertebral disc. The anchors 451 may be configured as barbed anchors, T-anchors, coiled anchors, darts, conical, elliptical or other configurations as will be recognized by those skilled in the art upon review of the present disclosure. In an exemplary embodiment, a barbed anchor 451 may include an elongated body having at least one barb extending laterally from its longitudinal axis. One end of the elongated body may be particularly configured to penetrate the tissues of an intervertebral disc when the anchor 451 is directed through tissue in a direction along its longitudinal axis. In an exemplary embodiment, an anchor 451 may be connected to an elongated body, band 454, filament, filament loop or eyelet 466 secured at, near or proximate its midpoint such that, after insertion in a longitudinal orientation, the anchor 451 tends to assume a position perpendicular to a line of force exerted by the loops 466 and/or band 454. Loops or eyelets 466 may be a rigid structure or may be a flexible structure defining a loop through which a band 454 may be positioned. In one aspect, the eyelets 466 are integral with or secured to the anchor 451 and are a rigid structure. In another aspect, the eyelets 466 are secured to the anchors 451 and are a flexible structure such as a wire, filament, line, tether or suture, for example. In an exemplary embodiment of a coiled anchor, a anchor 451 may include an elongated body in the form of a coil that is formed from flexible and resilient material such that it may be insertable from a lumen 464 and/or slot 465 in a shaft 461 in a substantially straightened or collapsed position and once dispensed from the shaft may resume its original shape. In an alternative exemplary embodiment of a coiled anchor, an anchor 451 may include an open-wound, helically configured rigid element that may be attachably connected to the distal end of the shaft 461. Rotation of the shaft 461 or displacement rod 463 may, for example, advantageously “screw” the coiled anchor into tissue of an intervertebral disc.
The anchors 451 may be elongated in shape. The anchors 451 may be integral with or secured to elongate members 454. The elongate members 454 can be secured to the anchors 451 through loops or eyelets 466 which may be integral with or attached to the anchors 451, can be secured to the anchor 451 through one or more band passages extending into or through the anchors 451. In one aspect, a band passage may extend through the anchor 451 perpendicular to or substantially perpendicular to the longitudinal axis of the anchor 451. In other aspect, a band passage may extend through the anchor 451 at other angles relative to the longitudinal axis of the anchor 451. Typically, the anchors 451 will be configured to permit at least partial placement within a lumen 464 and/or slot 465 of the shaft 461 of a fixation delivery apparatus 400. Alternatively, anchor 451 may have a defined cavity or passage to permit anchor 451 to be positioned at least partially over the distal tip of shaft 461 of a fixation delivery apparatus 400. In this alternative embodiment, anchor 451 may have a surface configured to pierce the soft tissue of the intervertebral disc and allow delivery of the anchor 451, or may even have a surface configured to pierce or otherwise become secured to the bony tissue of a vertebral body.
The anchors 451 are typically formed from a substantially biocompatible material of a metallic or polymeric biocompatible material such as, for example, titanium, NiTi alloy, stainless steel, platinum, gold, polyurethane, polycarbonate urethane, polyimide, polyamide, polypropylene, polyethylene, polypropylene, polyester, PET, or PEEK, or could be constructed from a biodegradable/bioabsorbable material such as, for example, collagen, silk, cellulose, polysaccharides, carbohydrates, polyglycolic acid, polylevolactic acid, polydioxanone, or racemic polylactic acid. In addition, the anchors 451 can be constructed of a combination of these materials.
One or more elongate members 454 may interconnect anchors 451 and/or pledgets 309 of fixation apparatus 450. At a first end or region, the elongate members 454 may secured to one or more anchors 451. The elongate members 454 may be tied to the anchors 451, may be mechanically secured to the anchors, may be integral with the anchors 451 or may be otherwise secured to the anchors as will be recognized by those skilled in the art upon review of the present disclosure. In one aspect, one or more anchors 451 may be slidably secured to the elongate members 454 or may be slidably received over the elongate members 454. Typically, one or more elongate members 454 may be tied to one another with one or more retention devices and/or knots 455 that may permit the cinching (or shortening) of the length of elongate members 454 separating two or more of the anchors 451. The retention devices and/or knots 455 in the band are typically movable along one of the elongate members 454 but may be movable along two or more elongate members 454. The retention devices and/or knots 455 are typically positioned between the anchors 451. One suitable family of retention devices and/or knots 455 include, but are not limited to, the Roeder knot 455 and its functional equivalents. These knots may be pre-tied during the assembly of a fixation apparatus 450. Alternatively, a mechanical element slidably received over a first band 454 and secured to the end of another band 454 which is lockable in a desired position over the first band 454 may also be used. In another aspect, two or more anchors 451 may include loops or eyelets 466 which may be comprised of looped elongate members 454 through which a band 454 in the form of a cinchable loop or “lasso” may be passed. The cinching of the elongate members 454, or a loop in a band 454, allows for taking-up slack and drawing towards one another intervertebral disc tissues so as to reapproximate, retain, reinforce or otherwise repair tissues surrounding a disc tear, incision, defect, rent, infirmation or delamination.
As noted previously, the elongate members 454 may be formed from a variety of materials. In one aspect, the elongate members 454 may be formed from sutures or suture materials commonly used by surgeons. The elongate members 454 may be configured to have sufficient strength to re-approximate or draw together tissue surrounding tear, rent, incision, defect or delamination in the annulus fibrosus of a patient. In one aspect, the elongate members 454 may be substantially inelastic to, among other things, permit a surgeon to sufficiently retain or draw the tissue of the intervertebral disc together by cinching the elongate members 454. In another aspect, the elongate members 454 may be formed from an elastic material and configured to be in a stretched position upon implantation in a patient to apply a closing force to a defect in an annulus fibrosus of a patient. The elasticity of the elongate members 454 may also be selected to substantially correspond to that of the intervertebral disc of the patient. The elongate members 454 may be string-like filaments having a construction and dimension, as disclosed herein and as will be understood by those skilled in the art upon review of the present disclosure, that are amenable to the delivery to and repair of the intervertebral disc, as well as engagement with the fixation apparatus 450. For example, an elongate member 454 may have a width greater than, in some embodiments far greater than, its thickness. When the elongate member 454 is formed from a suture or similar filamentous material, the elongate member 454 may, in some embodiments, have a width:height ratio of 1.25:1. In some embodiments, elongate members 454 may be constructed, wholly or partially, of a mesh tube. Moreover, different segments along the length of the band may have different dimensions and constructions. For example, the elongate member 454 may be constructed of thin material, such as nickel titanium alloy or stainless steel wire, close to the anchor, while the middle portion that may span the aperture may comprise a much wider band made of optionally softer material and/or a material that has a surface texture or porosity conducive to fibrotic ingrowth and repair or may be otherwise configured as disclosed elsewhere in the present disclosure and/or as will be understood by those skilled in the art upon review of the present disclosure.
In another embodiment, elongate members 454 and/or cinch line 470 may incorporate a retaining element (not shown) so as to temporarily retain or otherwise constrain 454 and/or 470 along the delivery apparatus so as to facilitate the management of the members by the physician prior to the physician's intent to delivery and/or deploy the treatment construct 450. These retaining elements could act as collets in the proximal region and/or the distal region of the delivery apparatus.
As noted herein, a patch-like device 600 in the form of a patch, membrane, scaffold, barrier, stent, sealing device, reinforcement, plug, occlusion device, or otherwise, may be provided for repair, reconstruction, reinforcement, re-approximation, or otherwise treatment of apertures, weakened, thinned or otherwise infirmed tissue such as tears, rents, defects, delaminations and/or incisions within an intervertebral disc. In one embodiment, an apparatus 600 may used in combination with other reparative apparatuses, such as fixation apparatus 450, for the re-approximating, reinforcing, or otherwise repairing tissues. Particularly, it is conceivable that some natural and surgically made defects may be relatively large and accordingly, reapproximation of tissues surrounding an aperture is not actually or practically possible without the introduction of additional material. A device 600 in accordance with the present inventions may provide the material for positioning in and around a defect to bridge some, all or a portion of the defect to facilitate a medically appropriate stabilization of the tissues. The patch 600 may function to reinforce the portion of an intervertebral disc through which a fixation apparatus 450 is implanted. And, patch 600 may be used to bridge tissues of a defect and may also act as a scaffold for tissue ingrowth.
The patch 600 may be configured as a membrane, webbing, mesh, scaffolding, barrier or otherwise as will be recognized by those skilled in the art upon review of the present disclosure. The patch 600 may be of a rigid construction, may be flaccid, or may of an intermediate rigidity. The patch may also have configurations that include multiple rigidities associated with different portions of the patch as may be necessary to address alternative defect pathologies and/or delivery and deployment considerations. The patch 600 may be of a solid material, webbing or otherwise, or may comprise one or more mounting cavities within the patch. In one aspect, the mounting cavities or receptacles may cooperate with a patch insertion tool 500 to assist in the placement of the patch 600. In one aspect, the patch 600 defines a single patch mounting cavity extending along its length and, accordingly, may be configured as a sleeve or a sock. In alternative embodiments, the patch 600 may define a plurality of mounting cavities which are configured to receive one or more projections, brackets, arms or otherwise mounting or retaining elements 504 or 506 of the patch insertion tool 500.
Patches 600 can be formed from a variety of materials or combinations of materials known to those skilled in the art. These materials are typically biocompatible. The patch 600 may be configured from natural or synthetic materials including, but not limited to, various polymers, metals and biological tissues, for example. In one aspect, the patch 600 may be formed from autograft para-spinal fascial tissue, xenograft, allograft, or other natural or processed collagenous materials. The material could also be polymeric such as a Dacron (polyester, or PET), polypropylene, polyethylene, polymethylmethacrylate, silicone, PTFE, ePTFE, Surlyn, or PEBAX material, for example. In some exemplary embodiments, the patch 600 could comprise biocompatible metal, such as NiTi alloy, chromium cobalt alloy, titanium, stainless steel or the like. Webbing materials could also be woven or non-woven, or braided. Patches may also be partially or wholly constructed from biodegradeable or bioabsorbable materials. It is also possible for the patches to be constructed, partially or wholly, from previously herein described materials, as well as to comprise of one or more of these materials, as may be generally understood by those skilled in the art. Patches may also comprise bioactive materials and may also be for mechanical, biochemical and medicinal purposes. The patch 600 may also be drug eluting, as known in the medical implant arts. Furthermore, in one exemplary embodiment, the material of the patch 600 may contain a structure sufficient to readily permit the passage of the distal portion of a shaft 461 of a fixation delivery apparatus 400 with little or no resistance while providing resistance to the dislodging of an anchor 451 dispensed within or through patch 600.
Patch delivery tools 500 in accordance with the present inventions are generally configured to position one or more patches 600 at positions in proximity, adjacent or within an intervertebral disk 200 of a patient. Typically, patch delivery tools 500 are configured to releasably secure devices 600 on or about the distal portions of delivery tools 500 such that, after a surgeon has secured at least a portion of the patch 600 to the intervertebral disk 200 of a patient, the patch 600 may be released from the patch delivery tool 500 and the patch delivery tool 500 may be removed from the patient.
The delivery apparatus body 460 may include a body cavity 477 within at least a portion of the delivery apparatus body 460. The delivery apparatus body 460 may be elongated and include a handle 476 at the proximal portion of the delivery apparatus body 460. The shaft 461 may be secured to the distal portion of the delivery apparatus body 460. A guide, pin, or projection 484 may extend into the body cavity 477 and may be received by slot or groove 485 of actuator 462 (see
The shaft 461 extends from delivery apparatus body 460 and may include a sheath 480. The shaft 461 may comprise a lumen 464 which may extend from the proximal portion to the distal portion of shaft 461. The lumen 464 is illustrated with a circular cross-sectional shape that may be suitable to accommodate the circular cross-sectional shape of the illustrated anchors 451 and to slidably receive displacement rod 463, although, alternative cross-sectional configurations could be employed to accomplish the same function. The lumen 464 of the shaft 461 may be in communication with body cavity 477 of the delivery apparatus body 460 and may permit the at least one displacement rod 463 and/or its components to be slidably received within shaft 461. As illustrated, the distal tip of the shaft 461 may be cut obliquely to form a sharp leading surface or point for ease of insertion into an intervertebral disc. The shaft 461 may include a slot 465 along its side to accommodate portions of fixation apparatus 450, such as elongate members 454, 466 and anchors 451, and knots 455 that may not reside completely within lumen 464.
The actuator 462 and/or the displacement rod 463 may be movably received within a portion of body cavity 477. As illustrated, the actuator 462 may function as a handle to interface with a user and extends proximally from the proximal end of the delivery apparatus body 460. A distal portion of the actuator 462 may be secured to a proximal portion of displacement rod 463. The displacement rod 463 is particularly shown as secured to the distal portion of the actuator 462. The actuator 462 may configured to advance displacement rod 463 in a 1 to 1 ratio. A displacement spring 486 may be positioned within the body cavity 477 between the distal portion of body cavity 477 and the distal portion of actuator 462, in the example shown. The displacement spring 486 may bias the illustrated actuator 462 and displacement rod 463 in a proximal direction. A groove 485 on actuator 462 may be configured to cooperate with the projection 484 of the delivery apparatus body 460. Those skilled in the art would realize this is an exemplary configuration and, for example, groove 485 could as easily be located on the apparatus body 460 and the pin 484 could reside on the actuator 462.
The displacement rod 463 may generally be configured to apply a motive force to dispense T-anchors 451 from the distal end of the lumen 464 and/or slot 465. The displacement rod, as shown, is an elongated structure having a substantially circular cross-sectional shape and may comprise a displacement rod lumen 482 extending along at least a portion of the length of the displacement rod 463. At least a distal portion of the displacement rod 463 may be slidably received within the lumen 464 of the shaft 461. The movement of the displacement rod 463 within lumen 464 may be modulated by actuator 462. As particularly illustrated, the actuator 462 is configured to advance the displacement rod 463 in a 1 to 1 ratio. A tether passage 483 may be defined in a proximal portion of the displacement rod 463. The tether passage 483 may permit a portion of tether 475 to extend from the displacement rod lumen 482 to be positioned within body cavity 477 of the delivery apparatus body 460. Although tether 475 here is used as a general term, those skilled in the art would recognize that tether 475 could be a wire, string, suture band or other elongate member to satisfy the same purpose.
The tether 475 may be provided to secure an anchor 451 prior to deployment. The proximal portion of tether 475 may be secured to the actuator 462, displacement rod 463, and/or delivery apparatus body 460. As illustrated, the tether 475 is secured to a portion of the actuator 462. More particularly, the distal portion of the actuator 462 defines a flange 487 about which tether 475 is looped around the flange 487 to secure the proximal end of the tether to the actuator 462. Advantageously, the distal end of the actuator 462 may have a tether severing cavity 488 which includes a lip 489. In addition, a tether severing element 490 may be provided in the distal portion of the body cavity 477. The tether severing element 490 may include a cutting edge 491. The tether severing cavity 488 and the tether severing element 490 may cooperate to sever the tether 475 and thus allow anchor 451 to be released from lumen 464 and/or slot 465. As illustrated, the tether 475 is cut by positioning the actuator 462 distally with the passage 483 and the lip 489 of tether severing cavity 488 overlapping the longitudinal axis of the cutting edge 491 of the tether severing element 490 to press the tether 475 against the cutting edge 491. Alternatively, if an automated cutting feature is not used, a tether access portal 478 may be provided through the delivery apparatus body 460 to permit access to the tether 475 with other cutting devices such as scissors or scalpels for example. Although tether 475 is drawn as a single element residing within lumen 464 and connected to anchor 451, an alternative embodiment may include tether 475 as a “looped” element wherein an end of the tether is passed through a receiving portion of anchor 451 and when, for example, a single filament of the tether 475 is cut the filament passes distally, through the anchor 451, and is removed with the delivery apparatus 400. This alternative embodiment may allow the physician to practice the repair with one less step (i.e., the excising of the trailing tether line 475 attached to anchor 451).
A sheath 480 may be secured about the outer surface of shaft 461. The sheath 480 may extend from the delivery apparatus body 460 to a location proximal to the distal end of shaft 461. A tissue stop 481 may be secured to the distal portion of shaft 461. As illustrated, the tissue stop 481 may also be particularly secured on sheath 480. The shaft 461 may further define a slot 465. Slot 465 may be configured to slidably receive components of fixation apparatus 450 as the components slide along the longitudinal axis of the shaft 461. As illustrated in
The illustrated fixation apparatus 450 include three anchors 451 in
As illustrated in
The guide, pin or projection 484 may be slidably received in groove 485 of the actuator 462. The guide 484 may be secured to or within the body cavity 477 of the delivery apparatus body 460. As illustrated, in
As illustrated in
In operation, the guide 484 may be initially positioned within a safety lock position 498 where the displacement rod 463 may be in a most proximal position with respect to shaft 461 and wherein the actuator 462 may be biased in a proximal position with respect to shaft 461 and/or by the displacement spring 486, as seen in
The second anchor 453 and fixation delivery apparatus 400 may remain secured to the first anchor 452 connecting bands 454 such as 454, 466 and/or trailing cinch line 470 of elongate bands, as shown in FIG. 48B. A loop in elongate member 454 may be configured to be at least long enough to extend from a first anchor location to a second anchor location prior to cinching band 454. The tip of shaft 461 of the fixation delivery apparatus 400 may be then repositioned adjacent to a second location on the intervertebral disc for insertion of the second anchor 453. The tip of the shaft 461 is inserted at the second location and the shaft 461 is again advanced into the intervertebral disc. The shaft 461 may again be advanced until the distal aspect of the tissue stop 481 or sheath 480 contacts an outer surface of the intervertebral disc or the tip of the shaft 461 has otherwise been determined to be at the desired location within the intervertebral disc. Once properly positioned, the displacement rod 463 may be advanced relative to the delivery apparatus body 460 by the surgeon to displace the second anchor 453 from the tip of the shaft 461 into the intervertebral disc. To do this, the surgeon may rotate the actuator approximately 90 degrees by sliding the guide 484 through a second radially extending portion 485b of the groove 485. The surgeon may then advance the actuator 462 distally within cavity 477 which may slide the guide 484 through the second longitudinal extending portion 485a of groove 485. The movement of the actuator may displace the second anchor 453 from the distal portion of shaft 461 by distally advancing the displacement rod 463 a second distance. The second distance being selected to be sufficient to displace the second anchor 453 from the lumen 464 and/or slot 465 of the shaft 461 into the intervertebral disc. The surgeon then removes the shaft 461 from the intervertebral disc leaving the second anchor 453 at the second anchor location within the intervertebral disc.
After insertion of at least the first anchor 452 and the second anchor 453, the loop of elongate member 454 is shortened by hand or by pushing on, for example, a slip knot 455 with a knot-pusher or similar device to apply a force to the knot to slide the knot along the band 454 and reduce the size of the loop which tends to draw towards one another the anchors 451 and adjacent tissues surrounding an annular defect. Typically, the tightening is managed using a cinch line 470 that can be manipulated by the surgeon. Once tightened, the excess cinch line 470 can be cut.
When inserting the first anchor 452 and second anchor 453 in series, the elongate member 454 may have a tendency to lie across or along the surface of the annulus fibrosus during the anchor insertion process. For instance, after the first anchor 452 has been inserted, since the elongate member 454 is connected to the first anchor 452 via its respective filament loop 466, a portion of the elongate member 454 may be drawn toward and along the surface of the annulus fibrosus. The elongate member 454 may thus interfere with movement of the tool 400 and/or the ease of desired placement of the second anchor 453 therefrom. Accordingly, it may be desirable to provide a means for releasably restraining the elongate member 454 from release from the tool 400 until after or during the process of insertion of the second anchor 453.
It is contemplated that one or more fixation apparatuses 450 (and their respective delivery apparatuses 400) as illustratively described and shown in
Furthermore, it is conceivable that, in order to repair an intervertebral disc annulus that is damaged, degenerated or otherwise infirmed with defects of a circumferential and/or delaminated physiology, one might employ one or more fixation devices 450 so as to draw together or otherwise radially stabilize or retain tissues in a reparative fashion. In this alternative embodiment (which may be additional or further described in application Ser. No. 11/120,750) there may not be an annular aperture readily apparent in the intervertebral disc, but rather the degenerative pathology may be recognized as high intensity zones under radiological examination, such as for example MRI and CT scans. It is also possible, given this type of repair, that the anchors 451 of apparatus 450 may be placed at spatially far greater distances apart (prior to foreshortening band 454) than may be needed for repair of annular apertures. For example, it is conceivable to repair some large posterior protrusions and/or delaminations of an annulus that anchors 451 could be deployed as far apart as the total posterior, or more, of the annulus so as to reparatively restore or otherwise stabilize the incompetent annular tissue.
As noted herein, the anchors for annulus fibrosus tissue fixation apparatus may be disposed in annulus fibrosus tissue of a disc, in the disc cavity for the nucleus polposus of the disc, through the entire disc itself, or in or through Sharpey's Fibers or in a vertebral body. A fixation apparatus may include one or more anchors in any one or more of any of these locations to facilitate the repair of a defect in the wall of the annulus fibrosus of a disc. Several exemplary embodiments of fixation apparatus for making such a repair are illustrated in
As shown, one or more soft tissue anchors 814 may be affixed into or through the annulus fibrosus 232. In the illustrated embodiment, each soft tissue anchor 814 has a T-anchor 815 with an elongate element 816 attached thereto. A link, connecting element or coupling 818 slidably connects the elongate elements 816 of each anchor 814. In one embodiment, a length of the connecting element 818 is shortenable by means of a moveable knot such as a Roeder knot, or its functional equivalent. The length of the connecting element 818 can be shortened by pulling on its associated tether 818a to, for example, shorten the loop defined by connecting element 818. Together, the soft tissue anchors 814 and connecting element 818 define a soft tissue anchor assembly (although the soft tissue anchor assembly is shown with two anchors connected to the connecting element, additional soft tissue anchors and/or connecting elements may be provided as an assembly).
In
An alternative embodiment of a fixation apparatus having at least one bone anchor is illustrated in
In an alternative embodiment (not shown), tether 831a may also include a slidable and locking element so as to be capable of shortening the distance between the bone anchor 831 and elongate member 832.
As shown, one or more soft tissue anchors 834 may be affixed into or through the annulus fibrosus 232. In the illustrated embodiment, each tissue anchor 834 has a T-anchor 835 with an elongate element 836 attached thereto that extends into and/or through the annulus fibrosus 232. A link, connecting element or coupling 838 slidably connects the elongate elements 836 of each tissue anchor 834. In one embodiment, a length of the coupling or connecting element 838 is shortenable by means of a moveable knot such as a Roeder knot, or its functional equivalent. The length of the connecting element 838 can be shortened by pulling on its associated tether 838a to, for example, shorten the loop defined by coupling 838. Together, the tissue anchors 834 and connecting element 838 define a soft tissue anchor assembly (although the soft tissue anchor assembly is shown with two soft tissue anchors coupled to a connecting element, additional soft tissue anchors and/or connecting elements may be provided on the assembly).
In
As noted above, the tissue anchors 834 may be disposed in the annulus fibrosus 232 at the same time, using a delivery tool such as illustrated in
In the fixation apparatus embodiment of
As noted in the illustrative embodiments herein (see, e.g.,
An expandable mesh bone anchor may also be used as a holding device inside of a vertebral body. The mesh anchor can have pre-attached tether elements attached thereto (e.g., sutures in the form of a shortenable elongate element) for connecting the bone anchor to its complementary tissue anchor or tissue anchor assembly in the annulus fibrosus. For insertion, an expandable mesh bone anchor has a small diameter. Once inserted into the vertebral body, the bone anchor opens up to a larger diameter and includes some means for locking the bone anchor in its larger diameter deployed shape. For use as an anchor in a vertebral body, an expandable bone mesh anchor is inserted through a pre-drilled hole and then deployed (i.e., expanded) inside the cancellous bone and seated up against the harder cortical bone, which allows for a strong supporting structure. The porous mesh formed by a deployed expandable mesh bone anchor construct also allows for growth in and around the construct. The bone anchor may also take the form of an adhesive or expandable material disposed onto or inserted into a vertebral body, or an adhesive may be used in conjunction with other types of bone anchors, such as a bone screw, T-anchor, barb or expandable element.
While the fixation apparatus embodiments illustrated in
The fixation apparatus 2030 is partially disposed within the tubular shaft 2050, with a pair of tethers 2070, 2072 of the fixation apparatus 2030 extending external to the delivery apparatus 2010 and connected to the tabs 2066, 2067, respectively. The fixation apparatus 2030 is, in one embodiment, configured to anchor a suture assembly (including a portion of the tether 2070) to a vertebral body adjacent to an intervertebral disc annulus having an aperture or defect to be repaired. Thus, in one embodiment, the fixation apparatus 2030 can include a bone anchor (not shown) such as the bone anchor 831 of the bone anchor fixation apparatus 830 illustrated in
In the illustrated embodiment, the ejection rod 2064 is partially slidably disposed within the tubular shaft 2050, and is configured to eject the bone anchor of the fixation apparatus 2030 from the tubular shaft 2050 into the desired implantation location (e.g., a pre-formed anchor bore in the vertebra 202 or 204 such as shown in
The tab 2066 is releasably coupled to a portion of the actuator 2060 and, in the undeployed state of
The fixation apparatus 2034 is partially disposed within the tubular shaft 2080, with at least one tension line 2100 of the fixation apparatus 2034 extending external to the delivery apparatus 2016 and connected to the tab 2096. The fixation apparatus 2034 is, in one embodiment, configured to anchor a suture assembly (including the tension line 2100) to the intervertebral disc annulus having an aperture or defect to be repaired. In various embodiments, the fixation apparatus 2034 is configured in a similar or identical manner as the soft tissue fixation apparatus illustrated in
The fixation delivery apparatus 2016 may, in most respects, have the same general functionality as, for example, the fixation delivery apparatus 400 described above and illustrated in
In various embodiments, the fixation delivery apparatus 2016 includes additional features also present in the fixation delivery apparatus 400. For example, the shaft 2080 may, in various embodiments, include a slot to facilitate loading and management of the fixation apparatus 2034. In addition, the fixation delivery apparatus 2016 may also include means for managing the elongate connecting member connecting the tissue anchors of the fixation apparatus 2034, similar or identical to the elastic band 473 shown in
Similar to the tab 2066 of the fixation delivery apparatus 2010, the tab 2096 is releasably coupled to a portion of the actuator 2090 and, in the undeployed state of
In use, the physician can use the bone awl 2020 (or other suitable instrument) to form an access bore in the vertebra 202 or 204 (see, e.g.,
Next, the fixation apparatus 2034 is deployed into the disc annulus fibrosus using the fixation delivery apparatus 2016 to facilitate partial or complete closure of the aperture in the annulus fibrosus. The configurations of the fixation apparatus 2034 during and after deployment are substantially identical or identical to the configurations of the soft tissue anchor assembly shown in
As shown in
As can perhaps be best seen in the cross-sectional view of
In the illustrated embodiment, the lumen 2366 includes a proximal segment 2370 extending substantially parallel to the longitudinal axis 2360 from the proximal end 2350, and a lateral segment 2376 extending from the proximal segment 2370. As shown, the proximal segment 2370 has a smaller diameter than the lateral segment 2376, thus forming a shoulder 2380 at the junction of the proximal and lateral segments 2370, 2376.
For illustration purposes, the connecting segment 2336 of the connecting element 2330 is shown inserted in the lumen 2366 in
The configuration of the bone screw 2325 advantageously allows the connecting segment 2336 to exit the bone screw 2325 parallel to the longitudinal axis 2360, thus allowing the bone screw 2325 to be threaded into the vertebra with the proximal end 2350 flush or substantially flush with the outer surface of the vertebra. Additionally, the radiused region 2368 of the inner surface of the lumen at the proximal end 2350 provides strain relief and reduces frictional wear on the connecting segment 2336 due to contact against the bone screw 2325.
As explained above, the fixation apparatus 2310 including the bone screw 2325 and the adjustable connecting element 2330 can be used in substantially the same manner as the bone screw 811 and the elongate member 812 described above and illustrated in
It will be appreciated that the particular configurations of the various adjustable elongate members and connecting elements associated with the soft tissue anchors and bone anchors/screws described and illustrated above are exemplary only. Accordingly, other configurations of these adjustable elongate members and connecting elements can be employed within the scope of the various embodiments of the present invention.
All patents referred to or cited herein are incorporated by reference in their entirety to the extent they are not inconsistent with the explicit teachings of this specification, including; U.S. Pat. No. 5,108,438 (Stone), U.S. Pat. No. 5,258,043 (Stone), U.S. Pat. No. 4,904,260 (Ray et al.), U.S. Pat. No. 5,964,807 (Gan et al.), U.S. Pat. No. 5,849,331 (Ducheyne et al.), U.S. Pat. No. 5,122,154 (Rhodes), U.S. Pat. No. 5,204,106 (Schepers at al.), U.S. Pat. No. 5,888,220 (Felt et al.),U.S. Pat. No. 5,376,120 (Sarver et al.) and U.S. Pat. No. 5,976,186 (Bao et al.).
Various materials know to those skilled in the art can be employed in practicing the present invention. By means of example only, the body portions of the stent could be made of NiTi alloy, plastics including polypropylene and polyethylene, polymethylmethacrylate, stainless steel and other biocompatible metals, chromium cobalt alloy, or collagen. Webbing materials can include silicone, collagen, ePTFE, DACRON, polyester, polypropylene, polyethylene, and other biocompatible materials and can be woven or non-woven. Membranes might be fashioned of silicone, polypropylene, polyester, SURLYN, PEBAX, polyethylene, polyurethane or other biocompatible materials. Inflation fluids for membranes can include gases, liquids, foams, emulsions, and can be or contain bioactive materials and can also be for mechanical, biochemical and medicinal purposes. The stent body, webbing and/or membrane can be drug eluting or bioabsorbable, as known in the medical implant arts.
Further, any of the devices or delivery tools described herein, or portions thereof, could be rendered visible or more visible via fluoroscopy, if desired, through the incorporation of radioopaque materials or markers. Preferably implantable devices are constructed with MRI compatible materials. In particular, devices and/or their components could be wholly or partially radiopaque, as result of, for example: compounding various radiopaque materials (e.g., barium sulphate) into device materials; affixing radiopaque materials to device structures (e.g., bands of platinum, gold, or their derivative alloys); deposition of radiopaque materials onto device structures (e.g., deposition of platinum, gold of their derivative alloys); processing radiopaque materials into device structures (e.g., braiding/weaving platinum or gold wires or its alloy derivatives). One inventive way to achieve radiopacity of a device described herein, for example treatment device 600, is placing one or more radiopaque marker bands onto filaments of braided device 600 before (or possibly after) creating end potions of the device.
Other embodiments of the invention will be apparent to those skilled in the art from consideration of the specification and practice of the invention disclosed herein. It is intended that the specification and examples be considered as exemplary only, with a true scope and spirit of the invention being indicated by the following claims.
This application is a continuation of U.S. application Ser. No. 13/440,838, filed Apr. 5, 2012, which is a continuation of U.S. application Ser. No. 12/553,583, filed Sep. 3, 2009, now U.S. Pat. No. 8,163,022, which is a continuation-in-part of U.S. application Ser. No. 12/251,295, filed Oct. 14, 2008, now U.S. Pat. No. 8,128,698, all of which are herein incorporated by reference in their entirety.
| Number | Name | Date | Kind |
|---|---|---|---|
| 1995970 | Dorough | Mar 1935 | A |
| 2609347 | Wilson | Sep 1952 | A |
| 2653917 | Hammon | Sep 1953 | A |
| 2659935 | Hammon | Nov 1953 | A |
| 2664366 | Wilson | Dec 1953 | A |
| 2664367 | Wilson | Dec 1953 | A |
| 2676945 | Higgins | Apr 1954 | A |
| 2683136 | Higgins | Jul 1954 | A |
| 2703316 | Schneider | Mar 1955 | A |
| 2758987 | Satzberg | Aug 1956 | A |
| 2846407 | Wilson | Aug 1958 | A |
| 2951828 | Zeile | Sep 1960 | A |
| 3531561 | Trehu | Sep 1970 | A |
| 3580256 | Wilkinson | May 1971 | A |
| 3867728 | Stubstad et al. | Feb 1975 | A |
| 3874388 | King et al. | Apr 1975 | A |
| 3875595 | Froning | Apr 1975 | A |
| 3895753 | Bone | Jul 1975 | A |
| 3990619 | Russell | Nov 1976 | A |
| 4006747 | Kronenthal et al. | Feb 1977 | A |
| 4007743 | Blake | Feb 1977 | A |
| 4013078 | Field | Mar 1977 | A |
| 4059115 | Jumashev | Nov 1977 | A |
| 4224413 | Burbidge | Sep 1980 | A |
| 4349921 | Kuntz | Sep 1982 | A |
| 4369788 | Goald | Jan 1983 | A |
| 4413359 | Akiyama et al. | Nov 1983 | A |
| 4502161 | Wall | Mar 1985 | A |
| 4512338 | Balko et al. | Apr 1985 | A |
| 4532926 | O'Holla | Aug 1985 | A |
| 4545374 | Jacobson | Oct 1985 | A |
| 4602635 | Mulhollan et al. | Jul 1986 | A |
| 4632100 | Somers et al. | Dec 1986 | A |
| 4663358 | Hyon et al. | May 1987 | A |
| 4669473 | Richards et al. | Jun 1987 | A |
| 4678459 | Onik et al. | Jul 1987 | A |
| 4736746 | Anderson | Apr 1988 | A |
| 4741330 | Hayhurst | May 1988 | A |
| 4743260 | Burton | May 1988 | A |
| 4744364 | Kensey | May 1988 | A |
| 4772287 | Ray et al. | Sep 1988 | A |
| 4781190 | Lee | Nov 1988 | A |
| 4798205 | Bonomo et al. | Jan 1989 | A |
| 4834757 | Brantigan | May 1989 | A |
| 4837285 | Berg et al. | Jun 1989 | A |
| 4844088 | Kambin | Jul 1989 | A |
| 4852568 | Kensey | Aug 1989 | A |
| 4863477 | Monson | Sep 1989 | A |
| 4873976 | Schreiber | Oct 1989 | A |
| 4884572 | Bays et al. | Dec 1989 | A |
| 4890612 | Kensey | Jan 1990 | A |
| 4895148 | Bays et al. | Jan 1990 | A |
| 4904260 | Ray et al. | Feb 1990 | A |
| 4904261 | Dove et al. | Feb 1990 | A |
| 4911718 | Lee et al. | Mar 1990 | A |
| 4917704 | Frey et al. | Apr 1990 | A |
| 4919667 | Richmond | Apr 1990 | A |
| 4932969 | Frey et al. | Jun 1990 | A |
| 4946378 | Hirayama et al. | Aug 1990 | A |
| 4955908 | Frey et al. | Sep 1990 | A |
| 4976715 | Bays et al. | Dec 1990 | A |
| 5002576 | Fuhrmann et al. | Mar 1991 | A |
| 5015255 | Kuslich | May 1991 | A |
| 5021059 | Kensey et al. | Jun 1991 | A |
| 5035716 | Downey | Jul 1991 | A |
| 5041129 | Hayhurst et al. | Aug 1991 | A |
| 5047055 | Bao | Sep 1991 | A |
| 5053046 | Janese | Oct 1991 | A |
| 5059193 | Kuslich | Oct 1991 | A |
| 5059206 | Winters | Oct 1991 | A |
| 5061274 | Kensey | Oct 1991 | A |
| 5062344 | Gerker | Nov 1991 | A |
| 5071437 | Steffee | Dec 1991 | A |
| 5085661 | Moss | Feb 1992 | A |
| 5100422 | Berguer et al. | Mar 1992 | A |
| 5108420 | Marks | Apr 1992 | A |
| 5108438 | Stone | Apr 1992 | A |
| 5116357 | Eberbach | May 1992 | A |
| 5122154 | Rhodes | Jun 1992 | A |
| 5122155 | Eberbach | Jun 1992 | A |
| 5123913 | Wilk et al. | Jun 1992 | A |
| 5123926 | Pisharodi | Jun 1992 | A |
| 5129912 | Noda et al. | Jul 1992 | A |
| 5141515 | Eberbach | Aug 1992 | A |
| 5147374 | Fernandez | Sep 1992 | A |
| 5171259 | Inoue | Dec 1992 | A |
| 5171278 | Pisharodi | Dec 1992 | A |
| 5171280 | Baumgartner | Dec 1992 | A |
| 5171281 | Parsons et al. | Dec 1992 | A |
| 5176682 | Chow | Jan 1993 | A |
| 5176691 | Pierce | Jan 1993 | A |
| 5176692 | Wilk et al. | Jan 1993 | A |
| 5192326 | Bao et al. | Mar 1993 | A |
| 5195541 | Obenchain | Mar 1993 | A |
| 5203787 | Noblitt et al. | Apr 1993 | A |
| 5204106 | Schepers et al. | Apr 1993 | A |
| 5207695 | Trout | May 1993 | A |
| 5222962 | Burkhart | Jun 1993 | A |
| 5222974 | Kensey et al. | Jun 1993 | A |
| 5242439 | Larsen et al. | Sep 1993 | A |
| 5254133 | Seid | Oct 1993 | A |
| 5258000 | Gianturco | Nov 1993 | A |
| 5258043 | Stone | Nov 1993 | A |
| 5269783 | Sander | Dec 1993 | A |
| 5269791 | Mayzels et al. | Dec 1993 | A |
| 5269809 | Hayhurst et al. | Dec 1993 | A |
| 5282827 | Kensey et al. | Feb 1994 | A |
| 5282863 | Burton | Feb 1994 | A |
| 5304194 | Chee et al. | Apr 1994 | A |
| 5306311 | Stone et al. | Apr 1994 | A |
| 5312435 | Nash et al. | May 1994 | A |
| 5313962 | Obenchain | May 1994 | A |
| 5320629 | Noda et al. | Jun 1994 | A |
| 5320633 | Allen et al. | Jun 1994 | A |
| 5320644 | Baumgartner | Jun 1994 | A |
| 5342393 | Stack | Aug 1994 | A |
| 5342394 | Matsuno et al. | Aug 1994 | A |
| 5344442 | Deac | Sep 1994 | A |
| 5354736 | Bhatnagar | Oct 1994 | A |
| 5356432 | Rutkow et al. | Oct 1994 | A |
| 5366460 | Eberbach | Nov 1994 | A |
| 5368602 | de la Torre | Nov 1994 | A |
| 5370660 | Weinstein et al. | Dec 1994 | A |
| 5370662 | Stone et al. | Dec 1994 | A |
| 5370697 | Baumgartner | Dec 1994 | A |
| 5374268 | Sander | Dec 1994 | A |
| 5376120 | Sarver et al. | Dec 1994 | A |
| 5383477 | DeMatteis | Jan 1995 | A |
| 5383905 | Golds et al. | Jan 1995 | A |
| 5390683 | Pisharodi | Feb 1995 | A |
| 5391182 | Chin | Feb 1995 | A |
| 5397326 | Mangum | Mar 1995 | A |
| 5397331 | Himpens et al. | Mar 1995 | A |
| 5397332 | Kammerer et al. | Mar 1995 | A |
| 5397991 | Rogers | Mar 1995 | A |
| 5398861 | Green | Mar 1995 | A |
| 5405352 | Weston | Apr 1995 | A |
| 5405359 | Pierce | Apr 1995 | A |
| 5405360 | Tovey | Apr 1995 | A |
| 5411523 | Goble | May 1995 | A |
| 5417691 | Hayhurst | May 1995 | A |
| 5417699 | Klein et al. | May 1995 | A |
| 5425772 | Brantigan | Jun 1995 | A |
| 5425773 | Boyd et al. | Jun 1995 | A |
| 5429598 | Waxman et al. | Jul 1995 | A |
| 5437631 | Janzen | Aug 1995 | A |
| 5437680 | Yoon | Aug 1995 | A |
| 5439464 | Shapiro | Aug 1995 | A |
| 5441502 | Bartlett | Aug 1995 | A |
| 5456720 | Schultz et al. | Oct 1995 | A |
| 5464407 | McGuire | Nov 1995 | A |
| 5464425 | Skiba | Nov 1995 | A |
| 5470337 | Moss | Nov 1995 | A |
| 5489307 | Kuslich et al. | Feb 1996 | A |
| 5492697 | Boyan et al. | Feb 1996 | A |
| 5496348 | Bonutti | Mar 1996 | A |
| 5500000 | Feagin et al. | Mar 1996 | A |
| 5507754 | Green et al. | Apr 1996 | A |
| 5507755 | Gresl et al. | Apr 1996 | A |
| 5514180 | Heggeness et al. | May 1996 | A |
| 5520696 | Wenstrom, Jr. | May 1996 | A |
| 5520700 | Beyar et al. | May 1996 | A |
| 5527342 | Pietrzak et al. | Jun 1996 | A |
| 5527343 | Bonutti | Jun 1996 | A |
| 5531678 | Tomba et al. | Jul 1996 | A |
| 5531759 | Kensey et al. | Jul 1996 | A |
| 5534012 | Bonutti | Jul 1996 | A |
| 5534028 | Bao et al. | Jul 1996 | A |
| 5534030 | Navarro et al. | Jul 1996 | A |
| 5540704 | Gordon et al. | Jul 1996 | A |
| 5540715 | Katsaros et al. | Jul 1996 | A |
| 5545178 | Kensey et al. | Aug 1996 | A |
| 5545229 | Parsons et al. | Aug 1996 | A |
| 5549617 | Green et al. | Aug 1996 | A |
| 5549679 | Kuslich | Aug 1996 | A |
| 5556428 | Shah | Sep 1996 | A |
| 5556429 | Felt | Sep 1996 | A |
| 5562684 | Kammerer | Oct 1996 | A |
| 5562689 | Green et al. | Oct 1996 | A |
| 5562736 | Ray et al. | Oct 1996 | A |
| 5562738 | Boyd et al. | Oct 1996 | A |
| 5569242 | Lax et al. | Oct 1996 | A |
| 5569252 | Justin et al. | Oct 1996 | A |
| 5569303 | Johnson | Oct 1996 | A |
| 5569306 | Thal | Oct 1996 | A |
| 5571189 | Kuslich | Nov 1996 | A |
| 5573286 | Rogozinski | Nov 1996 | A |
| 5573548 | Nazre et al. | Nov 1996 | A |
| 5578057 | Wenstrom, Jr. | Nov 1996 | A |
| 5582616 | Bolduc et al. | Dec 1996 | A |
| 5584862 | Bonutti | Dec 1996 | A |
| 5591177 | Lehrer | Jan 1997 | A |
| 5591223 | Lock et al. | Jan 1997 | A |
| 5593425 | Bonutti et al. | Jan 1997 | A |
| 5599279 | Slotman et al. | Feb 1997 | A |
| 5601557 | Hayhurst | Feb 1997 | A |
| 5613974 | Andreas et al. | Mar 1997 | A |
| 5618314 | Harwin et al. | Apr 1997 | A |
| 5620012 | Benderev et al. | Apr 1997 | A |
| 5624463 | Stone et al. | Apr 1997 | A |
| 5626612 | Bartlett et al. | May 1997 | A |
| 5626613 | Schmieding | May 1997 | A |
| 5626614 | Hart | May 1997 | A |
| 5634931 | Kugel | Jun 1997 | A |
| 5634944 | Magram | Jun 1997 | A |
| 5643319 | Green et al. | Jul 1997 | A |
| 5643320 | Lower et al. | Jul 1997 | A |
| 5645084 | McKay | Jul 1997 | A |
| 5645597 | Krapiva | Jul 1997 | A |
| 5649945 | Ray et al. | Jul 1997 | A |
| 5658343 | Hauselmann et al. | Aug 1997 | A |
| 5662658 | Wenstrom, Jr. | Sep 1997 | A |
| 5662681 | Nash et al. | Sep 1997 | A |
| 5662683 | Kay | Sep 1997 | A |
| 5669935 | Rosenman et al. | Sep 1997 | A |
| 5674294 | Bainville et al. | Oct 1997 | A |
| 5674296 | Bryan et al. | Oct 1997 | A |
| 5676698 | Janzen et al. | Oct 1997 | A |
| 5676701 | Yuan et al. | Oct 1997 | A |
| 5681310 | Yuan et al. | Oct 1997 | A |
| 5681351 | Jamiolkowski et al. | Oct 1997 | A |
| 5683417 | Cooper | Nov 1997 | A |
| 5683418 | Luscombe et al. | Nov 1997 | A |
| 5683419 | Thal | Nov 1997 | A |
| 5683465 | Shinn et al. | Nov 1997 | A |
| 5690677 | Schmieding et al. | Nov 1997 | A |
| 5695525 | Mulhauser et al. | Dec 1997 | A |
| 5697950 | Fucci et al. | Dec 1997 | A |
| 5702449 | McKay | Dec 1997 | A |
| 5702450 | Bisserie | Dec 1997 | A |
| 5702451 | Biedermann et al. | Dec 1997 | A |
| 5702454 | Baumgartner | Dec 1997 | A |
| 5702462 | Oberlander | Dec 1997 | A |
| 5704943 | Yoon et al. | Jan 1998 | A |
| 5709708 | Thal | Jan 1998 | A |
| 5716404 | Vacanti et al. | Feb 1998 | A |
| 5716408 | Eldridge et al. | Feb 1998 | A |
| 5716409 | Debbas | Feb 1998 | A |
| 5716413 | Walter et al. | Feb 1998 | A |
| 5716416 | Lin | Feb 1998 | A |
| 5718717 | Bonutti | Feb 1998 | A |
| 5725552 | Kotula et al. | Mar 1998 | A |
| 5725577 | Saxon | Mar 1998 | A |
| 5728109 | Schulze et al. | Mar 1998 | A |
| 5728150 | McDonald et al. | Mar 1998 | A |
| 5730744 | Justin et al. | Mar 1998 | A |
| 5733307 | Dinsdale | Mar 1998 | A |
| 5733337 | Carr, Jr. et al. | Mar 1998 | A |
| 5735875 | Bonutti | Apr 1998 | A |
| 5736746 | Furutoh | Apr 1998 | A |
| 5743917 | Saxon | Apr 1998 | A |
| 5746755 | Wood et al. | May 1998 | A |
| 5752964 | Mericle | May 1998 | A |
| 5755797 | Baumgartner | May 1998 | A |
| 5759189 | Ferragamo et al. | Jun 1998 | A |
| 5766246 | Mulhauser et al. | Jun 1998 | A |
| 5769864 | Kugel | Jun 1998 | A |
| 5769893 | Shah | Jun 1998 | A |
| 5772661 | Michelson | Jun 1998 | A |
| 5776183 | Kanesaka et al. | Jul 1998 | A |
| 5782844 | Yoon et al. | Jul 1998 | A |
| 5782860 | Epstein et al. | Jul 1998 | A |
| 5782864 | Lizardi | Jul 1998 | A |
| 5785705 | Baker | Jul 1998 | A |
| 5786217 | Tubo et al. | Jul 1998 | A |
| 5788625 | Plouhar et al. | Aug 1998 | A |
| 5792152 | Klein et al. | Aug 1998 | A |
| 5797929 | Andreas et al. | Aug 1998 | A |
| 5800549 | Bao et al. | Sep 1998 | A |
| 5800550 | Sertich | Sep 1998 | A |
| 5810848 | Hayhurst | Sep 1998 | A |
| 5810851 | Yoon | Sep 1998 | A |
| 5814051 | Wenstrom, Jr. | Sep 1998 | A |
| 5823994 | Sharkey et al. | Oct 1998 | A |
| 5824008 | Bolduc et al. | Oct 1998 | A |
| 5824011 | Stone et al. | Oct 1998 | A |
| 5824082 | Brown | Oct 1998 | A |
| 5824093 | Ray et al. | Oct 1998 | A |
| 5824094 | Serhan et al. | Oct 1998 | A |
| 5827298 | Hart et al. | Oct 1998 | A |
| 5827325 | Landgrebe et al. | Oct 1998 | A |
| 5827328 | Buttermann | Oct 1998 | A |
| 5836315 | Benderev et al. | Nov 1998 | A |
| 5842477 | Naughton et al. | Dec 1998 | A |
| 5843084 | Hart et al. | Dec 1998 | A |
| 5846261 | Kotula et al. | Dec 1998 | A |
| 5849331 | Ducheyne et al. | Dec 1998 | A |
| 5851219 | Goble et al. | Dec 1998 | A |
| 5853422 | Huebsch et al. | Dec 1998 | A |
| 5855614 | Stevens et al. | Jan 1999 | A |
| 5860425 | Benderev et al. | Jan 1999 | A |
| 5860977 | Zucherman et al. | Jan 1999 | A |
| 5865845 | Thalgott | Feb 1999 | A |
| 5865846 | Bryan et al. | Feb 1999 | A |
| 5868762 | Cragg et al. | Feb 1999 | A |
| 5879366 | Shaw et al. | Mar 1999 | A |
| 5888220 | Felt et al. | Mar 1999 | A |
| 5888222 | Coates | Mar 1999 | A |
| 5888226 | Rogozinski | Mar 1999 | A |
| 5891146 | Simon et al. | Apr 1999 | A |
| 5893592 | Schulze et al. | Apr 1999 | A |
| 5893889 | Harrington | Apr 1999 | A |
| 5895426 | Scarborough et al. | Apr 1999 | A |
| 5899920 | DeSatnick et al. | May 1999 | A |
| 5904703 | Gilson | May 1999 | A |
| 5916225 | Kugel | Jun 1999 | A |
| 5919235 | Husson et al. | Jul 1999 | A |
| 5922026 | Chin | Jul 1999 | A |
| 5922028 | Plouhar et al. | Jul 1999 | A |
| 5928284 | Mehdizadeh | Jul 1999 | A |
| 5935147 | Kensey et al. | Aug 1999 | A |
| 5941439 | Kammerer et al. | Aug 1999 | A |
| 5944738 | Amplatz et al. | Aug 1999 | A |
| 5948001 | Larsen | Sep 1999 | A |
| 5948002 | Bonutti | Sep 1999 | A |
| 5954716 | Sharkey et al. | Sep 1999 | A |
| 5954767 | Pajotin et al. | Sep 1999 | A |
| 5957939 | Heaven et al. | Sep 1999 | A |
| 5961538 | Pedlick et al. | Oct 1999 | A |
| 5964783 | Grafton et al. | Oct 1999 | A |
| 5964807 | Gan et al. | Oct 1999 | A |
| 5972000 | Beyar et al. | Oct 1999 | A |
| 5972007 | Sheffield et al. | Oct 1999 | A |
| 5972022 | Huxel | Oct 1999 | A |
| 5976174 | Ruiz | Nov 1999 | A |
| 5976186 | Bao et al. | Nov 1999 | A |
| 5980504 | Sharkey et al. | Nov 1999 | A |
| 5980558 | Wiley | Nov 1999 | A |
| 5984948 | Hasson | Nov 1999 | A |
| 6001130 | Bryan et al. | Dec 1999 | A |
| 6007567 | Bonutti | Dec 1999 | A |
| 6007570 | Sharkey et al. | Dec 1999 | A |
| 6007575 | Samuels | Dec 1999 | A |
| 6010525 | Bonutti et al. | Jan 2000 | A |
| 6019792 | Cauthen | Feb 2000 | A |
| 6019793 | Perren et al. | Feb 2000 | A |
| 6024096 | Buckberg | Feb 2000 | A |
| 6024754 | Engelson | Feb 2000 | A |
| 6024758 | Thal | Feb 2000 | A |
| 6027523 | Schmieding | Feb 2000 | A |
| 6027527 | Asano et al. | Feb 2000 | A |
| 6036699 | Andreas et al. | Mar 2000 | A |
| 6039761 | Li et al. | Mar 2000 | A |
| 6039762 | McKay | Mar 2000 | A |
| 6045561 | Marshall et al. | Apr 2000 | A |
| 6045573 | Wenstrom, Jr. et al. | Apr 2000 | A |
| 6053909 | Shadduck | Apr 2000 | A |
| 6063378 | Nohara et al. | May 2000 | A |
| 6066146 | Carroll et al. | May 2000 | A |
| 6066776 | Goodwin et al. | May 2000 | A |
| 6068648 | Cole et al. | May 2000 | A |
| 6073051 | Sharkey et al. | Jun 2000 | A |
| 6080182 | Shaw et al. | Jun 2000 | A |
| 6093205 | McLeod et al. | Jul 2000 | A |
| 6095149 | Sharkey et al. | Aug 2000 | A |
| 6099514 | Sharkey et al. | Aug 2000 | A |
| 6102934 | Li | Aug 2000 | A |
| 6106545 | Egan | Aug 2000 | A |
| 6113609 | Adams | Sep 2000 | A |
| 6113623 | Sgro | Sep 2000 | A |
| 6113639 | Ray et al. | Sep 2000 | A |
| 6117162 | Schmieding et al. | Sep 2000 | A |
| 6123715 | Amplatz | Sep 2000 | A |
| 6126682 | Sharkey et al. | Oct 2000 | A |
| 6139565 | Stone et al. | Oct 2000 | A |
| 6140452 | Felt et al. | Oct 2000 | A |
| 6143006 | Chan | Nov 2000 | A |
| 6143017 | Thal | Nov 2000 | A |
| 6146380 | Racz et al. | Nov 2000 | A |
| 6146406 | Shluzas et al. | Nov 2000 | A |
| 6146422 | Lawson | Nov 2000 | A |
| 6162203 | Haaga | Dec 2000 | A |
| 6168598 | Martello | Jan 2001 | B1 |
| 6171317 | Jackson et al. | Jan 2001 | B1 |
| 6171318 | Kugel et al. | Jan 2001 | B1 |
| 6171329 | Shaw et al. | Jan 2001 | B1 |
| 6174322 | Schneidt | Jan 2001 | B1 |
| 6176863 | Kugel et al. | Jan 2001 | B1 |
| 6179874 | Cauthen | Jan 2001 | B1 |
| 6179879 | Robinson et al. | Jan 2001 | B1 |
| 6183479 | Tormala et al. | Feb 2001 | B1 |
| 6183518 | Ross et al. | Feb 2001 | B1 |
| 6187048 | Milner et al. | Feb 2001 | B1 |
| 6190401 | Green et al. | Feb 2001 | B1 |
| 6200329 | Fung et al. | Mar 2001 | B1 |
| 6203554 | Roberts | Mar 2001 | B1 |
| 6203565 | Bonutti | Mar 2001 | B1 |
| 6206895 | Levinson | Mar 2001 | B1 |
| 6206921 | Guagliano et al. | Mar 2001 | B1 |
| 6221092 | Koike et al. | Apr 2001 | B1 |
| 6221109 | Geistlich et al. | Apr 2001 | B1 |
| 6224630 | Bao et al. | May 2001 | B1 |
| 6231615 | Preissman | May 2001 | B1 |
| 6241768 | Agarwal et al. | Jun 2001 | B1 |
| 6245080 | Levinson | Jun 2001 | B1 |
| 6245107 | Ferree | Jun 2001 | B1 |
| 6248106 | Ferree | Jun 2001 | B1 |
| 6248131 | Felt et al. | Jun 2001 | B1 |
| 6258094 | Nicholson et al. | Jul 2001 | B1 |
| 6264677 | Simon et al. | Jul 2001 | B1 |
| 6267772 | Mulhauser et al. | Jul 2001 | B1 |
| 6280453 | Kugel et al. | Aug 2001 | B1 |
| 6287324 | Yarnitsky et al. | Sep 2001 | B1 |
| 6293961 | Schwartz et al. | Sep 2001 | B2 |
| 6296659 | Foerster | Oct 2001 | B1 |
| 6306159 | Schwartz et al. | Oct 2001 | B1 |
| 6306177 | Felt et al. | Oct 2001 | B1 |
| 6312448 | Bonutti | Nov 2001 | B1 |
| 6319263 | Levinson | Nov 2001 | B1 |
| 6332894 | Stalcup | Dec 2001 | B1 |
| 6340369 | Ferree | Jan 2002 | B1 |
| 6342064 | Koike et al. | Jan 2002 | B1 |
| 6344057 | Rabbe et al. | Feb 2002 | B1 |
| 6344058 | Ferree | Feb 2002 | B1 |
| 6352557 | Ferree | Mar 2002 | B1 |
| 6355052 | Neuss | Mar 2002 | B1 |
| 6364897 | Bonutti | Apr 2002 | B1 |
| 6371984 | Van Dyke et al. | Apr 2002 | B1 |
| 6371990 | Ferree | Apr 2002 | B1 |
| 6391060 | Ory et al. | May 2002 | B1 |
| 6402750 | Atkinson et al. | Jun 2002 | B1 |
| 6402784 | Wardlaw | Jun 2002 | B1 |
| 6402785 | Zdeblick | Jun 2002 | B1 |
| 6409739 | Nobles et al. | Jun 2002 | B1 |
| 6419676 | Zucherman et al. | Jul 2002 | B1 |
| 6419702 | Ferree | Jul 2002 | B1 |
| 6419703 | Fallin et al. | Jul 2002 | B1 |
| 6419704 | Ferree | Jul 2002 | B1 |
| 6419706 | Graf | Jul 2002 | B1 |
| 6423065 | Ferree | Jul 2002 | B2 |
| 6425919 | Lambrecht | Jul 2002 | B1 |
| 6425924 | Rousseau | Jul 2002 | B1 |
| 6428562 | Bonutti | Aug 2002 | B2 |
| 6428576 | Haldimann | Aug 2002 | B1 |
| 6432107 | Ferree | Aug 2002 | B1 |
| 6432123 | Schwartz et al. | Aug 2002 | B2 |
| 6436098 | Michelson | Aug 2002 | B1 |
| 6436143 | Ross et al. | Aug 2002 | B1 |
| 6443988 | Felt et al. | Sep 2002 | B2 |
| 6447531 | Amplatz | Sep 2002 | B1 |
| 6452924 | Golden et al. | Sep 2002 | B1 |
| 6454804 | Ferree | Sep 2002 | B1 |
| 6464712 | Epstein | Oct 2002 | B1 |
| 6482235 | Lambrecht et al. | Nov 2002 | B1 |
| 6488691 | Carroll et al. | Dec 2002 | B1 |
| 6491724 | Ferree | Dec 2002 | B1 |
| 6494883 | Ferree | Dec 2002 | B1 |
| 6500132 | Li | Dec 2002 | B1 |
| 6500184 | Chan et al. | Dec 2002 | B1 |
| 6508828 | Akerfeldt et al. | Jan 2003 | B1 |
| 6508839 | Lambrecht et al. | Jan 2003 | B1 |
| 6511488 | Marshall et al. | Jan 2003 | B1 |
| 6511498 | Fumex | Jan 2003 | B1 |
| 6511958 | Atkinson et al. | Jan 2003 | B1 |
| 6514255 | Ferree | Feb 2003 | B1 |
| 6514514 | Atkinson et al. | Feb 2003 | B1 |
| 6524317 | Ritchart et al. | Feb 2003 | B1 |
| 6527794 | McDevitt et al. | Mar 2003 | B1 |
| 6527795 | Lizardi | Mar 2003 | B1 |
| 6530933 | Yeung et al. | Mar 2003 | B1 |
| 6533799 | Bouchier | Mar 2003 | B1 |
| 6533817 | Norton et al. | Mar 2003 | B1 |
| 6547800 | Foerster et al. | Apr 2003 | B2 |
| 6547806 | Ding | Apr 2003 | B1 |
| 6558386 | Cragg | May 2003 | B1 |
| 6558390 | Cragg | May 2003 | B2 |
| 6562052 | Nobles et al. | May 2003 | B2 |
| 6569187 | Bonutti et al. | May 2003 | B1 |
| 6569442 | Gan et al. | May 2003 | B2 |
| 6572635 | Bonutti | Jun 2003 | B1 |
| 6572653 | Simonson | Jun 2003 | B1 |
| 6575979 | Cragg | Jun 2003 | B1 |
| 6576017 | Foley et al. | Jun 2003 | B2 |
| 6579291 | Keith et al. | Jun 2003 | B1 |
| 6582453 | Tran et al. | Jun 2003 | B1 |
| 6592608 | Fisher et al. | Jul 2003 | B2 |
| 6592609 | Bonutti | Jul 2003 | B1 |
| 6592625 | Cauthen | Jul 2003 | B2 |
| 6596012 | Akerfeldt et al. | Jul 2003 | B2 |
| 6602291 | Ray et al. | Aug 2003 | B1 |
| 6605096 | Ritchart | Aug 2003 | B1 |
| 6607541 | Gardiner et al. | Aug 2003 | B1 |
| 6610006 | Amid et al. | Aug 2003 | B1 |
| 6610071 | Cohn et al. | Aug 2003 | B1 |
| 6610079 | Li et al. | Aug 2003 | B1 |
| 6610091 | Reiley | Aug 2003 | B1 |
| 6610666 | Akerblom | Aug 2003 | B1 |
| 6613044 | Carl | Sep 2003 | B2 |
| 6620185 | Harvie et al. | Sep 2003 | B1 |
| 6620196 | Trieu | Sep 2003 | B1 |
| 6623492 | Berube et al. | Sep 2003 | B1 |
| 6623508 | Shaw et al. | Sep 2003 | B2 |
| 6626899 | Houser et al. | Sep 2003 | B2 |
| 6626916 | Yeung et al. | Sep 2003 | B1 |
| 6635073 | Bonutti et al. | Oct 2003 | B2 |
| 6645227 | Fallin et al. | Nov 2003 | B2 |
| 6645247 | Ferree | Nov 2003 | B2 |
| 6648892 | Martello | Nov 2003 | B2 |
| 6648918 | Ferree | Nov 2003 | B2 |
| 6648919 | Ferree | Nov 2003 | B2 |
| 6648920 | Ferree | Nov 2003 | B2 |
| 6652561 | Tran | Nov 2003 | B1 |
| 6652585 | Lange | Nov 2003 | B2 |
| 6656182 | Hayhurst | Dec 2003 | B1 |
| 6669687 | Saadat | Dec 2003 | B1 |
| 6669707 | Swanstrom et al. | Dec 2003 | B1 |
| 6669729 | Chin | Dec 2003 | B2 |
| 6673088 | Vargas et al. | Jan 2004 | B1 |
| 6676665 | Foley et al. | Jan 2004 | B2 |
| 6679887 | Nicholson et al. | Jan 2004 | B2 |
| 6679914 | Gabbay | Jan 2004 | B1 |
| 6684886 | Alleyne | Feb 2004 | B1 |
| 6685695 | Ferree | Feb 2004 | B2 |
| 6685728 | Sinnott et al. | Feb 2004 | B2 |
| 6689125 | Keith et al. | Feb 2004 | B1 |
| 6692506 | Ory et al. | Feb 2004 | B1 |
| 6695858 | Dubrul et al. | Feb 2004 | B1 |
| 6696073 | Boyce et al. | Feb 2004 | B2 |
| 6699263 | Cope | Mar 2004 | B2 |
| 6706068 | Ferree | Mar 2004 | B2 |
| 6712836 | Berg et al. | Mar 2004 | B1 |
| 6712837 | Akerfeldt et al. | Mar 2004 | B2 |
| 6712853 | Kuslich | Mar 2004 | B2 |
| 6716216 | Boucher et al. | Apr 2004 | B1 |
| 6719761 | Reiley et al. | Apr 2004 | B1 |
| 6719773 | Boucher et al. | Apr 2004 | B1 |
| 6719797 | Ferree | Apr 2004 | B1 |
| 6723058 | Li | Apr 2004 | B2 |
| 6723095 | Hammerslag | Apr 2004 | B2 |
| 6723097 | Fraser et al. | Apr 2004 | B2 |
| 6723107 | Skiba et al. | Apr 2004 | B1 |
| 6723133 | Pajotin | Apr 2004 | B1 |
| 6723335 | Moehlenbruck et al. | Apr 2004 | B1 |
| 6726721 | Stoy et al. | Apr 2004 | B2 |
| 6730112 | Levinson | May 2004 | B2 |
| 6733531 | Trieu | May 2004 | B1 |
| 6733534 | Sherman | May 2004 | B2 |
| 6736815 | Ginn | May 2004 | B2 |
| 6740093 | Hochschuler et al. | May 2004 | B2 |
| 6743255 | Ferree | Jun 2004 | B2 |
| 6752831 | Sybert et al. | Jun 2004 | B2 |
| 6758863 | Estes | Jul 2004 | B2 |
| 6761720 | Senegas | Jul 2004 | B1 |
| 6764514 | Li et al. | Jul 2004 | B1 |
| 6767037 | Wenstrom | Jul 2004 | B2 |
| 6770076 | Foerster | Aug 2004 | B2 |
| 6773436 | Donnelly et al. | Aug 2004 | B2 |
| 6773699 | Soltz et al. | Aug 2004 | B1 |
| 6780198 | Gregoire et al. | Aug 2004 | B1 |
| 6783546 | Zucherman et al. | Aug 2004 | B2 |
| 6805695 | Keith et al. | Oct 2004 | B2 |
| 6805697 | Helm et al. | Oct 2004 | B1 |
| 6805715 | Reuter et al. | Oct 2004 | B2 |
| 6812211 | Slivka et al. | Nov 2004 | B2 |
| 6821276 | Lambrecht et al. | Nov 2004 | B2 |
| 6824562 | Mathis et al. | Nov 2004 | B2 |
| 6827716 | Ryan et al. | Dec 2004 | B2 |
| 6827743 | Eisermann et al. | Dec 2004 | B2 |
| 6830570 | Frey et al. | Dec 2004 | B1 |
| 6833006 | Foley et al. | Dec 2004 | B2 |
| 6835205 | Atkinson et al. | Dec 2004 | B2 |
| 6835207 | Zacouto et al. | Dec 2004 | B2 |
| 6835208 | Marchosky | Dec 2004 | B2 |
| 6841150 | Halvorsen et al. | Jan 2005 | B2 |
| 6843799 | Bartlett | Jan 2005 | B2 |
| 6852128 | Lange | Feb 2005 | B2 |
| 6860895 | Akerfeldt et al. | Mar 2005 | B1 |
| 6878155 | Sharkey et al. | Apr 2005 | B2 |
| 6878167 | Ferree | Apr 2005 | B2 |
| 6883520 | Lambrecht et al. | Apr 2005 | B2 |
| 6893462 | Buskirk et al. | May 2005 | B2 |
| 6896675 | Leung et al. | May 2005 | B2 |
| 6913622 | Gjunter | Jul 2005 | B2 |
| 6923823 | Bartlett et al. | Aug 2005 | B1 |
| 6932833 | Sandoval et al. | Aug 2005 | B1 |
| 6936070 | Muhanna | Aug 2005 | B1 |
| 6936072 | Lambrecht et al. | Aug 2005 | B2 |
| 6960215 | Olson, Jr. et al. | Nov 2005 | B2 |
| 6964674 | Matsuura et al. | Nov 2005 | B1 |
| 6966910 | Ritland | Nov 2005 | B2 |
| 6966931 | Huang | Nov 2005 | B2 |
| 6969404 | Ferree | Nov 2005 | B2 |
| 6972027 | Fallin et al. | Dec 2005 | B2 |
| 6974479 | Trieu | Dec 2005 | B2 |
| 6980862 | Fredricks et al. | Dec 2005 | B2 |
| 6984247 | Cauthen | Jan 2006 | B2 |
| 6997956 | Cauthen | Feb 2006 | B2 |
| 7001431 | Bao et al. | Feb 2006 | B2 |
| 7004970 | Cauthen et al. | Feb 2006 | B2 |
| 7033393 | Gainor et al. | Apr 2006 | B2 |
| 7033395 | Cauthen | Apr 2006 | B2 |
| 7037334 | Hlavka et al. | May 2006 | B1 |
| 7052516 | Cauthen, III et al. | May 2006 | B2 |
| 7094258 | Lambrecht et al. | Aug 2006 | B2 |
| 7189235 | Cauthen | Mar 2007 | B2 |
| 7217279 | Reese | May 2007 | B2 |
| 7223289 | Trieu et al. | May 2007 | B2 |
| 7309337 | Colleran et al. | Dec 2007 | B2 |
| 7318840 | McKay | Jan 2008 | B2 |
| 7320701 | Haut et al. | Jan 2008 | B2 |
| 7322978 | West, Jr. | Jan 2008 | B2 |
| 7329272 | Burkhart et al. | Feb 2008 | B2 |
| 7331982 | Kaiser et al. | Feb 2008 | B1 |
| 7371253 | Leung et al. | May 2008 | B2 |
| 7390332 | Selvitelli et al. | Jun 2008 | B2 |
| 8128698 | Bentley et al. | Mar 2012 | B2 |
| 8163022 | Bentley et al. | Apr 2012 | B2 |
| 8454697 | Bentley et al. | Jun 2013 | B2 |
| 20020019649 | Sikora et al. | Feb 2002 | A1 |
| 20020032483 | Nicholson et al. | Mar 2002 | A1 |
| 20020077701 | Kuslich | Jun 2002 | A1 |
| 20020082698 | Parenteau et al. | Jun 2002 | A1 |
| 20020111688 | Cauthen | Aug 2002 | A1 |
| 20020123807 | Cauthen, III | Sep 2002 | A1 |
| 20020147461 | Aldrich | Oct 2002 | A1 |
| 20020151979 | Lambrecht et al. | Oct 2002 | A1 |
| 20020173851 | McKay | Nov 2002 | A1 |
| 20030074075 | Thomas | Apr 2003 | A1 |
| 20030125807 | Lambrecht et al. | Jul 2003 | A1 |
| 20030130669 | Damarati | Jul 2003 | A1 |
| 20030153976 | Cauthen, III et al. | Aug 2003 | A1 |
| 20030158604 | Cauthen | Aug 2003 | A1 |
| 20030181983 | Cauthen | Sep 2003 | A1 |
| 20030195514 | Trieu et al. | Oct 2003 | A1 |
| 20030195628 | Bao et al. | Oct 2003 | A1 |
| 20030220649 | Bao et al. | Nov 2003 | A1 |
| 20030220690 | Cauthen, III | Nov 2003 | A1 |
| 20030220693 | Cauthen, III | Nov 2003 | A1 |
| 20030220694 | Cauthen, III | Nov 2003 | A1 |
| 20040039392 | Trieu | Feb 2004 | A1 |
| 20040054414 | Trieu | Mar 2004 | A1 |
| 20040097980 | Ferree | May 2004 | A1 |
| 20040153074 | Bojarski et al. | Aug 2004 | A1 |
| 20040260397 | Lambrecht et al. | Dec 2004 | A1 |
| 20050033363 | Bojarski et al. | Feb 2005 | A1 |
| 20050033440 | Lambrecht et al. | Feb 2005 | A1 |
| 20050038519 | Lambrecht et al. | Feb 2005 | A1 |
| 20050049592 | Keith et al. | Mar 2005 | A1 |
| 20050049704 | Jackson | Mar 2005 | A1 |
| 20050049708 | Atkinson et al. | Mar 2005 | A1 |
| 20050060038 | Lambrecht et al. | Mar 2005 | A1 |
| 20050149197 | Cauthen | Jul 2005 | A1 |
| 20050159762 | Nuutinen et al. | Jul 2005 | A1 |
| 20050256582 | Ferree | Nov 2005 | A1 |
| 20050283246 | Cauthen, III et al. | Dec 2005 | A1 |
| 20060060038 | Sammartin | Mar 2006 | A1 |
| 20060084994 | Atkinson et al. | Apr 2006 | A1 |
| 20060100711 | Cauthen | May 2006 | A1 |
| 20060129156 | Cauthen, III et al. | Jun 2006 | A1 |
| 20060129245 | Cauthen | Jun 2006 | A1 |
| 20060142864 | Cauthen | Jun 2006 | A1 |
| 20060161258 | Cauthen | Jul 2006 | A1 |
| 20060167553 | Cauthen | Jul 2006 | A1 |
| 20060173545 | Cauthen | Aug 2006 | A1 |
| 20060190085 | Cauthen | Aug 2006 | A1 |
| 20060241773 | Cauthen | Oct 2006 | A1 |
| 20060253152 | Evans et al. | Nov 2006 | A1 |
| 20060287731 | Cauthen, III et al. | Dec 2006 | A1 |
| 20070061012 | Cauthen, III | Mar 2007 | A1 |
| 20070061013 | Cauthen, III et al. | Mar 2007 | A1 |
| 20070073407 | Cauthen et al. | Mar 2007 | A1 |
| 20070088438 | Cauthen, III et al. | Apr 2007 | A1 |
| 20070100348 | Cauthen, III et al. | May 2007 | A1 |
| 20070100354 | Cauthen, III et al. | May 2007 | A1 |
| 20070118226 | Lambrecht et al. | May 2007 | A1 |
| 20070156244 | Cauthen | Jul 2007 | A1 |
| 20070156245 | Cauthen, III et al. | Jul 2007 | A1 |
| 20070185497 | Cauthen et al. | Aug 2007 | A1 |
| 20070198021 | Wales | Aug 2007 | A1 |
| 20070225814 | Atkinson et al. | Sep 2007 | A1 |
| 20070225815 | Keith et al. | Sep 2007 | A1 |
| 20070225816 | Keith et al. | Sep 2007 | A1 |
| 20070233257 | Keith et al. | Oct 2007 | A1 |
| 20070239280 | Keith et al. | Oct 2007 | A1 |
| 20070288041 | Cauthen | Dec 2007 | A1 |
| 20080033561 | Cauthen | Feb 2008 | A1 |
| 20090024165 | Ferree | Jan 2009 | A1 |
| 20090259260 | Bentley et al. | Oct 2009 | A1 |
| 20100094425 | Bentley et al. | Apr 2010 | A1 |
| 20120253392 | Bentley et al. | Oct 2012 | A1 |
| Number | Date | Country |
|---|---|---|
| 4323959501 | Jul 1994 | DE |
| 0020021 | Dec 1980 | EP |
| 0025706 | Mar 1981 | EP |
| 0042953 | Jan 1982 | EP |
| 0049978 | Apr 1982 | EP |
| 0076409 | Apr 1983 | EP |
| 0110316 | Jun 1984 | EP |
| 0122902 | Oct 1984 | EP |
| 0126570 | Nov 1984 | EP |
| 0145577 | Jun 1985 | EP |
| 0193784 | Sep 1986 | EP |
| 1797827 | Jun 2007 | EP |
| 1857055 | Nov 2007 | EP |
| 2054383 | Feb 1981 | GB |
| WO 9116867 | Nov 1991 | WO |
| WO 9423671 | Oct 1994 | WO |
| WO 9522285 | Aug 1995 | WO |
| WO 9531946 | Nov 1995 | WO |
| WO 9531948 | Nov 1995 | WO |
| WO 9627339 | Sep 1996 | WO |
| WO 9720874 | Jun 1997 | WO |
| WO 9726847 | Jul 1997 | WO |
| WO 9801091 | Jan 1998 | WO |
| WO 9805274 | Feb 1998 | WO |
| WO 9822050 | May 1998 | WO |
| WO 9820939 | Sep 1998 | WO |
| WO 9900074 | Jan 1999 | WO |
| WO 9902108 | Jan 1999 | WO |
| WO 9904720 | Feb 1999 | WO |
| WO 9916381 | Apr 1999 | WO |
| WO 9961084 | Dec 1999 | WO |
| WO 0020021 | Apr 2000 | WO |
| WO 0025706 | May 2000 | WO |
| WO 0042953 | Jul 2000 | WO |
| WO 0049978 | Aug 2000 | WO |
| WO 0061037 | Oct 2000 | WO |
| WO 0062832 | Oct 2000 | WO |
| WO 0076409 | Dec 2000 | WO |
| WO 0110316 | Feb 2001 | WO |
| WO 0112107 | Feb 2001 | WO |
| WO 0121246 | Mar 2001 | WO |
| WO 0122902 | Apr 2001 | WO |
| WO 0126570 | Apr 2001 | WO |
| WO 0128464 | Apr 2001 | WO |
| WO 0145577 | Jun 2001 | WO |
| WO 0193784 | Dec 2001 | WO |
| WO 0195818 | Dec 2001 | WO |
| WO 0217825 | Mar 2002 | WO |
| Entry |
|---|
| Ahlgren, B.D., MD, et al., “Anular Incision Technique on the Strength and Multidirectional Flexibility of the Healing Intervertebral Disc,” Spine 19(8):948-954 (1994). |
| Ahlgren, B.D., MD., et al., Effect of Anular Repair on the Healing Strength of the Intervertebral Disc: Spine 25(17):2165-2170 (2000). |
| Cauthen, Joseph C., “Annulotomy Study, Preliminary Results: Updated Feb. 1999 for all procedures with at least one year follow-up” (Table). Feb. 8, 1999. |
| Cauthen, Joseph C., MD., “Microsurgical Annular Reconstruction (Annuloplasty) Following Lumbar Microdiscectomy: Preliminary Report of a New Technique,” Abstract for Poster Presentation. AANS/CNS Section on Disorders of the Spine and Peripheral Nerves Annual Meeting (1999). |
| Cauthen, Joseph, Draft Abstract entitled “Microsurgical Annular Reconstruction (Annuloplasty) Following Lumbar Microdiscectomy: Preliminary Report of a New Technique” from abstracts@neurosurgery.org Sep. 4, 1998. |
| International Search Report and Written Opinion issued in PCT/US2009/060425, mailed Feb. 15, 2010, 16 pages. |
| Lehmann, Thomas R., M.D., et al., “Refinements in technique for Open Lumbar Discectomy,” International Society for the Study of the Lumbar Spine (1997). |
| Mineiro, J., et al., “Dynamic Neutralization With Dynesys Review of 113 Cases with More than 1 Year Follow-Up,” Spineweek 2004, Porto, Portugal May 30 to Jun. 5, 2004, Abstract B19, p. 181. |
| Ordway, N.R., et al., “Failure Properties of a Hydrogel Nucleus in the Intervertebral Disc,” North American Spine Society, pp. 168-169 (1997). |
| Osti, O.L., et al., “Annular Tears and Disc Degeneration in the Lumbar Spine,” The Journal of Bone and Joint Surgery 74-8(5);678-82 (1992). |
| Panjabi, Manohar, PhD., et al., “Intrinsic Disc Pressure as a Measure of Integrity of the Lumbar Spine,” Spine 13(8}:913-17 (1988). |
| Ray, Charles D., “Prosthetic Disc Nucleus Implants: Update,” North American Spine Society 13th Annual Meeting, p. 252 (1998). |
| U.S. Appl. No. 60/149,490, filed Aug. 18, 1999, (claimed for purposes of priority in U.S. Publication 2003/0125807), publicly available as of at least Jul. 3, 2003. |
| U.S. Appl. No. 60/375,185, filed Apr. 24, 2002, (claimed for purposes of priority in U.S. Pat. No. 6,878,167), publicly available as of at least Apr. 12, 2005. |
| U.S. Appl. No. 60/378,132, filed May 15, 2002, (claimed for purposes of priority in U.S. Pat. No. 6,878,167), publicly available as of at least Apr. 12, 2005. |
| U.S. Appl. No. 60/590,942, filed Jul. 23, 2004, (claimed for purposes of priority in U.S. Publication 2005/0256582), publicly available as of at least Nov. 17, 2005. |
| U.S. Pat. No. 6,447,535, 9/2002, Jacobs et al. (withdrawn). |
| Yasargil, M.G., “Microsurgical Operation of Herniated Lumbar Disc,” Lumbar Disc Adult Hydrocephelus, p. 81 (1977). |
| Number | Date | Country | |
|---|---|---|---|
| 20130268002 A1 | Oct 2013 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 13440838 | Apr 2012 | US |
| Child | 13908677 | US | |
| Parent | 12553583 | Sep 2009 | US |
| Child | 13440838 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 12251295 | Oct 2008 | US |
| Child | 12553583 | US |
