US20020040246A1 - Tissue press and system - Google Patents

Abstract

A tissue press for shaping or compressing a piece of tissue comprises first and second members movable relative to each other. A first forming element of a predetermined shape is selectively engageable on the first member. A second forming element of predetermined shape is selectively engageable on the second member. The first and second forming elements are positionable on opposite sides of the piece of tissue. The first and second members are relatively movable between a first spaced apart condition and a second condition in which the piece of tissue is held between the first and second forming elements. Means are preferably provided for monitoring and controlling the amount of pressure applied to the piece of tissue, in order to maintain the tissue in a viable living condition. Means may also be provided for draining off fluid from compressed. tissue, so that the tissue can be implanted in a compressed state and imbibe fluid from the host site. A retainer, which may be expandable, can be used to maintain the tissue graft in a compressed condition.

Description

BACKGROUND OF THE INVENTION
• Tissue grafting, including bone grafting, is well known. Tissue such as bone is removed from one part of a body (the donor site) and inserted into tissue in another (the host site) part of the same (or another) body. It is desirable to be able to remove a piece of tissue graft material which is the exact size and shape needed for the host site where it will be implanted. However, it is rarely possible to do this.[0001]
• Accordingly, various tissue grafting techniques have been tried to solve this problem. For example, Nashef U.S. Pat. No. 4,678,470 discloses a method of creating bone graft material by machining a block of bone to a particular shape, or by pulverizing and milling it. The graft material is then tanned with glutaraldehyde to sterilize it. This process can produce bone plugs of a desired shape.[0002]
• In the Nashef process,.the exogenic bone material selected for the graft is presumably dead at the beginning of the process. The process of pulverizing or milling the bone material destroys the structure of the bone tissue. The step of. tanning it with glutaraldehyde then renders the graft material completely sterile. This condition is not conducive to graft healing and ingrowth. Specifically, applicant has found that it is desirable to maintain graft tissue in a living state during the grafting process. The use of living tissue in a graft will promote bone healing.[0003]
Summary of the Invention
• The present invention is a tissue press for shaping or compressing a piece of tissue. The press includes first and second members movable relative to each other. First and second forming elements of different predetermined shapes are positionable on the first and second members on opposite sides of the piece of tissue. The first and second members are moved toward each other to shape or compress the tissue between the first and second forming elements.[0004]
• Means are preferably provided for monitoring and controlling the amount of force or pressure applied to the piece of tissue, in order to maintain the tissue in a viable living condition. Means may also be provided for draining off fluid from compressed tissue, so that the tissue can be implanted in a compressed state and imbibe fluid from the host site.[0005]
• The present invention is also a method of reshaping tissue for use as graft material comprising the steps of determining the shape which the tissue should possess as graft material; providing a tissue press, selecting forming, elements adapted to press tissue approximately to the desired shape, and placing the forming elements on the tissue press; placing the tissue in the tissue press between the forming elements; operating the tissue press to shape the tissue between the forming elements to give the tissue the desired shape; and controlling the pressure on the tissue during the shaping step to minimize damage to or necrosis of the tissue.[0006]
• The present invention is also a method which includes the steps of determining the shape and size which the tissue should possess as graft material; placing the tissue in a tissue press having forming elements adapted to press tissue approximately to the shape and size desired; compressing the tissue in the tissue press to give the tissue the shape and size desired; controlling the pressure on the tissue during the compressing step to minimize damage to or necrosis of the tissue; and draining off fluid expressed during the compressing step.[0007]
• In accordance with another feature of the present invention, a retainer is provided for retaining tissue. graft material in its compressed state. The retainer is placed around the compressed graft. The retainer can help to maintain the graft in a compressed configuration or in a specific shape for a period of time long enough to be placed in the body. The retainer may be made of a material which expands after it is placed in the body, to mechanically interlock the graft to the body.[0008]
GENERAL DESCRIPTION OF THE INVENTION
• With the apparatus and method of the present invention, bone or other tissue can be compressed or reshaped or both, while preserving the tissue alive.[0009]
Reshaping
• Often, reshaping of graft tissue is necessary to obtain the best possible graft. For example, in an anterior cruciate ligament reconstruction, the graft material which is removed usually has a triangular cross-sectional configuration. This graft material is placed in an opening in bone formed by drilling with a round drill. When the triangular graft material is placed in the round opening, there is minimal physical contact between the graft material and the surrounding bone. This reduces the holding power of the graft and also reduces the ingrowth ability of the graft.[0010]
• Thus, an important feature of the present invention is that bone or other tissue such as ligament is reshaped while still leaving it in a whole condition and without substantial tissue damage. The tissue is placed in the tissue press of the present invention and sufficient force is applied to reshape the tissue to the desired shape—for example, a cylindrical shape as needed for an anterior cruciate ligament reconstruction. Excessive pressure on the tissue, which can damage or kill the tissue, is avoided as described below. A properly shaped graft is thus provided which is still in a living condition.[0011]
Compression
• Compression of graft tissue is also sometimes desirable. Generally, tissue is stronger when it is more dense. Compressing graft tissue increases its density and thus strengthens the graft tissue. The graft tissue also stays together better.[0012]
• For example, a tendon is made of a plurality of fibers. The individual fibers are weak when separated or unraveled. If a tendon graft is implanted with the fibers in a loose condition, the graft is weak. On the other hand, if prior to implantation the tendon graft is compressed to orient and pack the fibers tightly, then the entire group of fibers acts as one whole unit and the graft is much stronger. Therefore, compressing the tendon graft gives it more mechanical integrity—making a smaller tendon graft much stronger.[0013]
• Similarly, bone tissue is stronger and better able to bear force when it is denser and more compact. Compressing bone graft tissue prior to implantation produces a stronger graft.[0014]
• Compression of bone or other tissue also allows a surgeon to convert a larger irregular shape into a smaller specific shape. Thus, the surgeon when removing the graft material from the donor site is not limited by the conditions at the host site but can remove the graft material in the best way possible from the donor site. Similarly, the surgeon when implanting the graft material at the host site is not limited by the shape of the material removed (as dictated by the conditions at the donor site) but can implant the graft material in the best way possible to fit the conditions at the host site.[0015]
• The anterior cruciate ligament, for example, attaches to the femur and tibia at specific isometric locations. When the ligament is being replaced in an anterior cruciate ligament reconstruction, typical uncompressed graft material can be many times the size of those locations. In such a case it is necessary to drill openings much larger than desired in the bone to attach the new ligament. The graft tendon then tends to fall eccentrically in this larger opening, the functional anatomy of the ligament can not be recreated, and the functioning of the knee joint is compromised.[0016]
• However, if the graft material for the new ligament is compressed in accordance with the present invention, its size can be reduced substantially. This allows the surgeon to drill a substantially smaller opening in the bone to attach the new ligament/graft structure, so as to recreate the functional anatomy of the ligament.[0017]
• With the present invention, it is also possible to make a composite graft. For example, the graft material for an anterior cruciate ligament reconstruction is preferably tendon in the middle with bone at both ends. In accordance with the apparatus and method of the present invention, bone tissue can be compressed around the ends of tendon tissue to form a substitute anterior cruciate ligament more closely approximating the original.[0018]
• It should also be noted that tissues other than bone and tendon can be worked with the tissue press. For example, a surgeon can harvest liver cells or pancreas cells and then compress them into a particular shape. They can then optionally be placed into a sack or some type of structural support which can be introduced into the body.[0019]
• With the present invention, graft material can be formed into almost any shape. A specific pair of forming (mold) parts, having a desired predetermined shape, are positioned on the tissue press, and the tissue is shaped or compressed between the forming elements. In addition to three-dimensional shaped parts, it is also possible to make a flat piece of graft material. For example, shaved skin can be placed on a flat plate, perhaps on a retaining mesh. The cells are then subjected to pressure to adhere them together. A flat, even, piece of graft material is formed which is suitable for skin grafting.[0020]
• Compressing graft material in accordance with the present invention also allows the surgeon to build up a larger piece of graft material out of several smaller parts. Sometimes a relatively large piece of graft material is needed for a particular host site. It is often not feasible to take such a large piece of graft material without damaging the donor area. To avoid this problem, several smaller pieces of graft material are placed in the tissue press and pressure is used to at least temporarily form the smaller parts together as one larger whole. The larger graft piece is then inserted into the host site.[0021]
• Compressing graft material in accordance with the present invention also aids in introducing additional materials to the graft material. These additional materials could be antibiotics, bone growth enhancers, tri-calcium phosphate, fibrin, allograft or autograft material, etc. When added to the graft material under pressure, the added materials adhere to and become a part of the graft material and not merely something added to the surface of it. By combining physiologic solutions or a carrier such as a gelatin, polysaccharides, antibiotics or synthetic bone materials to the compressed bone, for example, it is possible to create a plug of living bone with the other materials added into it. This plug has the graft properties of the bone tissue in the plug, as well as the properties of the added material.[0022]
• When tissue is compressed, fluid may be forced out of (expressed from) the tissue. If tissue in this compressed and defluidized state is laid back in a tissue pouch or in a bone hole, body fluids from the host site are absorbed by the graft material. This imbibition causes swelling of the graft material and thus creates a mechanical interlock between the graft and the host. Such a mechanical interlock is not produced with a typical implantation process in which graft tissue is not compressed. Further, the swelling (enlarging) of the graft material allows the graft material to fill an opening of any given shape with a perfect fit of the graft material therein.[0023]
Pressure monitoring and controlling
• As noted above, applicant has found that it is desirable to maintain bone graft tissue in a living state during the grafting process. It is important not to kill tissue used in grafting because the living graft cells provide a superior substrate for grafting and graft viability and improved tissue healing. There is significantly faster incorporation of living tissue than of dead tissue. The cells and the tissue that are implanted into the body therefore need to be maintained in a viable condition.[0024]
• Excess pressure on tissue can cause destruction of the tissue, disorganization of the tissue fibers and irregular mechanical structure which can damage the tissue graft. Thus, a feature of the present invention is that the pressure or force on the tissue being reshaped or compressed is monitored and controlled. Pressure can be monitored by suitable pressure sensors and readouts such as a pressure gauge. Pressure can be controlled by force limiting means such as a torque wrench or similar device.[0025]
• The desired pressure levels may vary. For example, it may be desirable to provide a higher compressive force for cortical bone than for cancellous bone. Similarly, it may be desirable to provide a higher compressive force for bone than for tendon tissue. The appropriate level of pressure or force is selectively available with the tissue press.[0026]
Retainers
• A separate device or structure can be used to maintain graft tissue in the compressed state prior to and during implantation. This separate device or structure can be a mesh sack, a ring around a cylindrically shaped graft material, etc. This additional retainer structure can assist the surgeon in introducing the graft tissue into the body in the compacted condition, to provide a denser stronger graft and to allow imbibition for creating a mechanical interlock. The retainer can be made of a material which expands when placed in the body, to provide a mechanical interlock for the graft tissue.[0027]
BRIEF DESCRIPTION OF THE DRAWINGS
• The foregoing and other features of the present invention will become apparent to one skilled in the art upon a consideration of the following description of the invention with reference to the accompanying drawings, wherein:[0028]
• FIG. 1 is a top plan view of a tissue press embodying the present invention;[0029]
• FIG. 2 is a top plan view of a tissue press similar to the tissue press of FIG. 1 and having a pressure sensing and monitoring mechanism;[0030]
• FIG. 3 is an elevational view of the tissue press of FIG. 2;[0031]
• FIGS. 3A and 3B illustrate a tissue press having means for removing excess tissue after compression;[0032]
• FIG. 4 illustrates a plurality of different forming elements for use in the tissue press of FIGS.[0033]1-3;
• FIG. 5 is a view of a tissue press in accordance with a second embodiment of the invention;[0034]
• FIG. 6 is a view of a tissue press in accordance with a third embodiment of the invention;[0035]
• FIGS. 7 and 7A illustrate a composite tissue graft such as compression of bone around tendon;[0036]
• FIG. 8 is a view of a tissue press in accordance with a fourth embodiment of the invention illustrating extrusion of tissue graft material;[0037]
• FIGS.[0038]9A-9F illustrates a plurality of different retainers for compressed tissue;
• FIGS. 10 and 10A illustrate an expanding tissue retainer;[0039]
• FIGS. 11, 11A and[0040]11B illustrate an expanding surgical. implant; and
• FIGS. 12 and 12A illustrate expanding surgical stabilization devices.[0041]
DESCRIPTION OF PREFERRED EMBODIMENTS OF THE INVENTION
• The present invention relates to a tissue press and particularly to a tissue press for shaping or compressing bone or other tissue. The present invention is applicable to various constructions of tissue shaping or compressing apparatus. As representative of the present invention, FIG. 1 illustrates a[0042]tissue press10.
• The[0043]tissue press10 includes abase12. Thebase12 has asupport surface14 for supporting thebase10 and thus thepress10 on a table or other support (not shown). Thebase12 has the same longitudinal cross-section throughout its width as is seen in elevation in FIG. 1. Twocylindrical pins16 protect upwardly from thebase12. AU-shaped saddle18 is secured to thebase12 byscrews20. Apin opening22 extends transversely through thesaddle18.
• The[0044]tissue press10 also includes ahandle30. Thehandle30 has aconnector portion32 received between the upwardly projecting side portions of thesaddle18 of thebase12. Apin opening34 extends transversely through theconnector portion32 of thehandle30. Theopening34 is aligned with theopening22 in thesaddle18. Apivot pin36 extends through thepin openings34 and22 in thehandle30 andbase12, respectively, and pivotally connects thehandle30 to thebase12.
• Extending from the[0045]connector portion32 of thehandle30 is a form-supportingportion40 of thehandle30. Achannel42 is defined on the lower side of the form-supportingportion40 between a pair of channel surfaces44. Thechannel42 extends transversely across the width of the form-supportingportion40. Extending from the form-supportingportion40 is acircular portion46 of thehandle30. Thecircular portion46 has a manuallyengageable surface48 for the application of force to thehandle30.
• A first forming[0046]element50 is slidably received on thebase12. The first formingelement50 has two vertically extendingpin openings52 which receive thepins16 of thebase12. The first formingelement50 has anupper surface54 which includes a formingsurface56. The formingsurface56 has acylindrical surface portion58. The first formingelement50 has the same longitudinal cross-section throughout its width as is seen in elevation in FIG. 1. It should be understood that the first formingelement50 can be connected with the base12 in any other suitable manner.
• A second forming[0047]element60 is slidably received in thechannel42 of thehandle30. The second formingelement60 has two projectingedges62 which engage the channel surfaces44 of thehandle30. The second formingelement60 has alower surface64 which includes a formingsurface66. The formingsurface66 includes acylindrical surface portion68. The second formingelement60 has the same longitudinal cross-section throughout its width as is seen in elevation in FIG. 1. It should be understood that the second formingelement60 can be connected with thehandle30 in any other suitable manner.
• In operation of the[0048]press10, a pair of formingelements50 and60 are selected which when brought together will shape a piece of livingtissue70 to the desired shape. For example, the formingelements50 and60 illustrated in FIG. 1 have cylindrical surface portions which will shape tissue into a cylindrical shape suitable for insertion into a round drill hole in bone. The first formingelement50 is slid onto thepins16 on thebase12. The second formingelement60 is slid into thechannel42 in thehandle30. Aset screw72 is tightened to secure the second formingelement60 to thehandle30.
• The piece of[0049]tissue70 to be shaped is placed between the first and second formingelements50 and60. Thetissue70 is preferably positioned on the formingsurface56 of the first formingelement50 as illustrated in FIG. 1. Thehandle30 is then brought toward the base12 in the direction indicated by thearrow74, by the application of force to thehandle30. The formingsurface66 with itscylindrical surface portion68 engages thetissue70, and forces thetissue70 against the formingsurface56 with itscylindrical surface portion58. Thetissue70 is thereby formed to the desired shape.
• It should be understood that with the[0050]tissue press10, tissue can be reshaped only, or reshaped and compressed. The amount and type of work performed on the tissue depends on the particular application, and is controlled by (i) the particular forming elements selected by the operator of the tissue press, and (ii) the amount of pressure or force applied to the tissue. For example, the forming elements can be selected so that they define between them a forming chamber having the same initial volume as the piece of tissue to be shaped. In this case, the piece of tissue is not compressed (that is, reduced in volume), but is merely reshaped. Alternatively, forming elements can be selected which will not merely reshape the piece of tissue but also will compress it, as described above. Because the first and second formingelements50 and60 ate removably received on thebase12 and handle30, respectively, the surgeon can easily select first and second formingelements50 and60 to reshape or compress thetissue70 as desired.
• As discussed above, it is important to control the pressure on the tissue in the[0051]tissue press10. There are many ways to do this. For example, in thepress80 shown in FIGS. 2 and 3, a second formingelement84 has anopening82 which extends between itsupper surface86 and its formingsurface88. Anopening90 in thehandle92 is aligned with and in fluid communication with theopening82. A pressure monitor device indicated schematically at94 is in fluid communication with theopening90 in thehandle92, and thus with the formingsurface88 on the second formingelement84. Thepressure monitor device94 can be any known device for displaying pressure, such as a dial readout, a bar movable axially in theopenings82 and90 in response to fluid pressure, etc. Thepressure monitor device94 displays the pressure at the formingsurface88 of the second formingelement84. This is the pressure applied to the tissue being pressed in thepress80. Thus, an operator of thepress80 can observe thispressure monitor device94 and limit the applied force accordingly, in order to avoid tissue damage or necrosis.
• Alternatively, a strain gauge of a known construction, indicated schematically at[0052]96, can be placed on the formingsurface88 of the second formingelement84. Electric wires (not shown) transmit signals from thestrain gauge96 to an electric readout device indicated schematically at94. The electric readout indicates electrically the pressure applied to the tissue in thepress80. Again, one can observe this pressure monitor device and limit the amount of force applied, in order to avoid tissue damage or necrosis. It should be understood that similar ways of monitoring the pressure on the tissue being pressed are the equivalent and are thus included within the scope of the invention.
• Any of the tissue presses of the present invention can include means for cutting off excess tissue. As an example, FIGS. 3A and 3B illustrate a[0053]tissue press91 having anindependent cutoff arm93 pivotally mounted adjacent thehandle95. Thecutoff arm93 has ablade portion97 operable to cut off excess tissue compressed by thetissue press91. Thecutoff arm93 is, of course, merely illustrative of the many equivalent structures usable to remove excess tissue after the compressing or shaping operation. Thus, the length of the tissue graft material, as well as its compressed diameter, can be selectively controlled by operation of the tissue press. It should be noted that this cutting off process can be effected with the edges of the forming elements themselves, as illustrated in the apparatus in FIG. 5.
• As noted above, the first forming[0054]element50 and the second formingelement60 are removably received on thebase12 and handle30, respectively. Thus, forming elements having forming surfaces with other shapes can be easily placed in thetissue press10, in order to shape or compress tissue into other shapes. A few of the many shapes obtainable are illustrated in FIG. 4.
• FIG. 4A, for example, illustrates the forming[0055]elements50 and60 of FIGS.1-3 which shape tissue into a cylindrical cross-sectional shape. FIG. 4B illustrates formingelements100 and102 which shape tissue into an oblong cross-sectional shape, between a formingsurface104 on the first formingelement100 and a formingsurface106 on the second formingelement102. FIG. 4C illustrates formingelements108 and110 which shape tissue into a square cross-sectional shape, between a formingsurface112 on the first formingelement108 and a formingsurface114 on the second formingelement110.
• FIG. 4D illustrates forming[0056]elements116 and118 which shape tissue into a triangular cross-sectional shape, between a formingsurface120 on the first formingelement116 and a formingsurface122 on the second formingelement118. FIG. 4E illustrates formingelements124 and126 which shape tissue into a generally flat shape, between a formingsurface128 on the first formingelement124 and a formingsurface130 on the second formingelement126. FIG. 4F illustrates formingelements132 and134 which shape tissue into a semi-circular cross-sectional shape, between a formingsurface136 on the first formingelement132 and a formingsurface138 on the second formingelement134. Again, it should be understood that other shapes are conceivable and consequently are included within the scope of the invention.
• In addition to three-dimensional shaped parts, it is also possible to make a flat piece of graft material. Forming elements like those shown in FIG. 4E are useful in this case. For example, a skin graft may be placed on an adhesive based mesh (possibly using fibrin) on the flat forming[0057]surface128. The cells are then subjected to pressure to adhere them together. The cells are spread out over a finer layer. A flat, even, piece of skin graft material is formed. This can then be cut or pressed or formed into a specific shape and then used as a skin substitute on the body.
• Any forming element useful in the present invention can be coated with a non-stick coating to reduce adhesions of the compressed tissue to the forming elements. For example, the forming element[0058]100 (FIG. 4B) is indicated as having anon-stick coating105 such as a Teflon® coating which may be applied in any suitable known manner. Such a coating can resist the binding of the tissue (or tissue additive such as fibrin discussed below) to the forming element.
• In a second embodiment of the invention, illustrated in FIG. 5, a[0059]tissue press150 is fluid operated (pneumatic or hydraulic) rather than manually operated. Thepress150 includes a base152 having asupport surface154 for supporting thebase152 and thus thepress150 on a table or other support (not shown). A first formingelement156 is attached to thebase152. The first formingelement156 may be slidably or otherwise attached to the base152 in any suitable manner which blocks movement of the formingelement156 relative to the base152 during operation of thepress150 and which allows for easy interchange of formingelements156. The first formingelement156 has an upwardly facing formingsurface158. Afluid drain opening160 is in fluid communication with the formingsurface158 of the first formingelement156.
• An air or[0060]hydraulic cylinder170 is fixed to thebase152 above the first formingelement156. Thecylinder170 has aport172 for the introduction of air or other fluid under pressure to operate apiston174 in a known manner.
• A second forming[0061]element180 is connected to thepiston174. The second formingelement180 is attached to thepiston174 in any suitable manner which blocks movement of the formingelement180 relative to thepiston174 during operation of thepress150 and which allows for easy interchange of formingelements180. The second formingelement180 has a formingsurface182 facing the formingsurface158 on the first formingelement156.
• A[0062]port176 in thecylinder170 is in fluid communication with the formingsurface182 of the second formingpat180. Connected to theport176 is a pressure monitor device shown schematically at178.
• In operation of the[0063]press150, a pair of formingelements156 and180 are selected which when brought together will shape tissue to the desired shape. The first formingelement156 is attached to thebase152. The second formingelement180 is attached to thepiston174. A piece of tissue to be shaped (not shown) is placed between the first and second formingelements156 and180. The piece of tissue is preferably positioned on the formingsurface158 of the first formingelement156.
• The[0064]cylinder170 is then actuated to move the second formingelement180 toward the first formingelement156. The formingsurface182 on the second formingelement180 engages the tissue, and forces the tissue against the formingsurface158 on the first formingelement156. Pressure on the tissue is controlled through observation of themonitor device178. The tissue is formed to the desired shape. Again, it should be understood that with thepress150 tissue can be reshaped only, or compressed also, depending on the application, the forming elements selected, and the amount of force applied.
• As discussed above, when tissue is compressed, fluid may be expressed from the tissue. In the[0065]press150, the second formingelement180 fits within the first formingelement156 to define between them a closed forming chamber in which the tissue is compressed. Expressed fluid is drained from the forming chamber through thefluid drain opening160. If a closed forming chamber is not formed, as for example with the open-ended forming elements shown in FIGS.1-4, then expressed fluid can drain outwardly from the tissue being pressed, without the need for a separate fluid drain port. Of course, a separate fluid drain port could be provided in any of the forming elements of the present invention.
• In a third embodiment of the invention, illustrated in FIG. 6, a[0066]tissue press200 includes a base202 having a support surface204 for supporting thebase202 and thus thepress200 on a table or other support (not shown). A first formingelement206 is attached to thebase202. The first formingelement206 may be slidably or otherwise attached to the base202 in any suitable manner. The first formingelement206 includes a plurality offirst fingers208 which together have a formingsurface210 to progressively compress bone or other tissue into a predetermined shape.
• An[0067]upper arm220 is pivotally mounted to thebase202 by apivot pin222. A second formingelement224 is connected to theupper arm220 in a suitable manner. The second formingelement224 includes a plurality ofsecond fingers226 which together have a formingsurface228 facing the formingsurface210 on the first formingelement206. Thesecond fingers226 are interdigitable with thefirst fingers208.
• In operation of the[0068]press200, a pair of formingelements206 and224 are selected which when brought together will progressively shape tissue to the desired shape. The first formingelement206 is attached to thebase202. The second formingelement224 is attached to theupper arm220. A piece of tissue to be shaped (not shown) is placed between the first and second formingelements206 and224. The piece of tissue is preferably positioned on the formingsurface210 of the first formingelement206. The upper arm is pivoted toward the base to move the second formingelement224 toward the first formingelement206. The formingsurface228 on the second formingelement224 engages the tissue, and forces the tissue against the formingsurface210 on the first formingelement206. The tissue is formed to the desired shape.
• Because the[0069]second fingers226 are interdigitable with thefirst fingers208, thepress200 is operable to compress tissue to different compressed sizes with only one pair of forming elements. As thesecond fingers226 come together with thefirst fingers208, they compress the tissue to a smaller and smaller diameter (shape). This allows for one pair of forming elements to provide compression to variable diameters or sizes. This works well with soft tissue applications, specifically tendons, to compress the tendon into a smaller shape. The amount of compression is based on the amount of pressure applied and the needed finished size.
• As noted above, it is important to control the pressure or force applied to the tissue by the tissue press. Accordingly, the present invention provides means for limiting the amount of pressure applied to the tissue by the tissue press, that is, means for blocking application to the tissue of force in excess of a predetermined amount. Such means are schematically illustrated in FIG. 6A, which illustrates a[0070]tissue press300 having a known torque wrench assembly included therein.
• The[0071]press300 includes abase302. Attached to the base in the manner described above is a first formingpart304. Also attached to the base is asaddle306. Received in thesaddle306 is theconnector portion308 of ahandle assembly310. Thepress300 also includes apivot pin312 pivotally interconnecting thehandle assembly310 and thebase302.
• The[0072]handle assembly310 includes a form-supportingportion314 to which there is attached in the manner described above a second formingpart316. Thehandle assembly310 also includes asecond portion318 connected to the form-supportingportion314 by adrive mechanism320. Thesecond portion318 includes aknurled section322 which is rotatable about anaxis324. On thesecond portion318 there is agauge326.
• The[0073]knurled section322 is rotatable about theaxis324 to set the torque value desired and as shown on thegauge326. Thereafter, thehandle assembly310 can be pivoted toward the base302 in the direction indicated by thearrow328 only until the preset amount of torque is applied. At that point, no more torque is transferred through thedrive mechanism320 to the form-supportingportion314. This limits the amount of pressure applied to the tissue by the second formingpart316, that is, blocks application to the tissue of force in excess of a predetermined amount.
• It should be understood that the torque wrench assembly or construction indicated in FIG. 6A is only illustrative of the many ways in which the amount of pressure applied to the tissue by the tissue press can be limited to a predetermined amount. There are other known mechanisms for performing the same function, and their use is included within the scope of the present invention.[0074]
• FIGS. 7 and 7A illustrate the use of a tissue press in accordance with the present invention to form a composite graft. As discussed above, with the present invention, it is also possible to make a composite graft. For example, the graft material for an anterior cruciate ligament reconstruction is preferably tendon in the middle with bone at both ends. In accordance with the apparatus and method of the present invention, bone tissue can be compressed around the ends of tendon tissue to form a substitute anterior cruciate ligament more closely approximating the original.[0075]
• Thus, as illustrated schematically in FIGS. 7 and 7A, the[0076]tissue press10 of FIGS.1-4 is being used to compressbone tissue240 aroundtendon tissue242 to form a substitute anteriorcruciate ligament244. Thetendon242 can be harvested from one site and thebone240 can be harvested from another site.
• It should be understood that the graft can be multiple tissue fragments rather than a composite material. Thus, the[0077]tissue press10, or indeed any tissue press in accordance with the present invention, can be used to compress, for example, multiple bone fragments into one larger piece. It should also be understood that the tissue press in accordance with the present invention can be used to add additional materials to body tissue material by pressure. For example, to bone tissue there can be added tri-calcium phosphate, an antibiotic, hydroxyapatite, allografts or autografts, or any other polymeric. This process is believed to be self-explanatory in light of the foregoing description, but for reference may be understood by referring to FIGS. 7 and 7A wherein240 would be the bone tissue or other tissue to which material is being added (squeezed in under pressure), and242 indicates the additional material being added to thetissue240.
• In this case, fibrin can be highly suitable for use as such an additional material. Fibrin is a blood component important in blood clotting. It can be separated or centrifuged from blood and has the nature of an adhesive gel. Fibrin can be used as an adhesive, either in a natural state or after being compressed, to hold together material such as separate tissue pieces pressed together in a tissue press of the present invention.[0078]
• In a fourth embodiment of the invention, illustrated in FIG. 8, a[0079]tissue press250 is operated to extrude rather than press material. Thepress250 includes a base252 having asupport surface254 for supporting thebase252 and thus thepress250 on a table or other support (not shown). Adie256 is attached to thebase252. Thedie256 may be slidably or otherwise attached to the base252 in any suitable manner which blocks movement of thedie256 relative to the base252 during operation of thepress250 and which allows for easy interchange of formingelements256. Thedie256 has an upwardly facingopening258. Anextrusion opening260 is in fluid communication with theopening258 of thedie256.
• An air or[0080]hydraulic cylinder270 is fixed to thebase252 above thedie156. Thecylinder270 has aport272 for the introduction of air or other fluid under pressure to operate apiston274 in a known manner. Aram280 is connected to thepiston274. Theram280 has asurface282 facing theopening258 on thedie256.
• In operation of the[0081]press250, adie256 is selected which will extrude tissue in the desired shape. Thedie256 is attached to thebase252. A piece of tissue to be extruded (not shown) is placed in theopening258 of thedie256. Thecylinder270 is then actuated to move the ram.280 toward thedie256. Thesurface282 on theram280 engages the tissue, and forces the tissue into and through thedie256, exiting through theopening260. The tissue is extruded in the desired shape. As discussed above, a fluid drain port can be provided in thepress250.
• It can also be useful to heat or cool the tissue being worked in a tissue press of the present invention. Accordingly, the present invention contemplates the use of means for selectively controlling the temperature of the piece of tissue while it is being compressed or shaped. As an example, illustrated schematically in FIG. 4 is a[0082]fluid passage284 extending from the outer surface of the formingelement124 and around the formingsurface128 thereof. Fluid which is either heated or cooled flows through thepassage284 and either cools or heats the material of the formingelement124 in the area adjacent the formingsurface128. Thus, the tissue, when it comes in contact with the. formingsurface128, can be selectively heated or cooled during the compression or reshaping operation. Heating can be useful in holding together materials being compressed, for example, and cooling can be useful to avoid tissue damage arising from overheating of tissue being compressed. It should be understood that other means of achieving these functions are contemplated, such as electrical heating elements. Further, both forming elements can be heated or cooled rather than just one. Any such equivalent structure is to be considered within the scope of the present invention.
• In accordance with another feature of the present invention, a retainer is provided for retaining tissue graft material in its compressed state. After the graft is compressed, the retainer is placed around the graft. The retainer can help to maintain the graft in a compressed configuration or in a specific shape for a period of time long enough to be placed in the body.[0083]
• The retainer may be one of many different shapes. The shape of the retainer is chosen to meet the specific application. There are a number of suitable shapes, such as a ring, a cylinder, a cage, a rectangular shape, a mesh, a suture-like wrap, etc. Some of these are illustrated schematically in FIGS.[0084]9A-9F. It should be understood that this is not an exhaustive listing, but rather that these are merely exemplary of the principle involved, and accordingly, the invention is not limited to these particular shapes. For example, a retainer may be provided which is in the particular shape of the tissue material being compressed, which can be rectangular, cylindrical, planar, etc.
• FIG. 9A illustrates a plurality of bands or rings[0085]290 used to hold together compressed tissue292. FIG. 9B illustrates acage294 which can be used to hold together the compressed tissue292 of FIG. 9A. Thecage294 includes a plurality of crossedfilaments296 which define between them a series ofopenings298 for tissue ingrowth. FIG. 9C illustrates anothercage300 which can be used to hold together the compressed tissue292 of FIG. 9A. Thecage300 includes a plurality of longitudinally extendingfilaments302 which define between them a series ofopenings304 for tissue ingrowth. FIG. 9D illustrates a solid-walled cylinder306 which can be used to hold together the compressed tissue292. FIG. 9E illustrates amesh cylinder308 which can be used to hold together the compressed tissue292. FIG. 9F illustrates the wrapping of a cord orsuture310 aroundcompressed tissue312.
• Any of these retainers may be made of various materials. The material of the retainer is chosen to meet the specific application. Some of the many materials which are suitable are biodegradable materials, ceramics (especially with bone-growth enhancers, hydroxyapatite, etc.); polymeric material such as Dacron or other known surgical plastics; metal; or composite materials.[0086]
• In use, the graft material may be pushed into the retainer structure after graft material is compressed. Alternatively, the graft material may be compressed with the retainer structure. After the graft material is compressed in the retainer, the combined structure of graft plus retainer is placed in the host site in the body. The retainer helps to maintain the graft in a compressed configuration or in the specific shape into which it was compressed for a period of time long enough to be placed in the body.[0087]
• If the retainer is made of a biodegradable material, then the retainer degrades and disappears after a period of time. If the retainer is not made of a biodegradable material, then the retainer remains in the body. Tissue ingrowth occurs to bind the host tissue to the graft material. Tissue ingrowth through and around the retainer, between the host tissue and the graft material, is promoted if there are openings as discussed above in the retainer.[0088]
• The invention, the retainer may, if desired, be made of a material which expands after it is placed in the body, to mechanically interlock the graft to the body. The expansion can take place in one of two ways. First, the retainer can itself be compressed, as with the tissue, then expand when placed in the body. Second, the retainer can be made of a material which expands when it comes in contact with water or other bodily fluids.[0089]
• (It should be noted that the tissue can itself be compressed then expand when contacted by water. As an example, a tendon can be compressed in a desiccated state, and as it imbibes water it expands and creates a firmer lock or tighter fit in the host site.)[0090]
• The expandable material can first be compressed with the tissue being grafted, and which then expands when placed in the body. The retainer is preferably made of a material which has more structural stability than the tissue being grafted, and provides mechanical integrity and structural support for the graft tissue. A retainer made of a solid polymeric material, for example, is useful to retain in a compressed state a tendon or bone tissue graft.[0091]
• These expandable materials can be used not only to retain graft material, but for any shape required for stabilization surgery, such as a wedge, screw, rivet, retaining ring, or spacer, an intramedullary rod, a joint replacement part such as a femoral component of acetabular cup, an expandable sleeve, or another mechanical structure. The expandable materials thus can be used both as a carrier or retainer for another material (e.g. tissue graft material) and on their own as a prosthetic element.[0092]
• There are a number of suitable materials which expand when they come in contact with water or other fluids. One is PEEK (polyether-etherketone). A desiccated bio-degradable material, or a desiccated allograft may also be used.[0093]
• As a simple example, an expandable retainer[0094]330 (FIG. 10) withgraft tissue332 therein is placed into a tissue orbone space334 defined by anedge336 inhost tissue338. As theretainer330 imbibes body fluids or water from thehost tissue338, it expands radially outwardly into the tissue orbone space334 and creates a mechanical interlock (FIG. 10A). It also expands radially inwardly and clamps on thegraft tissue332. Therefore, thegraft tissue332 is locked into the host site, without the necessity of damaging the tissue further through some other kind of attachment means.
• For example, a hip replacement (femoral head) is typically made of metal. To implant the replacement, the softer, inner cancellous bone of the femur is first removed. The inner surface of the cortical bone is then machined to provide a close fit between the external surface of the replacement and the hard outer cortical bone material. All this requires a substantial opening in the femur and still does not guarantee a close enough fit for the implant.[0095]
• If, instead, the implant is made of an expanding material such as PEEK, only a smaller opening is needed, thus reducing trauma to the bone. Although it is best to lock against the cortical bone, it is possible to implant solely in the cancellous bone, which because of the expansion of the implant provides a better fit than a metal implant. A benefit of implanting in the cancellous bone is reduction of the danger of putting the implant in so tightly that the cortical bone is split (wedged open). Further, if the opening in the bone is not exactly the same shape as the outer surface of the implant, the implant expands to provide a custom contoured fit to the bone and provide immediate mechanical stability. Thus, less machining of the bone is needed, while at the same time obtaining a closer fit.[0096]
• Thus, as illustrated in FIGS.[0097]11-11B, a hip replacement (femoral head)340 is made of PEEK or another expandable material. Thereplacement340 is inserted into anintramedullary channel342 cut into afemur344. Thereplacement340 is smaller in diameter than thechannel342. Thereplacement340 absorbs body fluids and expands to lock itself into thechannel342 in thefemur344. (It should be understood that the scale shown in FIGS.11-11B is exaggerated as to the amount by which thereplacement340 expands.)
• Similarly, a bone plate or other structure or tissue can be secured to a bone with a fastener made of such an expandable material. As illustrated schematically in FIGS. 12 and 12A, a[0098]bone plate350 is secured to abone352. In FIG. 12, afastener354 is used which has an unthreadedportion356 extending into thebone352. Thefastener354, or at least theunthreaded portion356, is made of PEEK or another suitable expandable material. Theportion356 imbibes fluid from thebone352 and expands radially outwardly, from an unexpanded condition as shown in phantom at358 to an expanded-condition as shown in solid lines at360, to lock thefastener354 into thebone352. This enables the securing of theplate350 to thebone352 without cutting threads into thebone352 as is usually done.
• In FIG. 12A, a[0099]fastener362 has a threadedportion364 extending into thebone352. The threadedportion364 is made of PEEK or another suitable expandable material. The threadedportion364 imbibes fluid from thebone352 and expands radially outwardly to additionally lock thefastener362 into thebone352. Alternatively, thefastener362 of FIG. 12A may have acoating366 on its portion threaded into thebone352. Thecoating366 is made of PEEK or another suitable expandable material. Thecoating366 imbibes fluid from thebone352 and expands radially outwardly to additionally lock the fastener into thebone352.
• When such a fastener is made of a non-metal expandable material, removal of the fastener simply entails drilling out the center thereof. This is much easier than with a typical metal bone screw.[0100]
• From the above description of the invention, those skilled in the art will perceive improvements, changes and modifications. Such improvements, changes and modifications within the skill of the art are intended to be covered by the appended claims.[0101]

Claims (61)

I claim:

1. A tissue press for shaping a piece of tissue to a particular overall shape for implantation, comprising:

first and second relatively movable members connected with each other;

said first member having a surface portion receiving a selected one of a plurality of first forming elements of predetermined shapes, said first forming element having a first forming surface for providing a first portion of the overall shape of the reshaped tissue,

said second member having a surface portion receiving a selected one of a plurality of second forming elements of predetermined shapes, said second forming element having a second forming surface for providing a second portion of the overall shape of the reshaped tissue,

said first and second forming elements being positionable on opposite sides of the piece of tissue to be shaped, and

actuator means connecting said first and second relatively movable members and operable to move said second forming element toward said first forming element to engage and shape the piece of tissue between the first and second forming elements.

2. A tissue press as defined inclaim 1 wherein each one of said plurality of first forming elements is removably received on said surface portion of said first member.

3. A tissue press as defined inclaim 2 wherein each one of said plurality of second forming elements is removably received on said surface portion of said second member.

4. A tissue press as defined inclaim 1 comprising means for draining off fluid from between said first and second forming elements.

5. A tissue press as defined inclaim 1 comprising means for monitoring the amount of pressure applied to the piece of tissue in order to minimize tissue necrosis.

6. A tissue press as defined inclaim 1 comprising means for limiting the amount of pressure applied to the piece of tissue in order to minimize tissue necrosis.

7. A tissue press as defined inclaim 1 wherein said first and second forming elements when brought together define between them an open forming chamber.

8. A tissue press as defined inclaim 1 wherein said first and second forming elements when brought together define between them a closed forming chamber.

9. A tissue press for shaping a piece of tissue to a particular overall shape for implantation, comprising:

a first forming element having a first forming surface for providing a first portion of the overall shape of the reshaped tissue;

a base member supporting said first forming element and including surface means for supporting said base member and thereby said apparatus on an external support surface;

a second forming element having a second forming surface for providing a second portion of the overall shape of the reshaped tissue, said first and second forming elements being positionable on opposite sides of the piece of tissue to be shaped;

a manually engageable member connected with said base member and supporting said second forming element, said manually engageable member being movable relative to said base member to move said second forming element toward said first forming element to reshape the piece of tissue between the first and second forming elements; and

means for blocking application to the piece of tissue of pressure in excess of a predetermined amount.

10. A tissue press as defined inclaim 9 comprising means for draining off fluid which may be expressed from the piece of tissue.

11. A tissue press for compressing a piece of tissue, comprising:

a base member;

a first compressing part on said base member for receiving the piece of tissue thereon;

a movable member connected with said base member and movable relative to said base member;

a second compressing part on said movable member, said first and second compressing parts being positionable on opposite sides of the piece of tissue when the piece of tissue is received on said first compressing part; and

said movable member being movable toward said base member to move said second compressing part toward said first compressing part to compress the piece of tissue between the first and second compressing parts.

12. A tissue press as defined inclaim 11 wherein said base member includes surface means for supporting said base member and thereby said apparatus on an external support surface, said movable member being pivotally supported by said base member.

13. A tissue press as defined inclaim 11 wherein said first and second compressing parts each include a cylindrical surface portion and cooperate to compress tissue into a cylindrical shape.

14. A tissue press as defined inclaim 11 comprising means for monitoring the amount of pressure applied to the piece of tissue.

15. A tissue press as defined inclaim 14 wherein said means for monitoring pressure comprises a pressure sensor in one of said first and second compressing parts for sensing the amount of pressure on the piece of tissue.

16. A tissue press as defined inclaim 14 wherein said means for monitoring pressure comprises display means for displaying the amount of pressure applied by said first and second compressing parts.

17. A tissue press as defined inclaim 11 comprising means for limiting the amount of pressure applied to the piece of tissue in order to minimize tissue necrosis.

18. A tissue press as defined inclaim 17 wherein said means for limiting comprises a pressure relief mechanism for blocking movement of said second compressing part, toward said first compressing part, upon the application of pressure to said piece of tissue in an amount above a predetermined amount.

19. A tissue press for compressing a piece of tissue, comprising:

first and second relatively movable support members connected with each other;

said first support member having a surface portion receiving a selected one of a plurality of first compression members having predetermined forms, said first compression member adapted to receive the piece of tissue thereon,

said second support member being movably connected with said first support member and having a surface portion receiving a selected one of a plurality of second compression members having various forms,

said first and second compression members being positionable on opposite sides of the piece of tissue to be compressed,

said first and second support members being relatively movable to move said second compression member toward said first compression member to engage and compress the piece of tissue between the first and second compression members;

means for draining off fluid which may be expressed from the piece of tissue to be compressed; and

means for limiting the amount of pressure applied to the piece of tissue in order to minimize tissue necrosis.

20. A tissue press for shaping a piece of tissue, comprising:

first and second members;

a plurality of first forming elements of different predetermined shapes selectively engageable on said first member,

a plurality of second forming elements of different predetermined shapes selectively engageable on said second member,

said first and second forming elements when on said first and second members being positionable on opposite sides of the piece of tissue, and

said first and second members being relatively movable between a first spaced apart condition and a second condition in which said piece of tissue is held between said first and second forming elements.

21. A method of reshaping tissue for use as graft material comprising the steps of:

determining the shape which the tissue should possess as graft material;

providing a tissue press;

selecting forming elements adapted to press tissue approximately to the desired shape;

placing the forming elements on the tissue press;

placing the tissue in the tissue press between the forming elements;

operating the tissue press to shape the tissue between the forming elements to give the tissue the desired shape; and

controlling the pressure on the tissue during said shaping step to minimize damage to or necrosis of the tissue.

22. A method of preparing tissue for use as graft material comprising the steps of:

determining the shape and size which the tissue should possess as graft material;

placing the tissue in a tissue press having forming elements adapted to press tissue approximately to the shape and size desired;

compressing the tissue in the tissue press to give the tissue the shape and size desired;

controlling the pressure on the tissue during the compressing step to minimize damage to or necrosis of the tissue; and

draining off fluid expressed during said compressing step.

23. A method as set forth inclaim 22 further comprising the step of implanting the compressed tissue as graft material in a body opening in a compressed and defluidized condition whereby the compressed tissue will imbibe bodily fluids and form a mechanical interlock with the surface defining the body opening.

24. A method as set forth inclaim 23 further comprising the step of placing a retaining member on the compressed tissue to maintain the compressed tissue in a compressed condition prior to implantation of the compressed tissue as graft material.

25. A tissue press for compressing or shaping a piece of tissue, comprising:

a first member, and a first forming element on said first member;

a second member connected with said first member, and a second forming element on said second member;

said second member being movable toward said first member to move said second forming element toward said first forming element to compress or shape the piece of tissue between the first and second forming elements; and

means for selectively controlling the temperature of the piece of tissue while it is being compressed or shaped.

26. A tissue press as set forth inclaim 25 wherein said means for selectively controlling the temperature of the piece of tissue comprises means for heating the piece of tissue.

27. A tissue press as set forth inclaim 25 wherein said means for selectively controlling the temperature of the piece of tissue comprises means for cooling the piece of tissue.

28. A tissue press for compressing or shaping a piece. of tissue, comprising:

a first member, and a first forming element on said first member;

a second member connected with said first member, and a second forming element on said second member;

said second member being movable toward said first member to move said second forming element toward said first forming element to compress or shape the piece of tissue between the first and second forming elements; and

means for selectively removing excess tissue from the piece of tissue after it is compressed or shaped.

29. A pneumatic press for compressing or shaping a piece of tissue, comprising:

a first member, and a first forming element on said first member;

a second member connected with said first member, and a second forming element on said second member;

said second member being movable, upon the application to said press of fluid under pressure, toward said first member to move said second forming element toward said first forming element to compress or shape the piece of tissue between the first and second forming elements.

30. A tissue press for compressing or shaping a piece of tissue, comprising:

a first member, and a first forming element on said first member;

a second member connected with said first member, and a second forming element on said second member;

said second member being movable toward said first member to move said second forming element toward said first forming element to compress or shape the piece of tissue between the first and second forming elements; and

a non-stick coating on at least one of said first and second forming elements to limit adhesion of the piece of tissue while it is being compressed or shaped.

31. Apparatus for shaping a piece of tissue, comprising:

first and second relatively movable members;

a plurality of first forming elements of different predetermined shapes selectively engageable on said first member;

means for connecting a selected one of said first forming elements with said first member;

a plurality of second forming elements of different predetermined shapes selectively engageable on said second member;

means for connecting a selected one of said second forming elements with said second member;

said first and second forming elements when connected with said first and second members being positionable on opposite sides of the piece of tissue; and

said first and second members being relatively movable between a first spaced apart condition and a second condition in which said piece of tissue is shaped between said first and second forming elements.

32. Apparatus as set forth inclaim 31 wherein said means for connecting comprises respective surface portions on said forming elements and said members for slidably receiving said forming elements on said members.

33. Apparatus as set forth inclaim 31 wherein said first and second forming elements include surface means for shaping the tissue into a flat shape.

34. Apparatus as set forth inclaim 31 wherein said first and second forming elements include surface means for shaping the tissue into a cylindrical shape.

35. Apparatus as set forth inclaim 31 wherein said first and second forming elements include surface means for shaping the tissue into an oblong shape.

36. Apparatus as set forth inclaim 31 wherein said first and second forming elements include surface means for shaping the tissue into a square shape.

37. Apparatus as set forth inclaim 31 wherein said first and second forming elements include surface means for shaping the tissue into a triangular shape.

38. Apparatus as set forth inclaim 31 wherein said first and second forming elements include surface means for shaping the tissue into a semicircular shape.

39. A method of preparing composite tissue graft material, comprising the steps of:

placing body tissue and at least one other element in a tissue press having forming elements adapted to press tissue approximately to the shape and size desired;

compressing the body tissue and the other element in the tissue press to form a composite tissue graft having the shape and size desired; and

controlling the pressure on the body tissue during the compressing step to minimize damage to or necrosis of the tissue.

40. A method as set forth inclaim 39 wherein the body tissue is bone and the other element is tendon.

41. A method as set forth inclaim 39 wherein the body tissue is bone and the other element is fibrin.

42. A method as set forth inclaim 39 wherein the body tissue and the other element are multiple smaller pieces of the same type of body tissue to be compressedly formed into one larger piece.

43. A method as set forth inclaim 39 wherein the body tissue is skin graft tissue and the other element is a retaining member therefor such as a retaining mesh.

44. A method as set forth inclaim 39 wherein the other element is selected from the group consisting of antibiotics, bone growth enhancers, tri-calcium phosphate, hydroxyapatite, allografts and autografts.

45. A method comprising the steps of obtaining fibrin as a component from body tissue and using the fibrin as an adhesive.

46. A method as set forth inclaim 45 further comprising the step of compressing the fibrin prior to using it as an adhesive.

47. A surgical implant made at least partially of a material which expands when it comes into contact with body fluids upon implantation into the body.

48. An implant as defined inclaim 47 wherein said material is PEEK.

49. An implant as defined inclaim 47 wherein said implant is a joint replacement part.

50. An implant as defined inclaim 47 wherein said implant is a surgical stabilization element such as a plate, rivet, or screw.

51. A surgical implant as defined inclaim 47 comprising a coating of a material which expands when it comes into contact with body fluids upon implantation into the body.

52. Apparatus for maintaining tissue graft material in a compressed condition, comprising a retainer for placement around the compressed tissue graft material prior to implantation of the compressed tissue graft material in the body.

53. Apparatus as defined inclaim 52 wherein said retainer is a cage.

54. Apparatus as defined inclaim 52 wherein said retainer is a mesh.

55. Apparatus as defined inclaim 52 wherein said retainer is biodegradable.

56. Apparatus as defined inclaim 52 wherein said retainer is made of a polymer.

57. Apparatus for maintaining tissue graft material in a compressed condition, comprising a retainer for placement around the compressed tissue graft material prior to implantation of the tissue graft material in the body, said retainer expanding after implantation in the body.

58. Apparatus as defined inclaim 57 wherein said retainer is made of a material which is itself compressed prior to implantation in the body and which expands upon implantation into the body..

59. Apparatus as defined inclaim 57 wherein said retainer is made of a material which expands when it comes into contact with body fluids upon implantation into the body.

60. Apparatus as defined inclaim 59 wherein said material is PEEK.

61. Apparatus as defined in claim60 wherein said material is a desiccated biodegradable.

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